June 29, 2009
The Real Health Care Issue
The Economist has an interesting piece on The benefits, and the costs, of living longer. Part of it is a look at health care:
[A]s a rule of thumb, the bulk of spending on an individual’s health care is concentrated in the last year or two of life, and particularly in the final six months.
This leads, especially in the U.S. to some rather stupid rationing. Ron Beasly at the Newshoggers explains this well with a personal case:
My 86 year old mother is in really good health but had started to be short of breath. They ran some diagnostic tests and discovered she had a bad heart valve. She was referred to a cardiologist who was ready to split her chest open and replace the valve. I asked him several questions:
1. She is in relatively good health now – following the surgery will she ever recover to be as good as she was before? The answer was probably not!
2. I told the doctor that I heard that being on a heart lung machine can have a negative impact on memory and asked him if that was true. The answer was yes, especially in older people.
3. The next question was what will happen if the valve is not replaced? The answer was the shortness of breath may gradually get worse.
4. I asked him if it were his mother would he suggest the surgery? The answer was NO!
The bottom line is they were going to perform a procedure that would cost 50 thousand plus dollars that would have left my mother worse off after the surgery because Medicare would pay for it.
At 63 years of age I cannot get health insurance at any price. I am denied procedures that could keep me alive for another 20 or 30 years while Medicare pays for procedures that add little or even have negative impacts on the health of the patient. That's rationing and foolish.
My father was treated to death in a hospital where he was kept alive for three month with dialysis, which with a clear mind he had earlier rejected, while it was simply obvious that he was slowly dying.
A hospice where he could have died without pain and with good care would have been a tenth of the costs than the therapy to death provided to him. The saved money could have been used to provide better care for younger people.
The society must come to a better sense with the inevitability of death and stop spending money on people who are certain to die soon despite high-cost procedures.
Aging societies with negative birthrate like most of Europe and Japan will otherwise ruin themselves.
Countries like the U.S., which by a systemic failure provides full health care to elderly while denying it to its younger productive people, will cripple their population.
There are sound reason why health care insurance in the future will have to be public. As the private insurance providers get more sophisticated about their customers (DNA tests etc), they will not take any risky person at all but provide only to those who are expected to pay more in than they will get out. That isn't insurance, in which by definition risk gets distributed unevenly, but robbery.
The U.S. as well as other countries needs universal health-care provided by a public system. But that is not the only issue.
The real central issue in health care and the single most effective way to limit health care cost is to accept death as a natural occurrence and to stop to prolong live it at all costs by medical means.
Unfortunately the discussion about that are still missing.
Posted by b on June 29, 2009 at 02:27 PM | Permalink
i take this personally
i am also vehemently opposed to any form of eugenics. the idea is repulsive to me morally
practically though, i am not so far from death - with a very destabilised diabets 1, with the likelihood of other heart attacks, & now with the possibility of cancer
i'm in my fifties. i am not hungry with life. indeed i lived with a more volatile death for a very long period of time. the medicines that keep me 'healthy' are very expensive, & will require on the very near future expensive surgery. morally, i feel i have given a very great deal to french society & the health care i receive (which has been fought for on the streets & on the shop floor) is a form of recompense for that work. i still feel i have a great deal to give though it will depend on a semi permanant relation with health care
i feel it is the right of everyone - for me it is is the most basic justice - health care & there is in most cases a social service even in being treated - in my case the permutation of my sicknesses is the basis of research by the two professors who are in charge of my care - hopefully that research will be of service to someone other than myself
so these two issues - the one of eugenice & the other - health care as a form of social justice & it is true to suggest each years the predators of capital take more from civil society than the many people who require health care
& as a social democrat, b - you are aware that it was class struggle that has won people that right
Posted by: remembereringgiap | Jun 29, 2009 2:52:46 PM | 1
The really sad thing is the bastards who try to play on your grief and despair, if they think you have money. I know my mother was able to make her wishes known, and I saw to it that she was not molested in the name of medical science. The doctors here in the US can be just as bad as administrators though, so what can you do? A living will, and organizations like Hospice will protect you if you or your family know about them, but so many people don't know or take the care they need to. I'm 48 years old, but my grave is already paid for (I've even danced on it) and my living will already written and witnessed.
Posted by: Jim T. | Jun 29, 2009 3:01:26 PM | 2
@r'giap - as a social democrat, b - you are aware that it was class struggle that has won people that right
Of course I am. I also would never deny good health-care to anyone with some serious chance of recovering to a multi-year future life.
Still we need to come to some sense of how much we put into the last month edge of old people. Like with my father and Ron Beasly's mother good care at that stage is very fine. Invasive medical therapy is not.
