Sunday, March 16, 2008

Here we go again . . .

Flame me all you want but I am here to make the point again: We Americans must do SOMETHING to guarantee access to health care for all, including those with preexisting conditions.

Dr. Terry Hamblin recently posted to his blog about problems with the UK's public health service, the NHS. (Follow this link and search for "Travails of the NHS.") He describes the messes that can be created when bureaucrats, including committees of doctors, attempt to decide on treatment without expert knowledge. If it were not so sad it would be funny: Terry quotes one doctor who read about CLL briefly and said: "I have been reading about this subject for two hours. I am now an expert in the condition."

What is the take-home lesson here? I think it is pretty clear: The best standard of care requires that doctors with (genuine) expertise in a given condition be allowed to make the decisions.

But a couple of
those who posted comments about Terry's piece drew another lesson, seen through the filter of their myopic glasses: "Cautionary tales such as this make me oppose national health systems being imposed in the US, " wrote one. "I'm not sure why there is such a hue and cry over the 'failure' of the American health care system when it is in many cases the envy of the world. . . . Changing to a bureaucratic-run system will be made at the peril of the patient."

Hmm. Somehow American veterans have managed to survive the bureaucracy at VA hospitals, and somehow elderly Americans have managed to cope with Medicare without keeling over in large numbers.

But those are asides. The essential point is this: The failures of bureaucracy do not mean that the US should not have a health care system that provides access to all. Access to health care is a moral issue independent of the manner in which it is instituted.

And bureaucracy is not the province of government-run care alone: We have all heard of -- and indeed, many of us have experienced -- cases in which bureaucrats working for health insurance companies in the US make ridiculous calls. They deny treatment, refuse to approve the right treatment, or reject an appropriate test. (Ask the family of Nataline Sarkisyan, or ask Hilary Skvov and then read this.) Indeed, the bozos making these decisions in the US often have no medical training at all; their job is counting beans. They could read about a given condition for two hours and still not know their asses from a hole in the ground, nor would they care. (A committee of doctors -- we should be so lucky!) In America, the fox guards the henhouse. The quality of our care may be excellent but getting access to it is another matter entirely -- even if you have insurance.

Ignorance is ignorance, be it in the public or private sectors. When it comes to patient care, doctors should be calling the shots. Coming up with a fair, workable system may be tricky but it is not impossible. We sent men to the moon, ferchrissakes. Americans want as much freedom of choice as possible, and as light a regulatory touch as possible, but they also want to be able to get the care they need. I have enough faith in my country to believe that we can finesse these matters and devise a system that works reasonably well for all.

None of this takes away from the fact that access to health care is a moral right in a civilized society. I will never forget the post I saw from a CLL patient who lost his job because of his condition and, having also lost his health care, was trying to combat his CLL with herbs. I am almost as sick and tired of those who use "bureaucracy" as an excuse to deny their fellow citizens coverage as I am of CLL.


Anonymous said...

Of course. Any civilized society worth its salt would not have medical care be just another consumer item. Our current system is disgusting. A friend's wife is a gynecologist and she has told me that she is unable to give what she considers to be an adequate annual exam to her patients because insurance companies don't pay enough for it - AND SHE IS FORBIDDEN TO TELL HER PATIENTS THIS FACT.

I'm not sure I agree that the quality of our care here in the U.S. is excellent, overall. Too much medication, too much surgery, too much isolation of the disease from the person as a whole.

Anonymous said...

I agree that "ignorance is ignorance, be it in the public or private sector" but having dealt with this ignorance on many levels as a physician for the last 33 years I am very wary of the "blind" push for a system of universal health care. If we aren't careful we'll end up with a much less worthy system.

I have taken care of numerous uninsured people for free over my career and have always considered that a moral responsibility of my position. In a bureaucracy I fear that that feeling would disssipate.

To date, the biggest problem that i've faced with such "pro bono" care has been getting the proper medications for people...though I have usually been able to cajole the drug companies to provide them. With a system of universal health care I fear that this mechanism will vanish and worry that people, such as you, David, may not be able to access such therapies as HSCT as they get "swallowed up" by the bureaucracy.

You simply can't comprehend how much money could be spent on health care, much of which could easily be argued as "necessary" which isn't utilized under the present system.

I was even careful with how often I gave my own children medications and allowed them to have tests when they were ill...let the system run wild and we may get a run-away train.

I enhave encountered situations akin to those described by Dr. Hamblin over the years, but usually have been able to finesse or bypass them.



