Some thoughts on health care

(Previous posts worth checking out are here and here.)

Health-care costs -- and whether to go to a government-run payment system -- is an issue that could dominate the 2008 elections. But as always, the debate could benefit from some decluttering.

First, let's be clear on what we're talking about. Opponents of any sort of national health care deride it as "socialized medicine". In fact, they use that label to describe any government involvement in the health-care system, however small.

But true socialized medicine is when the government is the health-care system -- it owns the hospitals, employs the doctors, and decides what procedures are included and what are not.

That's not generally what is under discussion here in the States. We're mostly talking about a "single-payer" system -- wherein the government pays for medical care, but it is provided by private hospitals, doctors and clinics.

But that's just the beginning.

Proponents of the current system warn of rationing -- as if care isn't rationed now, by ability to pay. Nor do they mention all the personal bankruptcies related to medical costs.

They warn about bureaucracy -- as if there isn't plenty of bureaucracy involved right now. The only advantage is that you get to choose among several private bureaucracies instead of being stuck with one big government bureaucracy.

They warn about lack of choice -- as if workers have much choice now. At a good-sized company, an employer might offer two or three health plans. But most workers are lucky to have health insurance at all -- and often, even when it's offered, it's expensive or has big coverage gaps.

They warn that people will stop trying to become doctors if salaries are squeezed. But doctor pay actually isn't a big factor in rising health-care costs, and so shouldn't be the primary focus of cost-control efforts. Even under a single-payer system, doctors should still be well-paid.

(And never mind that one of the reasons for high medical salaries is the staggering cost of medical school. If those costs could somehow be ameliorated -- say, by hospitals agreeing to shoulder some of that debt when they hire new MDs -- we could have lower salaries without discouraging new doctors).

PERVERSE INCENTIVES
The current system is also riddled with Catch-22s that might make sense individually but end up being senseless in aggregate.

My brother's a doctor. He's a family practitioner, which if you know anything about medicine means he's not primarily in it for the money. Yet for an FP he makes money hand over fist because he happens to have a patient base that is generally young and healthy -- meaning he can pack lots of appointments into an hour, the most profitable way to operate given his employer's payment system (which, in turn, is based on insurance reimbursement schedules.)

He has a colleague who is really detail-oriented, likes talking to patients and takes time with them. She ends up with all the hard cases -- and because those patients take a lot more time, she makes a lot less money. Yet the system would collapse without her -- she frees up the other doctors to see more patients.

Does that compensation system make sense?

Then there's the bureaucratic craziness caused by having to deal with dozens of different insurers, all of whom have their own coverage and reporting requirements.

My brother knows all this. He can rattle off a dozen perverse incentives caused by the current health-care system.

Would single payer solve some of those problems? Yes. Would it introduce other problems? Almost certainly. Whether the tradeoff is acceptable depends on how its structured.

COMPARING THE TWO
The biggest advantage of the current system is that if you've got the money you can get the care you want, when you want it.

The biggest advantages of a single-payer system would be universal coverage (no more "preexisting condition" exclusions) and an end to medical-related bankruptcy. It would also relieve businesses of the burden of providing health insurance, making them more competitive in the global marketplace.

One of the remaining big issues -- quality and availability of care -- comes down to details in the design and administration of the single-payer program.

The remaining big issue would be cost. It would make no sense to move to single-payer if, after subtracting the cost of providing universal coverage, it cost more than the system it was replacing, or provided far worse outcomes for the same price. But that, again, depends on the specific structure of the single-payer program.

I still think the simplest thing to do would be one of the following:

1. A mandatory insurance system like that being tried by Massachussetts;

2. Pass a law requiring insurance companies to treat the entire country as one giant risk pool, with discounts or surcharges allowed for measurable health risks like age, obesity, smoking, skydiving, etc. Then let individuals buy insurance themselves. It would take the burden off of businesses and let the market work while giving everyone access to group rates. One could combine this with a "must buy health insurance" law in order to avoid free-riders. Or one could simply let people take their chances.

If I were going to introduce a single-payer system of universal coverage, I'd simply introduce it without banning other systems -- an extension of Medicare, say but with higher compensation. Then I'd let employers choose whether to keep providing private insurance or offload their employees into the government system.