I know that it is a difficult issue to think and talk about. But resources are by definition limited. Does it make sense to let young ones die while keeping old alive?
Posted by: b | Jun 29, 2009 3:17:40 PM | 3
b, Victor Fuchs has been sounding this alarm for the last fifty years. In particular, I remember a book from the early '70's called Who Shall Live?
Posted by: alabama | Jun 29, 2009 4:04:17 PM | 4
This is a problem the US armed forces are facing: battlefield care is resulting in fewer fatalities but a higher percentage of wounded. Many of these are severely wounded, the ones who would've died of their wounds even a few years ago. And it is a lot more expensive to maintain a permaently disabled vet who survives combat wounds than to pay out a widow's pension.
Posted by: ralphieboy | Jun 29, 2009 4:11:21 PM | 5
My mother at age 91 fell and broke her hip, ended up with a surgery to repair the broken hip, which was successful. While in the hospital she was diagnosed with kidney failure, which was the cause of her fainting which had caused her fall. They wanted to do a cut-down, install a stint in the artery under her collar bone, and start her on dialysis. The nephroligist tried to guilt me into the procedure (as did my wife) and I flatly refused, and having mom's final directive in-hand there was nothing they could do. When I had finished listening to the pleas and guilt-tripping of the doctor, I asked him if he thought I had made the right decision - I was confident of what he would say and wanted to get my wife off my back, and he said "Absolutely."
Posted by: ds | Jun 29, 2009 4:28:32 PM | 6
B, I've been lucky, I still have 2 grandparents and knew a couple of my great grandparents. Fortunately none of their deaths were sad.
Perhaps I am a bit naive but I think we should be talking about this issue far more. Another thought provoking piece.
Posted by: scott | Jun 29, 2009 4:33:01 PM | 7
Here in the US, insurance companies are mostly fronts for unregulated banking. That's why they don't "distribute risk" in the form of payouts - they're not really in the insurance business.
Posted by: Jeremiah | Jun 29, 2009 4:36:13 PM | 8
I am with remeberinggiap. there is no reason why the car industry should be supported because it supplies jobs, but not the health industry.
b refusing health care is simple, but you have to fight hard to get the best you can get, and it is - as should be - a human right.
when access or rights start to be age based you will regret it the day you are old.
Posted by: outsider | Jun 29, 2009 4:42:14 PM | 9
it is quite simple for me - the 20th century was the century of those profiteers who pillaged & raped our world to the very last drop of sweat
this century should be the century of social justice, civil rights & equality of opportunity
in brief the rich must pay for a century of their crimes
Posted by: remembereringgiap | Jun 29, 2009 4:54:20 PM | 10
Global Health Equity
Don’t foolishly advise Paul Farmer that his bold projects can’t succeed. For the past 20 years, Farmer’s been toppling orthodoxies concerning the delivery of health care to people of developing nations, and to our country’s inner city poor. In a talk full of insights and anecdotes, Farmer brings his audience up to date on his groundbreaking work and methods.
"For me, an area of moral clarity is: you're in front of someone who's suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it, and you act". -Medical anthropologist and physician Paul Farmer and a recipient of the MacArthur " genius" grant for his work treating tuberculosis in Haiti.
Posted by: Uncle $cam | Jun 29, 2009 5:00:41 PM | 11
I too think that statistic of most healthcare costs are incurred in the last 6 months of life to be a bit dramatic. if you get sick before you die that is how it will work out. would it not be similar to that old saying about wearing seatbelts that most accidents occur within 20 minutes of home? If 99% of your driving occurs close to home, it is only logical that the accidents will happen there too.
cutting off care when you are a certain age sounds way too much like euthanasia and that scares the living crap out of me. I can just see some young doctor making the rounds with an eye on the bottom line putting people to sleep.
who gets to make these decisions? if it is the patient himself and it is done before hand and not when spaced out on medication I have no problem with it. all other options are open to fraud.
Posted by: dan of steele | Jun 29, 2009 5:03:39 PM | 12
you know the economist is a neocon organ, right? should we apply the same standard to you that you applied to juan cole?
Posted by: get a grip | Jun 29, 2009 5:37:12 PM | 13
get a grip, why dontcha !
Posted by: remembereringgiap | Jun 29, 2009 5:43:17 PM | 14
Bernard isn't the first to call Juan Cole out, nor will he be the last. This link says it all, imho.
Posted by: Jim T. | Jun 29, 2009 6:06:51 PM | 15
jim t, not the same issue.
rememberingeringgiap, i'm still waiting for your archival smackdown gems you were forever promising to resuscitate.