David Arenson said...

The second commenter makes a valid point, that we should not throw out the baby with the bathwater.

I also appreciate the doctor's willingness to take on patients for free. Unfortunately, not all doctors share that generous approach. I think it is too much to ask the uninsured or underinsured to rely on charity. Nor is this fair to doctors, who deserve some compensation for their work.

I favor universal access to health care along the lines proposed by John Edwards, which maintains the private system while offering separate access through a Medicare style program. I do not favor doing away with the private option. And I agree that there needs to be better cost control -- certainly if we could stop burdening our emergency rooms with the uninsured, that would be a start. And I'll even hand the Republicans one: let's find a way to control the cost of malpractice insurance by placing some sort of reasonable limits on lawsuits.

As to people like me -- well, here I am, ready and willing to pay for good insurance. But no one will take me. I had trouble getting insurance BEFORE I was diagnosed with CLL. I was turned down for having had a squamous cell skin cancer removed four years before. This was hardly a major health condition.

And what did I end up with? Insurance through a state program for small businesses. I am ever grateful for it but it does not cover SCTs. And how can I get a SCT if I need one? Either by getting into a clinical trial or by moving to another state for the sole purpose of getting into a state-sponsored pool for sick people like myself -- which Arizona, along with a majority of states, does not have. Could I be any worse off under an Edwards-style system? Or in the UK? The answer, clearly, is no.

The system, as it is, is simply not adequate or fair. Everyone can see the wheels coming off. The last thing I want is a government bureaucracy dotting every "i" and crossing every "t" when it comes to determining who can have what treatment. But what I do want is a system that guarantees access to a reasonable standard of care for everyone. Maybe, just maybe, we Americans can come up with something even better than exists elsewhere. We're going to have to try, whether we like it or not.

Anonymous said...

This is the doctoer again (OH, my mother is so proud...):

I hear you, David, and agree that access is important for all so long as we can come up with a reasonable system. To do this will be a Herculean task and will necessitate an apolitical approach if that is possible, removing the influence of the lobbyists for insurance companies and pharmaceutical companies as well as the egos of various politicians on both sides of the aisle.

It is surprising to me, for example, how quickly the Democrats jumped all over Bush's suggestion to make health care benefits taxable when provided by employers while simultaneously providing a standard deduction for healthcare coverage which would be sufficient to pay for most people...especially those in the bottom half of the income scale. This was almost surely UNIONS AT WORK!

Those of us who must pay for our own healthcare must pay fully with post-tax dollars while those who have it provided with their employment effectively pay with pre-tax dollars, a patently unfair system which serves to drive up the cost of healthcare insurance and simultaneously penalizes those who must buy their own healthcare. No matter what you think of Bush you must admit that this proposal was a good one, even though it would hardly solve the entire problem. Nevertheless, partisan politics got in it's way and no progress was made.

If we allow politics to play a role in our healthcare system we risk devaluing it and getting less than we can afford so that a few can benefit more than most.

The Doctor

Anonymous said...

Priorities, priorities. We COULD have afforded national health care if: A) Saddam Hussein hadn't attacked New York City and we didn't have to go to war; or B)we didn't NEED to bail out Bear Stearns. Now that Iraq situation seems to be pretty much "fixed" (at least I don't hear about it much on the news), and Wall Street is happy again, I agree, we should devote our attention to providing health care to all Americans. Unless something more pressing comes along, like another moonwalk or martian flyby.....

Anonymous said...

There you go again...

At least (finally) you distinguish between quality of care and access to health insurance.

First of all, no one including the 20 million illegal immigrants can be refused care at an emergency room.

Are you going to extend taxpayer's money to everyone who can sneak into the country???

Most of your fellow left-wingers would! No wonder health care is so expensive!

Be forewarned, America. You are about to ruin your health care system, in pursuit of the liberal's dream of having big government run everything.

Do you want the DMV to treat your ulcer? That is what you will get.

I have a idea for you. Move to Mexico or Cuba and let that government give you CLL treatment. (Or even the UK, where rituximab, which you have used, isn't available, ever, for CLL.)

BTW, it is illegal for an employer to fire you because of your health status.

Anonymous said...

Your column is a crack-up! First you whine about how expensive and ineffective treatment is, then you whine that you can't get some insurance company to spend $1,000,000 on you!