Or maybe they'd keep it as a cheap option. That would result in a health-system structured in tiers: basic coverage for everyone, with consumers having the option of buying private insurance to supplement it if they so desired. Providers, in turn, could charge what they wanted. If they charged more than the government plan paid, patients would have to pay the difference -- either out of pocket or through the supplemental private insurance they bought.

All these things should be on the table. If we were to approach this pragmatically we should try the more market-based approaches first, in order to avoid creating a self-sustaining government program that would be hard to kill if it proved a disaster. But a full-fledged single-payer system shouldn't be dismissed out of hand. If the middle paths fail, it remains the logical next step.

health care, politics, midtopia

Et cetera

Finishing off the day, a roundup of outrage, humor and the merely interesting:

IRAQI PARLIAMENT ADJOURNS FOR AUGUST
Ignoring pleas from the United States, legislators took their month-long recess. They won't be back until Sept. 4, making it that much harder to make progress on the various "benchmark" laws we are asking them to pass. The report on the military surge in the Baghdad area will be due in September, and now it's highly unlikely that we will be able to point to any legislative successes to accompany it. Which makes it that much more unlikely that voters will support our continued presence. Even worse is that the main culprit is the government of Prime Minister Nouri al_Maliki, not rebellious members of Parliament.

HE IS DEAD TO US
After Newt Gingrich declined to defend Alberto Gonzales during his appearance this weekend on Fox News Sunday, host Chris Wallace dropped this little bomb: "By the way, we invited White House officials and Republicans on the Senate Judiciary Committee to defend Attorney General Gonzales. We had no takers."

SURGEON GENERAL REPORT 'NOT POLITICAL ENOUGH'
A 2006 report commissioned by former Surgeon General Richard Carmona -- on the link between poverty and poor health -- was held up by a political appointee with no background in medicine or public health because the report wasn't political enough. That's according to several current and former health officials. The appointee, Will Steiger, acknowledged he told Carmona the report needed to promote administration policies, but he denied that that dispute held up its release; he said the report was delayed because of "sloppy work, poor analysis and lack of scientific rigor." Steiger is the scion of a well-connected Republican family; his expertise is in education and Latin American history. And a "former administration official" said the report is just one of several that the administration has bottled up because they didn't like the conclusions.

Gonzales, Iraq, Carmona, politics, midtopia

Business backs universal health care

I'm catching up on my reading, and just finished an interesting piece on the prospects for health-care reform.

I've argued before that health coverage needs to be de-linked from employment status. It's both a fairness factor for employees (why should I pay more for worse coverage simply because I work for a small business?) and an economic factor for employers, to whom rising health care costs represent a barrier to hiring and a competitive disadvantage versus foreign companies who bear no such burden.

Now, at last, business seems to be reaching the same conclusion. As Sen. Ron Wyden, a longtime advocate of universal coverage, notes, "The refrain from business was, 'We can’t afford to do universal health care.' Now the refrain is, 'We can’t afford not to do it.'"

Which is why you have the odd spectacle of a union-busting CEO, Steve Burd of Safeway supermarkets, joining former Republican National Committee chairman Ed Gillespie to form the Coalition to Advance Health Care Reform, a business advocacy group that will push universal coverage.

One might be forgiven for being skeptical, and think this is just another Orwellian-named group whose actual agenda is to scuttle universal care. But Burd has been walking the walk for a while, giving talks to business groups promoting the idea. And one can certainly see the self-interest involved. The real trick will be in the details. Everybody wants universal care -- but what level of benefits? At what cost? Who pays? And who manages it? Those are the things that will need to be ironed out.

Still, it's good to see the various interest groups starting to line up behind the general idea of comprehensive coverage. It's only a first step, but a very important one.

Burd, health care, politics, midtopia

Meningitis vaccine puts health before profits

It's not as simple as that, but the math is pretty stark. GlaxoSmithKline, which spent decades and more than $400 million developing a meningitis vaccine, expects to sell it only in Africa, and at a price that will never cover the cost of development.

As the story notes, this is not an entirely selfless act. Some of it is PR, attempting to repair the damage done by a lawsuit over AIDS drugs a few years back. Some of it is marketing, establishing a presence in markets where GSK may hope to sell other drugs down the road.

Nor is it a solution to finding cures for "neglected" diseases -- illnesses that occur solely in the developing world, and thus have no rich-nation market that can be charged higher prices to pay for the development costs. Companies cannot be expected to routinely write off $400 million for the global good.

