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California Road Trip, Day 10, Los Angeles

Bob Wickline in Burbank

Winding our way up Tujunga Canyon driving to our host’s house, we ran into a bevy of emergency vehicles tending to a car that fell off a cliff.  While our host, Dr. Bruce Hector investigated the situation, I reviewed the events of the day.

Dr. Norm Castillo, from Corvallis-Oregon PNHP, and Dr. David Cantor, a retired local gastroenterologist joined us at the Burbank event.  Norm’s family has roots in Cuba and, though David said he was from Iowa, his swarthy, Latino appearance and accent, belied the truth that he immigrated from Argentina early in his medical career.

They both expressed dismay at health disparities that can be attributed, in part, to the injustices that naturally follow treating health care as a commodity.  One of Dr. Cantor’s first patients in this country, many decades ago, had been passing blood in his stool for over a year before he sought care.  Why?  No health insurance.  He recalls being shocked that the United States, the world’s richest country didn’t care for it’s people’s health care needs.  We still don’t and he was mad as hell.

Dr. Castillo spoke to our infant mortality rate, which in 2004, at almost 7 per 1,000 live births puts us at 29th internally (dropping from 12th in 1960) . More disturbing, the rate for Blacks is significantly higher for blacks than Whites.   For individual cities the discrepancy is especially startling.  In San Francisco the rate for Whites was 2.6, compared with 12.3 for Blacks.  In San Jose: 4.2 for vs. 10.5.  In San Diego: 3.5 vs. 12.7.  In Sacramento: 7.1 vs. 12.5.  In our nations capitol, DC, the rate for Black infant mortality is an embarrassing 17.5.

At the earlier event in Monterey Park, a somewhat heckling “reporter” tried to get me to agree to the statement, “We have the best health care system that money can buy”.  I wouldn’t go their.  More accurately, if you have excess wealth and you get very sick, the U.S. is a great place to receive high quality care.  However, if you are an average person, of average means, and you get very sick in our country, you will probably, though not certainly, get the care that you need.  In the process, you and your family will probably lose everything, just like 750,000 of your neighbors who went bankrupt last year because of health care costs.  Three quarters of them had health insurance when they became ill.

Dr. Hector returned from his accident investigation to report that we were unlikely to “get home” in the near future unless we turned around.  An hour later, in the wee hours of the morning, we sat comfortably sipping whiskey in his humble canyon abode.  Sometimes, getting home requires taking an alternative route.  The Patient Protection and Affordable Care Act is the road we are on today, but we need to find a different road to accomplishing affordable care for ALL.

–paul hochfeld

California Road Trip, Day 9, Santa Barbara

Santa Barbara Sunrise

By all accounts, last evening’s presentation in Santa Barbara was packed and powerful.  The “local” speakers were superb.  I wasn’t there.

By all accounts, last evenings presentation in Santa Barbara was packed and powerful.  The “local” speakers were superb.  I wasn’t there.   I rejoined the MAHD California road trip today, after three days at the American College of Emergency Physicians meeting in Las Vegas, where I was startled by the number of docs who hadn’t heard of PNHP.  There were a few (very few) talks of relevance to health reform, but I had the extreme pleasure of hearing ER Dr.Brent Asplin, from Minnesota, in a very well attended session, addressing the question, “How do we get VALUE for all the money were are spending on health care?”… and then go on to say, “The problem is cost.  The solution is organization”  He stresses, as a society, we will never get value for our money unless everybody is covered.  The cost of caring for people before they get sick is trivial compared to treating them after they fall into the ranks for the ill.

When a portion of the population isn’t “covered”, the hidden and not so hidden costs, both financial and social, to everybody are substantial.  Though he didn’t mention single payer, he appears to make a case that without an inclusive, real system, we will never find value and never control costs.  And how will we EVER find value while we literally waste 20-25% of ALL our health care dollars servicing the insurance industry that adds nothing to health and complicates the lives of those who actually care for you?

On the escalator, after the talk, I asked an older doc, even older than I, what he thought.  With great angst, he stated, “Whenever we mix money, politics and medicine,  we will get nowhere.  I used to care.  Now, I am just trying to finish my career.”  I identify with his despondency, but can we really afford to not care?

-paul hochfeld

California Road Trip, Day 8

Outside SLO Library

Sarcastic News Flash!!!  Insert tongue into cheek now.

Today we learned from our friends in San Luis Obispo that California has solved the problem of obtaining health care for their 6.5 million uninsured and their millions of underinsured!  Two days ago the Governator signed into law a bill that allows health care clinicians from out of state to come to California to provide free medical care, just like clinicians do in other third world countries.