Posted by: get a grip | Jun 29, 2009 7:00:33 PM | 16
Every alternative offered to 'fix' healthcare has it's share of pitfalls. I have mostly lived in societies which have go to whoa cradle to grave free healthcare systems although more and more they are being amended and watered down in response to the sucking sound which is caused by the flow of knowledge and expertise into healthcare markets that are 100% economically driven eg amerika.
If a health system is to provide across the board care and not be in a position of training their experts only to see them go overseas chasing higher wages (or as the experts fresh out of the state subsidied training plan like to rationalise it "where my ability is respected") they have to allow a degree of privatisation to keep a range of experts.
But that is like being a little bit pregnant, that "degree of private health service" bullshit.
How can any health system survive providing across the board services when some experts (say psychiatrists) can only earn $80 grand a year and others (say eye surgeons) can expect an annual pre tax income of $4 million? Both train for the same amount of time, while the personal qualities required of either aren't identical, they are in equally short supply, sometimes, it could be argued that the personal requirements of the lower paid experts are in shorter supply than the requirements of the higher paid experts. Certainly that could be argued with psychiatrists compared to eye surgeons whose most lucrative procedure (cataract removal) is carried out by technicians in those countries not subject to the closed shop self regulatory regime that most western societies have allowed to evolve around their medical experts.
Put simply there is a race on right now, one where the outcome is by no means certain. The race for healthcare resources is between the bourgeois citizens of amerika and the health services of the rest of the world; whose ability to provide services to their citizens is being seriously compromised by a combination of a completely distorted medical expert labour market and the ludicrous intellectual property legislation which allows a corporation to charge hundreds of thousands of dollars to supply medication that only cost cents to produce.
Ironically in many cases the R&D costs of this expensive medication has been borne by the very socially owned healthcare systems who are now being held to ransom over drug charges. This because the model has become distorted by the insane free market theories of the loony neo-cons, whereby the cost of a drug isn't a factor of the cost of it's inputs (how much it cost to produce) but rather is a factor of demand (however much the market will bear). The consequence of that is thousands of highly (and expensively) trained scientists and experts devoting their lives to pills more likely to induce an erection in a white middle aged, middle class male while drugs to combat diseases which wipe out millions of poor and usually unwhite humans are ignored.
We probably imagine that the problem will end following the culmination of protests and social action by citizens of those countries whose health systems are being destroyed by the existence of the amerikan model, combining with the majority of amerikans who are getting buggered by their model as well.
Unfortunately the proponents of the healthcare industry have a different scenario one where amerikans without healthcare are marginalised to the point of nonentity while those other societies are riven by dispute between the older citizens suffering from a lack of basic health services and the younger members of that society angry at being forced to pay for the increasingly expensive and untenable healthcare.
In amerika peeps have to fight to keep their parents free of needless intervention whereas in other parts of the world the fight can be to ensure the parent isn't put down like an old dog past its use by date.
This is why I have always questioned euthanasia movements, they only ever seem to get any traction in states with public health systems which makes me really suspicious about the decisions in borderline cases.
The solution to limited health resources isn't some form of euthenasia, it is to separate healthcare priorities from economic priorities, and that is a big ask in most societies where it seems the dream of every parent is to have a son or daughter become a doctor. This isn't just about status, being a healer, it is also about economic security. Medical experts have become expert in manipulating community attitudes to ensure their incomes remain nearly inviolate, and it is that flaw in social perceptions which is ruthlessly exploited by the health industry to maintain their monopolies in virtually every organised society.
Old Fidel fell for the bs I know that Cuba has done a great deal of good around the world with it's plethora of medical experts, but it is likely that producing so many doctors has come at the expense of other equally important technocrats.
I don't have any experience with cuban medicine and I'm sure the experts are very likely quality carers, but after the collapse of the USSR, mobs of medical experts from behind the old iron curtain (where the numbers of medical experts were also considerably higher than found 'in the west') turned up in this part of the world (Australasia) and I have to say that some of them were dangerously inadequate, causing even higher rates of medical misadventure than the previous grossly understaffed hospitals.
But we have had some shockers from capitalist societies too, the most famous being an amerikan psychiatrist who was of a gender other than that stated, (which wasn't an issue - the personal deceit was), whose post grad qualifications and resume also didn't stand up to close scrutiny and who was appointed chief executive of mental health services for a big chunk of the country. This was a particularly amusing story unless you were a patient I suppose. If I could remember more of the details I would provide a link as it wasn't very long ago, although finding no longer current news is becoming increasingly difficult on the interweb (funny that! nah it's just a combination of circumstances nothing to see move along please sorry bout the digression)
So back to the point. the world's health systems are creaking from the stress caused by distortions arising from the crazy amerikan model but even though the solution is obvious to anyone with half a brain, the odds of these issues being resolved is far less certain.