But it is a sign that pharmaceutical companies are waking up to the complex world they operate in, and that profit motive is not the only valid consideration for their research efforts. GSK is doing an extraordinary thing, and millions of lives will likely be saved because of it. Good for them.

GlaxoSmithKline, meningitis, Africa, health care, politics, midtopia

Walter Reed claims more victims

The Army surgeon general, Kevin Kiley, is the latest casualty of the Walter Reed scandal, choosing to retire under pressure from lawmakers and the acting secretary of the Army, Pete Geren.

The move comes the same day the Army inspector general released a report criticizing the Army's system for evaluating and caring for wounded soldiers, calling it understaffed, undertrained and overwhelmed by the number of wounded. Some of the examples given were surreal -- such as a care facility that lacked wheelchair access.

It's worth noting that the report was ordered back in April 2006, an indication that the Army was aware of and addressing some problems nearly a year before the current scandal broke. On the other hand, it makes the reaction of senior Army brass even more inexplicable. How could they downplay problems when they already knew about many of them? And the fact that the report took a year to produce indicates the military bureaucracy still does not have a wartime sense of urgency.

Walter Reed, Kiley, military, politics, midtopia

Heads roll among Army brass

Yesterday, the uproar over poor conditions at Walter Reed Army Medical Center claimed the career of a two-star general. Today, it claimed the Secretary of the Army.

Secretary Francis Harvey apparently ran afoul of Defense Secretary Robert Gates because, after firing Maj. Gen. George Weightman, he replaced him with another general with links to the controversy.

I haven't been commenting on this scandal because I haven't had a chance to read the Post's stories. Anyone who has ever been through the military medical system knows what a bureaucratic nightmare it can be. I wanted to make sure the Post wasn't making a big deal out of what, for the military, is routine -- however inexcusable it may be.

But with some corrections underway and a push by President Bush and Gates for a top-to-bottom review, not to mention the nearly unprecedented sacking of two senior officials, it seems clear that the administration is taking this seriously and not liking what it sees. Sad as it is to see our soldiers treated this way at any time, much less in the midst of a war, it's good to see it being addressed forcefully.

On the other hand, this would never have come to light without the investigative work of the Washington Post -- a prime example of why a vigorous and free press are important to the country.

military, politics, midtopia

New Jersey grants gay civil unions

New Jersey becomes the third state to allow either civil unions or marriage.

Meanwhile, a Michigan court ruled earlier this month that the state's recent gay-marriage ban also outlaws domestic-partner benefits to government employees, including those who work for public universities. The logic: health benefits cannot be provided if doing so is based on treating same-sex relationships similar to marriage.

And so while New Jersey expands freedom and fairness, Michigan trips into the minefield of litigation and unintended consequences caused by a hastily passed, too-broadly drawn constitutional amendment that singles out a minority for discrimination. Another 20 states with similar bans probably will face similar troubles -- unless they take the route Alaska took and decide the law doesn't apply to such benefits.

Of course, some people are happy that this will hurt gay families. Take Gary Glenn, president of the American Family Association's Michigan chapter:

“For the average Michigan taxpayer whose family does not receive government-paid insurance of any kind, this was a victory because Michigan taxpayers will no longer be forced to subsidize homosexual relationships among government workers as if those relationships are equal or similar to marriage,” he says.

That logic is so disingenuous, not to mention mean-spirited, I don't even know where to begin.

The AFA, by the way, also warns against witchcraft, specifically attacking a middle school newspaper for publishing an 8th-grade girl's article on her Wiccan aunt and Wiccan beliefs. This is a little ironic, considering they have a "religious freedom" section of their Web site where they purport to stand up for religious expression.

Such routine hypocrisy aside, it'll be interesting to see if there is a second wave of constitutional amendments amending the gay-marriage bans. I wouldn't expect outright repeals, but at the very least we might see language exempting domestic partner benefits or allowing civil unions. And the lessons of these first states -- moral as well as legal -- will likely slow the rush to adopt similar measures in the remaining states.

I stand by my prediction that in 20 years, the country will largely look back on this brouhaha and ask "what was the big deal"? Gay marriage laws will go the way of sodomy laws, falling state by state until the Supreme Court repeals the last few holdouts. Because manifest unfairness rarely survives for long, even when it involves something as visceral as homosexuality.

gay marriage, politics, midtopia

A cure for cancer?