I have no problem having the rich get better healthcare than the middle class or the poor. After all, they earned this money, they should be able to spend it on health care if they want! Don't you agree?

BTW, your boy Edwards is gone, gone, gone!

Anonymous said...

You Republicans are so full of shit that you should be using Preparation H instead of toothpaste. Sure, keep the government out of the marketplace, laissez-faire, let the marketplace make its own corrections. So why aren't you screaming about the government's artificially propping up companies such as Bear Stearns? It's downright unAmerican, is what it is. You are hypocrites, ignorant, or insane.

David Arenson said...

I see the right wing nut jobs are back again. As the doctor pointed out in his post, we have to somehow get beyond partisan politics to reform the health care system intelligently, and reform is coming whether you like it or not.

Emergency rooms are clogged with the uninsured, whether they are in the country illegally or not. There may be 12 million illegal aliens in the US but there are also 47 million uninsured US citizens. In October 2006 Marilyn felt a sharp pain in her abdomen at night while we were staying in the Phoenix area. We went to the ER at Banner Hospital in Mesa. It was a zoo. There were sick, moaning people laying on the floor of the waiting room, which was jammed to capacity. Some people said they had been there well more than 12 hours. It was such a potential cesspool of germs for an immune compromised patient like myself that we left. Now, of all those people whose conditions had gotten to the sick and moaning on the floor stage, how many could have avoided that had they been insured to begin with, and had their problems been dealt with before they got out of hand? Does it really make financial sense -- let alone moral -- to let these people develop festering problems that become more expensive to treat ?

As to the rich buying medical care -- so long as everyone is guaranteed access to a reasonable standard of care, if there are those who want to pay for something more, then I have no problem with it.

Two other points:

It may be illegal for an employer to fire you because of your health status, but that doesn't mean it doesn't happen. There are ways around these things.

I never "whined" about treatment being ineffective. As to expense, I was trying to address the need for cost control that earlier commenters had brought up.

As to insurance not covering me -- or not covering a host of people with prexisting or troublesome conditions -- well, I suppose we just ought to let insurance companies decide, right? In which case only the healthy will be covered, and the sick will be dropped from the rolls. Walk in those shoes for five minutes and tell me everything is peachy the way it is. . . . Oh, that's right, you don't give a damn about anybody else. That's a tenet of your philosophy.

Anonymous said...

David, this is "the doctor" again...Emergency rooms have been overcrowded cesspools forever. As a medical student in the early 1970's and as a trainee I could blame poverty or a lack of insurance, but this isn't really the case as I've practiced in an affluent area and most of the people clogging my ER DO have GOOD insurance...they just don't use medical care optimally and everything backs up.

Unless there are free urgent care centers and an incentive for primary care physicians to see people promptly and 'semi-urgently" the problem will not go away and may actually worsen with universal healthcare.

Education of the populace and incentives for PCPs to see people more promptly are the only possible solutions.

Your friend, the doctor

Anonymous said...

I just get a kick out of the left-wing crazies. They have no argument, so they resort to obscenities and personal insults!

How funny!

Conservatives are more mature and responsible (we are the ones that clean up the left-wing messes left after they are done mucking up the country). So we don't resort to such tactics.

Listen, I'm not a huge fan of Mr. Bush and in retrospect, we bit off a lot in Iraq. However, we were attacked by Islamo-fascists and we had no choice but to defend ourselves. Unfortunately, few elsewhere in the world want to do the heavy lifting, so we foot the bill.

Going beyond your insults, I will disagree with you that I don't care about anyone else. Anyone who knows me knows that's not true.

There are solutions to the health insurance situation that are short of socialization. Getting folks out of the ER that could be served by a walk-in 24/7 clinic is one, and that is being tried.

As you know, CVS, Walgreen's and other pharmacies are opening up clinics in some of their stores, and that's another solution.

The real 'problem' is that with MRIs, CT scanners, rituximab and the host of other, expensive, health care items, costs are high.

If we can every cure cancer as we've 'cured' CML, the costs will come down for everyone.

I just fear that innovation will disappear from health care because the government bureaucrats will spend the money earmarked for health care, on something else.

Please leave the insults out of this, OK David? I've not insulted you, have I?

David Arenson said...

I think the doctor makes an interesting point about urgent care centers and being able to see a doctor promptly. Perhaps there needs to be some sort of reward/incentive system for doctors and patients. This is exactly the sort of thing that needs to be considered when we start redesigning the system.