Posted by: Debs is dead | Jun 29, 2009 7:23:44 PM | 17
rememberingeringgiap, i'm still waiting for your archival smackdown gems you were forever promising to resuscitate.
I see no where that r'giap offered to look them up FOR you, nor should he; especially, as your approach and disposition is quite indignant. He merely made mention that they are there should you decide to peruse them.
What is it w/folks whom waltz into communities and speak as if they had any kind of ascendancy or pre-eminence, often talking to others with an attitude of contempt. Mean spirited right off the bat... and then expect something other than reciprocity of same?
Posted by: Uncle $cam | Jun 29, 2009 8:51:28 PM | 18
it would seem we have had our fair share of them in these last weeks - enough to convert oneself to a certain form of monasticism. our real regard for each other creates considerable tension for these trolls - having to offer the kind of poor pedagogy (unfortuantely not the pedagogy of the poor(friere) that you have mentioned from time to time) -- that we are an "echo chamber", we are 'ideologues" etc etc - if only they knew, my dear uncle
Posted by: remembereringgiap | Jun 29, 2009 9:01:23 PM | 19
My only complaint about the hospice industry is that many employed in this industry, mainly the docs, like to think of themselves as almost God-like when it comes to predicting death among the dying. But the sad thing about it is that they score only slightly better than the average Joe Blow off the street at predicting when those who are dying are gonna draw their last breath.
From my experience in hospice, as opposed to critical care, I've noticed that for some unexplained reason many patients who are classified as dying or near death get a second wind after being weaned off of life-sustaining things -- anything from cardiopulmonary drugs all the way to food and water. For some unexplained reason, living on nothing but opiates coupled with lots of touchy-feely stuff often has a paradoxical effect on the dying, causing them to live far longer than the most wonkish Doctor Death around could have ever predicted.
But if those employed in hospice, mainly the docs, would view what they do as more of an art than a science, they'd stop putting so much damn weight on predicting death among the dying. Then again, if it's proven that hospice care isn't well-grounded in science, then the hospice industry would be at great risk of losing health care dollars from Uncle Sam. Needless to say, when it comes to the amount of available public funds floating around, the arts pale in comparison to the sciences. This may explain why hospice docs make it a top priority of theirs to fine-tune their so-called "scientific" skills at predicting death among the dying.
Posted by: Cynthia | Jun 29, 2009 9:02:32 PM | 20
in france, at least for me but i think not, the care & attention of the medical community which i have worked with since i was here & am now subject to their treatment, is quite extraordinary. their attention to details & their willingness to share & even form a partnership with the patient - i find humanity of the highest form. it is not machinal. it has a heart. it is an ideal republican institution. i remember jérôme's texts about his son & they too reminded me what a republican institution can be. certainly, as debs suggest - there are people here who would like to bring the american system but i can assure you every time it is touched here there are massive demonstrations in the street. it is evident then that i am not the only one who holds our health system here in high regard
Posted by: remembereringgiap | Jun 29, 2009 9:17:16 PM | 21
$cam #18 "Mean spirited right off the bat..."
Why do you assume they are new to these parts?
Just ignore the obvious trolls. Why is that so difficult a concept for so many of the regulars here to wrap their heads around?
There are message boards out there frequented by high school dropouts who would have learned in five minutes to stop directly responding to known troublemakers (even in cognito ones) and stop grinding everything to a screeching halt over obvious flamebait. We, on the other hand, have had the same circular meltdowns for years now every time one of the usual suspects decides to tweak a thread.
Makes a person wonder what the point of trying to hold down a conversation around here is when they are so easily derailed by something half-heartedly pulled out of the ass of a relatively small number of persistent and chronic attention whores.
Posted by: Monolycus | Jun 29, 2009 9:17:21 PM | 22
a large part of good hygiene is watching what you eat & cooking your own food or its cooked by someone likewise mindful. Over-medication carries a huge price. And the hospital is where all the germs are. And if I could, I would either grow my own food (from trusted seedlings) or buy produce from a mindful farmer.
Posted by: jony_b_cool | Jun 29, 2009 9:27:51 PM | 23
I don't sockpuppet, mono. But I do great parodies of your sensitive gongorisms.
That wasn't "me."