It sounds too good to be true. But everything I can find says this could be legitimate.

A molecule used for decades to combat metabolic diseases in children, may soon be available as an effective treatment for many forms of cancer, University of Alberta researchers are reporting.

In results that “astounded” school scientists, the molecule, known as DCA, was shown to shrink lung, breast and brain tumours in both animal and human tissue experiments. The study is being published today in the journal Cancer Cell.

Besides being known and safe, the drug is in the public domain -- meaning if this pans out, treatments would be dirt cheap. On the downside, it might be difficult to get it through clinical trials and bring it to market, since there's little or no profit in it for drug companies. So public financing of the trials may be necessary.

And those clinical trials are crucial. Lab results and even animal testing are nice, but the drug industry is littered with compounds that passed those two hurdles and failed in human testing. Such trials are expensive and take time, so any actual treatment is still years away.

But if this works, it would be way, way cool.

DCA, cancer, medicine, midtopia

Unpleasant math

What can $1.2 trillion buy?

Less than half of that would let us double cancer research funding, treat every American who has diabetes or heart disease and immunize every child on the planet against measles, whooping cough, tetanus, tuberculosis, polio and diptheria -- all for a decade.

$350 billion would provide a decade of universal pre-school.

$100 billion over a decade would be enough to fully implement the 9/11 Commissions recommendations and provide more aid to Afghanistan.

Or you could choose, as we have, to blow it all on Iraq. And that's a relatively conservative estimate.

The sheer scale of waste and forgone opportunities boggles the mind.

Iraq, budget, money, politics, midtopia

Health care tsunami

Amazing what a Democratic sweep of Congress will do. Suddenly, everyone is talking about health care.

On Monday, the insurance industry outlined a plan to provide insurance coverage to the 47 million uninsured Americans. They propose using tax credits and government programs to buy the insurance, at an estimated cost of $300 billion over 10 years.

And yesterday, Minnesota Gov. Tim Pawlenty -- facing a Democrat-controlled state legislature -- said he wants to extend health insurance to all children, a startling about-face for a man who threw people off of MinnesotaCare in his first term as he struggled to close the state's budget deficit without raising taxes.

Call me cynical, but do you suppose either of those two things would have occurred had the Republicans kept control?

No matter. Pawlenty's willingness to reconsider long-held positions is one reason I said it wouldn't be a disaster if he were re-elected. And with businesses, the insurance industry and prominent Republicans all suddenly producing plans to improve health coverage, it's going to be very hard for opponents to claim a solution -- however partial -- is impossible or socialist or the like.

There are a lot of questions to be answered, notably cost controls and the increasing shifting of costs from employer to employee. But that's what debate is for. The discussion looks to be healthy, and likely to lead to something productive. Finally.

Score one for divided government.

Pawlenty, health care, politics, midtopia

No Iraq War Syndrome yet

On the good news front, researchers have found no evidence of an "Iraq War Syndrome" similar to the "Gulf War Syndrome" that affected veterans of the 1991 invasion.

They examined whether there had been an increase in ill health in soldiers returning from Iraq and compared the mental and physical health of forces who had been deployed and those who had not.

They found only slight increases in symptoms but reserve forces experienced more mental health problems than regular forces.

The most interesting side note is that this seems to knock the legs out from under the "depleted uranium" theory of causation. Depleted uranium, being exceedingly dense, is used in Western tank armor and antitank rounds. The general nervousness surrounding "radioactive" materials led many people to assert that the rounds caused health problems by creating fine dust particles that can be inhaled.

This never made much sense, since depleted uranium is less radioactive than natural uranium. Even uranium miners -- exposed to much higher doses for much longer periods of time -- come out clean.

Depleted uranium weaponry was used as much or more in the Iraq war as it was in 1991. If it was a serious cause of health problems, they would have shown up in the current study. They did not.

Speaking as a former tanker, I'm relieved. I never worked with DU rounds, but the effectiveness of DU -- both as protection and weapon -- is not something I would give up lightly. Even if they posed a health threat, I'd be willing to accept a slight increase in long-term health risks in exchange for surviving the war. It just doesn't make sense to increase your odds of dying now by 10 percent in order to reduce your odds of dying 30 years from now by 5 percent. If you want to live forever, don't volunteer for a combat branch of the military.

depleted uranium, health, Iraq, politics, midtopia

Contraception: The new abortion

Researchers using federal data have found two interesting trends that chart the relationship between abortion and contraceptives.