This legislation was sparked by the group Remote Area Medicine who first brought their medical and dental teams to Los Angeles last year.  On the first day, they were overwhelmed as thousands of people lined up at their door.  Many of the people who showed up had insurance but had found that they still couldn’t afford necessary care.  Welcome to third world America!

But let’s get serious, the news isn’t all bad.  Our experience in San Luis Obispo is that this is a passionate community of physicians and health advocates.  We had lunch with 4 local doctors who wanted to learn more about single payer.  One doctor had spent the past ten months organizing a comprehensive free clinic for the community.

Our forum at the local library was attended by over 120 people who shared their caring and their stories with us.  One physician told us that he was happy to be employed by the state prison system.  The pay is good and he can focus on taking care of his patients without insurance company hassles.  He reminded us that prisoners cannot legally be denied necessary medical care, unlike those outside of prison.  He was able to spearhead an initiative to ban all tobacco products in the prison which resulted in a 40% decrease in referrals to cardiologists.  Oh the horrors of socialized medicine!

We need a health care system that is universal and promotes preventative measures to improve health, just like those in the California prison system.  We need single payer now.

California Road Trip, Day 8, Las Vegas

"The Strip"

Special report from Paul Hochfeld…

Since when is Las Vegas in California?  Explanation.  After the Santa Cruz event, I left the Road Trip for three days to attend the American College of Emergency Physicians meeting, in Las Vegas, where PNHP has a table among the other “exhibitors”.  Every so often, a supporter shakes our hands then shakes his/her head in agreement, “We didn’t fix it, did we?”  Occasionally, someone questions, “What are you selling?”  We explain the history and purpose of Physicians for a National Health Program.  Single payer supporter or not, every Doctor agrees that our sick care non-system is profoundly broken.

The Exhibit Hall

Vegas is surreal. The exhibit hall is equally surreal. Our humble PNHP table is surrounded by multi-hospital emergency groups (who charge local groups up to 32% for “management fees”), billing/coding companies, drug pushers, purveyors of a variety of software packages, and assorted medical gizmo manufacturers.

“Vendors” use every trick imaginable to seduce emergency physicians to ask about their wares.  Examples includes shapely ladies (of course), free ice cream serves by a ‘50’s era candy store owner, raffles, and plenty of other give-aways, including the usual pens, bags, candy, coffee, and water bottles.  The most insulting was the Elvis impersonator bedecked with sequins!   That’s the depths to which our sick care non-system has sunk.

Their shared goal is to “game” the system to maximize collections from patients and third party payer.  More revenue for providers translates into more money to share with those providing products and services to physicians.   Sadly, the complexity of dealing with fourteen hundred insurance carriers makes so many of these vendors valuable.  After all, health care is a commodity and the goal is maximum profits.

I rejoin the MAHD Road trip tomorrow night after our Santa Barbara presentation.  We will “lose” Margaret Flowers on Friday, but Carol Paris, also of Baucus Eight notoriety will join us for several presentations in the L.A. area.  We’re like a well oiled machine with replaceable parts.

California Road Trip, Day 7

The "Gates of Hell"

“ The evidence is conclusive that our people do not yet receive all the benefits they could from modern medicine. For the rich and near-rich there is no real problem since they can command the very best science has to offer…Among the majority of the population, however, there are great islands of untreated or partially treated cases…Although it is a principle of far-reaching and, perhaps, of revolutionary significance, I think there are few who would deny that our ultimate objective should be to make these benefits available in full measure to all of the people.”

This quote was spoken by Dr. Ray Lyman Wilbur, the first President of Stanford University, in 1932 and sadly it is still appropriate now. Today we traveled to Stanford to speak to faculty and medical students about P-PACA and Single Payer.

In defense of the political feasibility of P-PACA, but not really explaining its nuances or fatal flaws, was Dr. Arnold Milstein.  Out of only a handful of slides was a photo tribute to a woman he considers a “friend” and “smart and reasonable.”  The infamous Nancy Ann DeParle.  This is the same DeParle who earned $6 million from sitting on the boards of at least 6 companies that were targets of federal investigations, whistleblower lawsuits and other regulatory actions, and now is commonly known as Obama’s “Healthcare Czar.”  Dr. Milstein’s main point focused on the fact that smart people in Washington did the best they could.

In defense of single payer was Mad As Hell Doc Margaret Flowers. Her job was simple because all that she had to do was show the evidence of the failure of the market when it comes to health care and the evidence of the success of single payer. Margaret compared P-PACA to HR 676 based on 9 criteria such as universality, affordability, and sustainability and the striking differences couldn’t of been more obvious.