As to the last commenter, I don't mean to insult anyone. I get a little passionate on this subject, especially when someone dismisses my views as "whining." These are serious life-and-death matters to many millions of people.

But, hey, I think we agree on one thing: I also do not want to see innovation gone from health care. I want to see adequate spending on research. CLL is the example I know best and in that case the UK manages to be pretty innovative and it has both public and private care.

Some might argue that liberals get trapped in their own thinking but I would answer that conservatives do also: They seem to think that any requirement that people be provided with insurance/access will somehow cause the sky to fall.

The key to fair and reasonable reform is for all of us to leave our reflexive thinking at the door and try to work this out with an open mind.

Terry Hamblin said...

Providing health care is fraught with difficulties whether the mthod of providing it is insurance-based or taxation-based. It is so expensive that it must be rationed. In some countries it is rationed by cost in others by delay. Ideally, everyone would have access by need. Although cancer therapies are costly they are by no means the largest item on NHS budgets. Indegestion treatments are. PPIs are dished out like sweets to anone with a bit of dyspepsia. A paper in today's BMJ demostrates that it would be more sensible to do the tests to diagnose Helicobacter pylori and treat that with a mixture of PPIs and antibiotics and while suggesting that those who are negative for the test buy their own antacids over the counter at the pharmacy.

Educating the public to understand their illnesses and choose appropriate treatment would have a greater impact of health care than changing the system of paying for it. That's why the internet is so important.

If I could change one thing about the American system it would be to asign everyone a primary care physician and referral through hijm or her would be the normal route to a specialist.

David Arenson said...

Terry wrote:

"If I could change one thing about the American system it would be to assign everyone a primary care physician and referral through him or her would be the normal route to a specialist."

That is, in fact, becoming a fairly common practice under managed care (HMOs and PPOs -- Health Maintenance Organizations and Preferred Provider networks). This is the way my plan works. As a practical matter, my primary care doc will give me any referral I ask for (dermatologist, eye doctor, hem/onc). Some plans are more stingy and controlling with referrals and put pressure on the primary care doctors to minimize them.

Anonymous said...

In theory leaving referrals toPCPs makes a lot of sense if they are well-trained, available and responsive to patients needs.

In reality this is often not the case and in my specialty practice the PCPs too often treat the patients incorrectly and wait too long to refer them to our group. Once they've been around the block the Davy patients (who I at least try to educate) learn to call me directly.

A reviewer might say that I do tooany procedures, order toomany tests or use expensive drugs, but I feel that I try to provide the best Heath care possible...what a conundrum!

Your friend,

The doctor

Anonymous said...

I meant Davy not Davy patients

Anonymous said...

Savy not Davy!

Anonymous said...


Anonymous said...

Luckily two doctors who have a different perspective are posting on this topic. Somewho their words carry a lot more weight that this 'right-wing crazy' who is 'full of sh*t' as so delicately put by one of Dave's articulate and thoughtful compatriots.

The primary physician as 'gatekeeper' is how my HMO worked and is how my PPO works now. The specialist doesn't want to be bothered with unnecessary visits, so at least at the first visit on the matter needs to be through the primary care physician. I have no problem with that.

Let's throw away the nonsense put out by liberal organizations with axes to grind including the United Nations and self-promoters such as Michael Moore.

(The problem with the statistics is legion, and too involved to get into, but infant mortality is calculated differently in different countries, and America has many very rural areas such as Indian reservations that are very unlike England or Japan.)

The only 'real' problem is people who can't or won't buy health insurance.

The rest of the system is fine and I'd argue the best in the world. Dr. Hamblin may disagree with me, but I do have some pride in my own system.

I've also had excellent care of my incurable cancer. The only thing I'd ask for now is a cure!

David Arenson said...

"Davy patients?" I thought you were talking about me at first. . . .

Actually, this has turned out to be an interesting discussion of a contentious topic. Obviously there are some sharp disagreements but I am learning something here as I hope you all are.

The last commenter did say something I must disagree with: "The only 'real' problem is people who can't or won't buy health insurance."

Alas, one of the many real problems is insurance companies that will not cover people with preexisting conditions and have no incentive to. These people are left at the mercy of whatever care they can scrounge.

Another problem is that insurance is simply too expensive for the working poor and much of the lower middle class -- ever read "Nickeled and Dimed"? -- people who make too much to qualify for public care (if available) but who cannot afford to pay today's premiums.