Between 1994 and 2001:

1. The rate of unplanned pregnancies rose by 30 percent among poor women. The abortion rate also rose.

2. The rate of unplanned pregnancies fell 20 percent among affluent women. The abortion rate also fell.

Asked what was driving the trends, the authors noted that some state and federal reproductive health programs have been cut or made more restrictive in recent years. State and federal programs have increasingly focused on abstinence rather than contraception, and some analysts have argued that the shift is leading to less use of contraceptives and more unintended pregnancies.

(snip)

The authors said the growing disparities between richer and poorer women appeared to be the result of greater contraceptive use by the more affluent. The health statistics center, which is part of the Centers for Disease Control and Prevention, reported in 2004 that after decades of increasing contraceptive use, the trend stalled in the late 1990s and began to decline after that. The decline occurred almost entirely in poorer women.

Gee, imagine that. Reduced use of contraceptives leads to more abortions. Sounds like common sense, doesn't it? So why am I writing about it?

Because some people -- some relatively influential people -- disagree. Some Christian conservatives are starting to jump on the same bandwagon that Catholic groups have occupied for decades: life begins at fertilization, and anything that interferes with that is abortion. And they're willing to use laws and government regulations to force everybody to conform to their beliefs.

This weekend's New York Times Magazine had a cover story on the phenomenon. Some quotes:

"We see contraception and abortion as part of a mind-set that's worrisome in terms of respecting life. If you're trying to build a culture of life, then you have to start from the very beginning of life, from conception, and you have to include how we think and act with regard to sexuality and contraception." -- Edward R. Martin Jr., a lawyer for the public-interest firm Americans United for Life

(snip)

Dr. Joseph B. Stanford, who was appointed by President Bush in 2002 to the F.D.A.'s Reproductive Health Drugs Advisory Committee despite (or perhaps because of) his opposition to contraception, [wrote in] a 1999 essay: "Sexual union in marriage ought to be a complete giving of each spouse to the other, and when fertility (or potential fertility) is deliberately excluded from that giving I am convinced that something valuable is lost. A husband will sometimes begin to see his wife as an object of sexual pleasure who should always be available for gratification."

Here's what happened during the FDA's consideration of Plan B, the "morning after" pill.

After the agency's advisory committees voted in favor of over-the-counter status for Plan B at the end of 2003, and after it was further approved at every level of the agency's professional staff, standard procedure would have been for the Center for Drug Evaluation and Research arm of the F.D.A. to approve the application.

But one member of the F.D.A.'s Reproductive Health Drugs Advisory Committee had reservations: Dr. W. David Hager, a Christian conservative whom President Bush appointed to lead the panel in 2002. (After an outcry from women's groups, who were upset at Dr. Hager's writing that he used Jesus as a model for how he treated women in his gynecology practice, he was shifted from chairman of the panel to ordinary member.) Dr. Hager said he feared that if Plan B were freely available, it would increase sexual promiscuity among teenagers.

F.D.A. staff members presented research showing that these fears were ungrounded: large-scale studies showed no increase in sexual activity when Plan B was available to them, and both the American Academy of Pediatrics and the Society for Adolescent Medicine endorsed the switch to over-the-counter status. Others argued that the concern was outside the agency's purview: that the F.D.A.'s mandate was specifically limited to safety and did not extend to matters like whether a product might lead to people having more sex.

Meanwhile a government report later found that Dr. Janet Woodcock, deputy commissioner for operations at the F.D.A., had also expressed a fear that making the drug available over the counter could lead to "extreme promiscuous behaviors such as the medication taking on an 'urban legend' status that would lead adolescents to form sex-based cults centered around the use of Plan B."

In May 2004, the F.D.A. rejected the finding of its scientific committees and denied the application, citing some of the reasons that Dr. Hager had expressed.

The drug's manufacturer reapplied two months later, this time for permission to sell it over the counter to women ages 16 and up, seemingly dealing with the issue of youth. Then, last August, Crawford made his announcement that the F.D.A. would delay its decision, a delay that could be indefinite.

Note the outsized influence of anti-contraceptive advisors at the FDA, and the FDA's reaction when the stated concern (use by adolescents) was addressed.