Following the presentations, the MAHD marched with local single payer advocates to the “Gates of Hell” in the Rodin Sculpture Garden where we expressed our anger at health injustice in this nation and our conviction to end it.

“Political feasibility” ignores true human suffering and continues to tie our sick care non-system to a sinking ship.  We just rearranged the deck chairs on the Titanic and think we’ll miss the iceberg.

California Road Trip, Day 6

Santa Cruz

Santa Cruz, Sept. 28

“We’re number 1!”  Not hardly.

During our “physician briefing”, prior to our Santa Cruz presentation, we learned that the Public Health Agency of Canada has published a travel advisory for, of all places. California, which is in the midst of the biggest outbreak of pertussis (whooping cough) in 50 years.   Because of four thousand cases and nine infant deaths, so far, this year, California is being treated as we treat underdeveloped countries, whose health care systems are primitive or otherwise failing, thereby putting travelers at risk.

How can this be?  Don’t we have the best health care system in the world.  Nope.  Number 37th actually.  Many health insurance plans don’t cover routine immunizations, many of which are recommended as for public health.  Isn’t PPACA going to change this by covering preventive care?  Nah.  It only applies to new/renewed policies and many older group policies will remain “grandfathered” which means that some provisions will never apply to them.  They will pay for a portion of expensive treatment, but not for prevention.  Their profits will put YOUR infant at risk by keeping whooping cough endemic in your community.

That’s why I call it a sick care non-system.

California Road Trip, Day 5

La Pena Cultural Center

Yesterday, Margaret Flowers joined us on the stage at La Pena Cultural Center and will remain with us through Santa Barbara.    As expected, the “standing room only” crowd was mostly the choir.  One might ask, “What’s the point?”   The choir is our best tool, but only if they get out of the choir pews.  Only by giving them (you?) the intellectual tools, insights and confidence to speak with friends, neighbors and communities we will be be able to educate those who don’t yet understand the subtleties of the single payer solution and why PPACA didn’t fix it.  We surely can’t count on Media to do this for us.

As an aside, en route to our morning event at Santa Clare Valley Medical Center, I visited a grade school friend and his wife, who recently underwent an outpatient “lumpectomy”.   The hospital bill, not including physicians fees, was $50,000, which will be discounted substantially for her insurance carrier, possibly to as low as $15,00   Without insurance, she would be expected to pay the full bill.   Of course, different carriers “settle” for different amounts.   Are there ANY other “industries” where different customers pay such drastically different amounts for the same services?  With everybody in the same risk pool, everybody would pay the same amount… and the average primary care provider would not have to spent more than $60,000 per year on billing services to navigate the chaos… as they do today.

California Road Trip, Day 4

Sept. 26

NEWSFLASH!!!!  Yesterday, the Associated Press released the results of a poll performed in partnership with the Robert Woods Johnson Foundation and Stanford University that confirms what Fox has been telling us.  It’s true that 60% of Americans are NOT supportive of the Patient Protection an Affordable Care Act (aka P-PACA, Obama Care, Baucus Care, PeePee-Caca).  As it turns out, however, twice as many of those who don’t support it think it should have gone farther.  They believe we need more government involvement in health care care so we can have a real system that isn’t designed to service the insurance industry.  We are not alone.

On the road again…posts by Paul Hochfeld

Morning #1.  Willow Creek, Sept. 23.

On the road again…  Yesterday, we wound our way through the fabulous Trinity Alps to our host’s house near Willow   Creek, half way up the side of a mountain.  As the near-full moon sets and the Sun is about to illuminate the valley below, let’s call this Morning #1

Fittingly, the first phase of health care reform- PPACA (aka Obama Care)- begins today.  Is it good or bad?  Over the last few days, the Mad As Hell Doctors have explored this important question through a series of meandering email exchanges that resemble yesterday’s mountain roads.  Winding and harrowing.

Here’s our “party line”… Undeniably, PPACA does a few good thing that are beneficial to a few people, but overall it further entrenches Health Insurance Industry by subsidizing their flawed product with more tax dollars.   We still don’t have anything resembling a real system, with true universal and equal access to care.  Rising costs remain a cancer to our economy and, without question, some of your neighbors will continue to suffer unnecessarily because of financial barriers to care.  We can do better.

Morning #2, hosted in the wooded hills behind Arcata, the Hippie Capital of the West.