Another very real problem is costs. Premiums rise to cover expenses and even then cannot do so. The cost of medical care is not a left or right issue and somehow needs to be addressed. I'm willing to consider intelligent suggestions, no matter which side of the spectrum they come from.

Certainly one approach to reform -- though it does not sufficiently address the cost of providing care -- is the Massachusetts-style plan, also being considered in California, that requires insurers to insure everyone, establishes subsidies for those who have trouble paying, and requires everyone to purchase insurance. I have no objection to this approach in principle, it is a step in the right direction and better than nothing.

There are many ways to skin a cat. I am for whatever is the most workable so long as everyone is covered.

Anonymous said...

Once again, I am reminded of this: "In America, health insurance is a great thing until you get sick."
What makes this such a volitile discussion? Pride in America? We can be proud but also we should tweak the areas that need to improve. I am afraid that health insurance needs more than "tweaking". I have great insurance, but then I don't have cancer. I am not thinking about me, myself and I, but all our citizens who can't afford health insurance. As for the person who wrote about the fact that any person could cross border's and go to the emergency room to get treatment----Why is that so offensive to you? At one time I think we were called-"Land of the Free"....bring me your tired.....etc. The first American's to hit this land were illegal aliens to every Native American here. but, they fixed that. They killed them.

"Give Me Liberty or give me death" Now it is, "Give me health insurance or I will die."

Grateful said...

One of the anonymouses said:

>> First of all, no one including the 20 million illegal immigrants can be refused care at an emergency room. <<

In the US, this is correct only for emergency care, and only until the patient is stabilized, no matter how much more medical care the patient requires. The law governing this is called EMTALA, and a quick google will find some good explanations.

As a doctor noted, ERs are often clogged with people, many of whom do not need emergency care but have no where else to go due to a lack of health insurance. Many of these people are refused care at ERs, although only after wasting valuable ER resources because the ER must determine whether or not they need medical care.

Other times, ER visitors receive only enough care to stabilize them, not to resolve their medical condition.

Grateful said...

Hmmm....I should have previewed my entry. I meant to say the ER must determine whether or not they need EMERGENCY care and not just medical care.

Anonymous said...

To the person who posted, 'why does it bother you that anyone can sneak across the border and receive free medical care?'

I'll tell you why! It's my money they are stealing.

America is a fairly well-off nation, but we are not wealthy enough to supply American-quality care to every last person in the world, all 6,000,000,000 of them.

It is unfortunate that many people in the world do not have high quality of care, or even adequate medical care. That is not my problem.

If every country in the world had a functioning democracy and s relatively free economic system, they could have decent health care. But do we have to 'nation-build' every dictatorship in the world? I think not. We couldn't afford it if we wanted to. Besides, there is so much opposition to a Republican president fighting a war, we'll have to wait until a Democrat gets elected before the chattering class will suddenly find their patriotism.

As to the ER versus long-term care, yes, that is correct. It is also true that Medicaid, the healthcare system for the poor, provides healthcare for legal residents of this country.

I do applaud innovated, cost-effective solutions to healthcare (and other problem areas) concerns. One is the burgeoning growth of 'walk-in' clinics associated with hospitals and pharmacies.

I use one close to my house instead of going to the emergency room. The cost is magnitudes cheaper and I get a doctor's opinion as to whether I need to go to the ER or not.

As far as the Massachusetts program goes, the latest news is that there are even more cost overruns as the program is spending far more than was projected.

Sound familiar?

'We can't save the world' Sorry!


I am an American who was dx with CLL in Japan after living and working there for 14 years. I left Japan soon after my dx and still am untreated for CLL. My wife is Japanese and we may return to Japan simply for the security of their healthcare system: we arrived in fall of 2005 and through a friend I got a job that offered health benefits. I worked their for 14 months b4 moving on to a better job, again with healthcare benefits but was on COBRA for 3-4 months b4 I became eligible for healthcare. In August of 2008 I left that job for another and again went on COBRA. In December of 2008 1/3 of the company was laid off, just as I had paid my first health insurance premium. 3 months later I am still unemployed and am on COBRA I got from the 2nd job. Thank God I kept the COBRA as the last job had less than 20 people so was not eligible for COBRA (I am in Georgia).

Were I still in Japan my employment status would not matter; I would have coverage regardless. What a mess our healthcare system is. It is difficult to talk to Americans about it as they (we) are conditioned to believe from birth that we are the greatest country on earth so naturally everything we do is the greatest as well.