Why the opposition to Plan B? The stated reason is that it is an abortifacent, on the theory that at least occasionally it prevents the implantation of a fertilized egg.

But since Plan B is simply a higher dosage of regular birth-control hormones, the same arguments could be applied to the Pill. And IUDs. (And breastfeeding, BTW). And never mind that many of these same groups also oppose other forms of contraception, like condoms and diaphragms. Or that this represents a moving of the goalposts in the abortion debate.

The story sums up the underlying issue nicely:

The conservative [viewpoint is] that giving even more government backing to emergency contraception and other escape hatches from unwanted pregnancy will lead to a new wave of sexual promiscuity. An editorial in the conservative magazine Human Events characterized the effect of such legislation as "enabling more low-income women to have consequence-free sex."

And that is relevant how?

Does effective contraception reduce the risk of pregnancy, and thus reduce a barrier to sex? Undoubtedly. But that's a personal choice, and nobody else's business. It's something to be addressed by education and persuasion, not legislation and regulation.

I have no problem with people believing that contraception is against their beliefs. I have no problem with people trying to persuade others to feel the same. But I have a big problem with using the regulatory process to try to impose those beliefs on others. If you don't want to use contraceptives, don't; but don't try to get them legally restricted so that others can't use them, either.

I also find this argument unpersuasive:

Rector says that abstinence programs can't properly be combined with other elements in a comprehensive sex education program because the message is lost when a teacher says: "One option you might want to consider is abstaining. Now let's talk about diaphragms."

If you can't make the case for abstinence compelling in context, then it's a weak argument. It's almost a "victimology" response to argue that information on contraception must be muzzled in order for abstinence education to be effective.

True, it may be a matter of emphasis. But I doubt most sex ed classes throw abstinence away as a one-liner. And if they do, the answer is to provide curricular guidelines. Spend time emphasizing the advantages of abstinence. Discuss the risks and downsides, from pregnancy to STD to social and mental impacts. Then say "If despite all that you're going to have sex, here's what you can do to reduce but not eliminate some of the risks."

And never mind that study after study has found abstinence-only programs to be ineffective.

The good news is that the people cited in this article still represent a minority view. The article mentions that 98% of sexually-active women have used some form of birth control. It also notes this, about sex ed:

A poll released in 2004 by National Public Radio, the Kaiser Family Foundation and Harvard's Kennedy School of Government found, for example, that 95 percent of parents think that schools should encourage teenagers to wait until they are older to have sex, and also that 94 percent think that kids should learn about birth control in school.

Exactly as I outlined above.

And a final statistical note:

Countries in which abortion is legal and contraception is widely available tend to rank among the lowest in rate of abortion, while those that outlaw abortion — notably in Central and South America and Africa — have rates that are among the highest. According to Stanley K. Henshaw of the Guttmacher Institute, recent drops in abortion rates in Eastern Europe are due to improved access to contraceptives. The U.S. falls somewhere in the middle in rate of abortion: at 21 per 1,000 women of reproductive age, it is roughly on par with Nigeria (25), much better than Peru (56) but far worse than the Netherlands (9).

I repeat: feel free to be personally against contraceptive use. But don't use the levers of government to force everyone else to conform to your beliefs.

birth+control, Plan B, abortion, contraception, politics, midtopia

Vitamins trouble pharmacist's conscience

Apparently some pharmacists in Seattle have moral issues with antibiotics and vitamins:

According to the complaint, someone at the Swedish pharmacy said she was "morally unable" to fill a Cedar River patient's prescription for abortion-related antibiotics.

(snip)

The complaint also includes an incident from November 2005 in Yakima, in which a pharmacist at a Safeway reportedly refused to fill a Cedar River patient's prescription for pregnancy-related vitamins. The pharmacist reportedly asked the customer why she had gone to Cedar River Clinics and then told the patient she "didn't need them if she wasn't pregnant."

As the same subject is debated here in Minnesota -- thanks to a bill sponsored by the ubiquitous Tom Emmer -- how far are we willing to go in allowing pharmacists to let their conscience be their guide?

With a few narrow exceptions, I don't think we should pass a law compelling all pharmacists to dispense every single medication customers demand. By the same token, I don't think pharmacists should have special legal protection for refusing to do so. They're free to refuse, and their employer is free to fire them.