Posted by: slothrop | Jun 29, 2009 10:14:46 PM | 24
I agree with r'giap here. In modern societies, first rate health care should be given to anyone and everyone. Health care discrimination whether based on age or ability to pay is morally wrong. The health of a human being is about dignity and patient welfare, not cost analysis options.
Ron Beasly's personal story about his 86 year old mother's unnecessary surgery is a poor example. Unnecessary surgery with the added purpose of ripping off Medicaid is immoral and a crime. And why should such a surgery/prep/recovery costs be over $50,000 ? Costs in the medical field are so inflated that it has become a poor joke.
As a somewhat off-topic side story (and forgive me if I have told this before), when I had my gall bladder removed, the surgeon sent me a bill for approx. $6000. I asked him what if I paid cash instead of using my insurance company, what would it cost then? The price was reduced by 1/2 if I paid it myself instead of my insurance company. I similarly bargained with the hospital, anesthesiologist, etc. All reduced their bill significantly. I am self-employed and pay for my own health insurance. Many years ago, I took out a policy that offered a return of premium benefit waiver, where, after about 20 years, I am returned all premiums paid for what has not been collected. I have never collected on health insurance and am now ready to file to get all my premiums paid back.
Also, jony_b_cool makes some good points about personal health and hospital hygiene.
Posted by: Rick | Jun 29, 2009 11:54:38 PM | 25
How much is life worth? The $440 billion question
Tito Fojo, M.D., Ph.D., of the Medical Oncology Branch, Center of Cancer Research at the National Cancer Institute, in Bethesda, Md., and Christine Grady, Ph.D., of the Department of Bioethics, the Clinical Center at the National Institutes of Health, tackle the controversy concerning the life-extending benefits of certain cancer drugs and the extent to which their cost should factor in deliberations.
The authors illustrate cost-benefit relationships for several cancer drugs, including cetuximab for treatment of non-small cell lung cancer, touted as "practice changing" and new standards of care by professional societies, including the American Society of Clinical Oncology.
They ask, "Is an additional 1.7 months [the additional overall survival for colorectal cancer patients treated with cetuximab] a benefit regardless of costs and side effects?"
According to Fojo and Grady, in the U.S., 18 weeks of cetuximab treatment for non-small cell lung cancer, which was found to extend life by 1.2 months, costs an average of $80,000, which translates into an expenditure of $800,000 to prolong the life of one patient by 1 year. At this rate, it would cost $440 billion annually, an amount 100 times NCI's budget, to extend the lives of 550,000 Americans who die of cancer annually by 1 year.
Every life is of infinite value, the authors say, but spiraling costs of cancer care makes this dilemma inescapable.
"The current situation cannot continue. We cannot ignore the cumulative costs of the tests and treatments we recommend and prescribe. As the agents of change, professional societies, including their academic and practicing oncologist members, must lead the way," the authors write. "The time to start is now."
Of course another solution would be to end the patents and for the state to produce the meds itself.
Posted by: b | Jun 30, 2009 2:20:59 AM | 26
I'm surprised that so many here seem to be interpreting b's post as if he was saying that some people should be refused medical attention.
I perceive him as pointing out that people -- and doctors, in particular -- should be thinking more about the value of a shorter, happier life when compared against a longer (even much longer), miserable one.
Often, living longer and getting treatment are simply not the right choice. Sometimes, it's better just to accept that one's going to be dying and go on with one's life.
Certainly, if i had the choice of being hooked up to a dialysis machine, in a hospital, for three or four months of never getting out of bed, or retiring to a hospice or my own home to die in three or four weeks, i'd choose the latter.
I hate hospitals, i hate being confined in large, sterile institutions, and i will do everything in my power not to die in one.
Posted by: china_hand2 | Jun 30, 2009 3:32:04 AM | 27
I couldn't resist a comment about the awful self absorption of the other, that which appears to labour under the illusion that all negative references are to it. Which is particularly peculiar at present when so many others are also vainly attempting their petty disruptions.
Anyway since this bar is closing and it is unlikely we will bump into each other in the cloud, I thought I better say adieu here and now as I haven't sighted your nym in an age.
Posted by: Debs is dead | Jun 30, 2009 7:32:58 AM | 28
I say get-a-grip is also whazzizname is also Parviz and is also....
who the fuck cares?
Blah blah blah.
Posted by: china_hand2 | Jun 30, 2009 11:56:01 AM | 29
Thanks, Debs. I've been here, I've just been keeping myself out of the fray. Anyway... before the door closes, if we don't meet again, please know that your acquaintance has been very much appreciated. I wish you and yours all the best.
Posted by: Monolycus | Jun 30, 2009 12:03:55 PM | 30