The exception I see is those rare cases where, for instance, it's a small town with only one pharmacy and no competition for fifty miles. Even then, mail-order prescriptions would solve most of the problem. But there will be times when a patient needs medication right now, and they should be able to get it. If it comes down to a choice, a pharmacist's conscience does not trump a patient's health or well-being.

A hat tip to Moderate Left for the initial link.

Minnesota, pharmacists, politics, midtopia

Massachusetts tries health insurance for everyone

The Massachusetts legislature has passed a bill requiring everyone in the state to buy health insurance, much the way car insurance works in most places.

Under the bill, the state would offer subsidies to private insurers to cover more low-income families. Companies with more than 10 workers that don't offer health insurance to their workers would pay $295 to the state for each worker, money that will be used to subsidize the health insurance of others.

Something to watch; it's one of several models of universal health care being bandied about. This is one of the most market-oriented ones. And being pushed by Mitt Romney, a Republican governor in a blue state. If it works, it could find national support -- and could fuel Romney's presidential aspirations.

For a more comprehensive take on health care, here's what I wrote a few weeks ago.

Romney, health insurance, health care, Massachusetts, politics, midtopia

Expensively mediocre health care

A new study in the New England Journal of Medicine found that, contrary to conventional wisdom, every American -- regardless of gender or ethnicity -- gets roughly equal routine medical care.

Other studies have shown evidence of racial disparities in treatment, and this study doesn't totally refute those. There are still disparities in access to some kinds of specialized care, and the methodology doesn't really address barriers to seeking care in the first place. But once people sought care, they were treated generally the same.

The real kicker, though, is that that the care was rather uniformly mediocre.

The study ... found that though there are some disparities, the world's most affluent health system fails to provide all patients with optimal care at least 40 percent of the time.

"Differences exist, but they pale in comparison to the chasm between where we are today and where we should be," said chief author Dr. Steven Asch of Rand Health and the Veterans Affairs Health Care System in Los Angeles. "No matter who you are, it's almost a flip of the coin as to whether you get the care that experts want for you."

We spend more money per capita on health care than any other nation on earth. And what do we get? Mediocrity.

There are many things wrong with our health-care system beyond the skyrocketing costs. Most reimbursement systems end up giving bizarre incentives to health-care providers, driving up overall costs. And it simply makes no sense that the cost and quality of health-insurance coverage depends on one's employment status. Not only is that bad policy from a public health perspective, but increasingly it is a competitive disadvantage to American businesses and a barrier to hiring, constricting employment and economic growth.

It is time we seriously considered alternatives.

People talk about health-care rationing, but the alternative to rationing is exploding costs -- which eventually leads to rationing by ability to pay. Perhaps exploding costs would be acceptable if we were getting top-of-the-line care for all that money, but we're not.

Should nationalized health care be on the table? Sure. I don't think it's the best alternative, but it's arguably better than the system we have now.

Worried about a huge new bureaucracy? Right now we're subject to a private medical bureaucracy instead of a government one.

National health care limits choice and results in long waiting lists for non-emergency procedures? Well, all systems have their problems. I just don't see the logic in trying to boast about our system and bash every flavor of national health care out there. None of the systems are perfect; they all represent different attempts to address the cost/benefit ratio.

Say what you will about national health care on an individual level, but on a macro level it seems to keep the population pretty healthy at reasonable cost. And it's not at all clear that waiting lists are an inevitable result of a single-payer system.

But rather than looking at the extremes, I think the more useful discussion would be "is there a combination that provides maximum choice while reducing costs appreciably?" And if we can de-link health insurance coverage from our employment status, so much the better.

I actually agree in large part with the Heritage Foundation on this, especially their assessment of the problems with the current system. We may quibble a bit on the details, but their system is workable and, with a bit of residual government involvement, equitable.

My solution would look like this:

Instead of employers providing insurance, they simply boost your pay by the current premium amount, and you go out and buy coverage yourself. Tax credits help ensure that the money is spent on health care, and that the very poor can afford health care. Future increases are left to the market: the cost of health care becomes just one more factor that workers consider when weighing a salary offer.

Medical costs would automatically become linked to performance, insurance products would become more closely tailored to individual needs, you wouldn't lose your insurance coverage when you lose your job (or be forced to change doctors when you switch jobs), and employers would no longer be locked into ever-higher medical premiums -- eliminating a growing barrier to hiring. Small businesses -- the engine of economic growth -- could compete for the very best workers who might otherwise go to large companies simply for the cheaper, better health coverage.

There would still need to be some government involvement, to ensure adequate coverage for people with very expensive medical problems that a true market system, without the "group" aspect of coverage, would lock out. There might have to be a law requiring that everyone have health insurance, much like we do with car insurance. But overall you'd have better coverage and better care without a new bureaucracy deciding what each individual medical procedure is worth.


health care, politics, midtopia

Terri Schiavo all over again

The Minnesota House will consider a bill requiring that "incapacitated persons" be provided with food and water.

The bill would create a presumption in law that a person incapable of making his or her own health care decisions would be given food and water. The law would provide for three exemptions:

• If food and water would not contribute to keeping the person alive or would not provide the person comfort.

• If the person had completed a health care directive explicitly authorizing the withholding or withdrawal of food and water.

• If there is "clear and convincing evidence that the person, when legally capable of making health care decisions, gave express and informed consent" to withhold or remove food and water.

What I fail to understand is why legislators think things like this are any of their business. If someone is incapacitated, those closest to them should make decisions regarding their care. Not the government, not me, not you. Nobody can plausibly claim to know the wishes of the patient better than those who know them best.

The exceptions don't address this. I've made it clear to my wife that I don't want to be kept alive if I'm ever in a Schiavo-like condition. But my health-care directive remains unfinished. Would my wife's testimony alone be considered "clear and convincing evidence" of my wishes? It sure wasn't in the Schiavo case.

The last thing we need in end-of-life decisions is more laws, more lawyers and more public nosiness. Leave such decisions to the family, except in cases where there is reason to believe that the family does not have the patient's best interests at heart. Litigate the exceptions, not the norms.


right to die, Schiavo Bill, Minnesota, Schiavo, politics, midtopia

Clearing the smoke over "partial-birth" abortion

The Supreme Court yesterday agreed to weigh the constitutionality of a ban on partial-birth abortion.

I generally steer clear of abortion topics because they're almost always pointless. You either think it's okay or you don't. If you're a moderate the issue tends to be where to draw the line, but even then the lines don't move much.

But the bloviating over this case threatens to obscure the underlying facts. So I'll do my best to lay it out.

WHAT'S AT STAKE
The claims: Pro-lifers will have you believe they're trying to put an end to a horrifying procedure that kills thousands of babies every year merely for the mother's convenience. Pro-choicers will have you believe that if we restrict this procedure, it's only a matter of time before abortion itself is outlawed.

The facts: Late-term abortions (not all of which are "partial-birth" procedures) are exceedingly rare. In 2002 there were 1.5 million abortions. Only 320 occurred after the 26th week of pregnancy. There is not an epidemic of heartless women killing their babies at the last moment. Conversely, restricting this procedure will not significantly harm abortion rights.

MEDICAL NECESSITY
The claims: Pro-lifers say there is no medical reason for the procedure. Pro-choicers say there are times when it must be used.

The facts: The case filings are full of testimony from doctors and patients outlining why late-term abortions are medically necessary. On the other hand, pro-lifers may have a point if they argue that there are alternative procedures that achieve the same medical end without the gruesomeness of partial-birth.

THE LANGUAGE OF THE BILL
The claims: Pro-lifers say they are trying to outlaw a particularly gruesome and unnecessary form of abortion. Pro-choicers say they prefer that the procedure be rare, but that the definition of "partial-birth abortion" in the bill is so broad that it could outlaw procedures used as early as the 12th week, and there is no exception for the health of the mother.

The facts: Well, the claims are the facts in this case. But the bill's sponsors need to make sure the language is specific enough that it only affects the procedure they describe to the public. Otherwise it's a bait-and-switch. And there's no reason to exclude a "health" exception, since that exception was very clearly required by previous Supreme Court rulings. The bill's sponsors were picking a fight.

So in the end, the debate isn't about whether partial-birth abortion is a good thing or not. It's about how the term is defined and what exceptions the law should recognize -- for a procedure used in less than 0.02% of all abortions in this country.

Sensible people would carefully define the term and allow a "mother's health" exception. But sensible people are in short supply in abortion arguments.

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abortion, partial birth, supreme court, politics, midtopia