Last evening, our event at the Bayside Grange drew an enthusiastic audience of over two hundred who, I hope, learned something that they can share with their friends and neighbors.  Since, it’s apparent that we can’t count on Major Media, it up to YOU to take the discussion to your communities, either one-on-one or in small gatherings.  It’s OUR job to make sure you have the tools to answer difficult questions about Single Payer health care.  Isn’t that Socialism?  What about choice?  How can we afford it?

The easy answer to the last question is “We can’t afford not to do it!”  Consider all the money we are now spending on health care as our “health tax”, as do just about all the other industrialized countries.   That’s over $7,000 per capita.  By putting everybody in the same risk pool, getting rid of the 1,400 middle men (insurance companies) that don’t add anything to our “health”, we can save 20-25% of the total.   With those savings, we can accomplish true universal access and make sure everybody gets the care they need when they need it… instead of wandering into our emergency rooms in critical condition costing ALL of us more money in our sometimes futile attempts to “save them”.

We’re all paying for everybody anyway so why don’t we create a system to reflect it!

Morning #3.  Santa Rosa, Sept. 25

Before leaving Eureka, Philip (dwarfed by the tree) and I shared a couple of beers with a dear friend and his grown son who own the local concrete/gravel company.   Of course, the talk turned to health care.  By their accounts, like other small businessmen, virtually, every time they interface with the “government”, whether dealing with environmental regulators or marketing/supplying their products to local, county or state governments, they find waste and workers who have little regard for the efficiencies they cherish in the private sector.  I can’t argue with their experience, yet I explain that the laws of supply and demand are upside down in health care.  The suppliers (that would be doctors) dictate demand by the tests/interventions that we order.  Furthermore, unlike any other industry, we are all paying for everybody anyway and the for-profit private health insurance industry is a middle man that adds NOTHING to the quality of the product (health) while adding 20-25% to total cost.  My friends “get it”, but when it comes to discussing the solution, they go right, embracing smaller, less intrusive government, while I go left, to a single payer system managed by those charged with the well being of all of us, aka government.

The following day, en route to Santa Rosa, I stopped briefly to gawk at the Redwoods, where it occurred to me that without government regulations, all of the large groves would eventually disappear into lumber for our decks.  Isn’t it the responsibility of government to reign in the self-serving urges of private (and corporate) interests, who have a long history of profiting from plundering the planet while leaving the REAL cost of repairing their damage to all of us?  It may be a stretch, but so it is with health care.

The for-profit private health insurance industry spends a lot of money dividing us into risk pools: Medicare, Medicaid (MediCal), the Vets, Employees of large/small companies, and Individuals with/without previous medical conditions.   Using taxpayer subsidies, they profit from being the middle man in the care of those who are least expensive, while the government (that would be the taxpayer) pays for the care of those who are most expensive … the old, the sick, and the disabled.   The taxpayer gets screwed again while corporations manipulate the political process thereby ensuring their continued profits.

By simply putting everybody in the same risk pool, we could save a substantial amount of money which would give us more resources to care for everybody.  Who administers the risk pool?  That would be the single payer.  The government.  Can we trust them to do it?  Wait, wait.   “Them” is “we”.  We trust the government to run the post office, we have cheapest postal rates in the world, and they never lose a package.  The VA Health System gets better results that the community, has high patient satisfaction, and does so at less cost.   Virtually every other developed country of the world has some form of “single risk pool”… and they get better results at half the cost.  In the meantime, United Health Care spends “our” money on very slick, expensive television ads try to convince you they are more concerned about YOU than their profits.

Back to my friends, throughout the (late) evening, we laughed, listened, agreed to disagree, caught up on family stuff and looked forward to our next opportunity to verbally spar, while sharing our friendship.   Respectful conversations with those who don’t yet share our insights are crucial to the “cause” of single payer.  Don’t be afraid to talk to those who aren’t already part of the choir.  Are we going to change their minds?  Probably not in the short run, but we’ll have fun trying.

Going Dutch?

The following is a response to recent questions about the new health care legislation’s potential benefits.  Mad As Hell Doctor Sam Metz provides a brilliant comparison when presented with this query:  ”Because the Netherlands and the U.S. have an individual mandate and use for-profit insurance companies to finance health care, can Americans expect to enjoy the same cost-effective results as do the Dutch?”

Almost every industrialized country providing universal cost-effective health care follows three rules:

1.     All citizens are in a single risk pool with a single schedule of benefits.

2.     Cost sharing to patients is minimal.

3.     Financing is provided by regulated, not-for-profit agencies.

There are three exceptions among industrialized nations. The US violates all rules. Consequently, we rank last on almost every measure of public health while spending twice as much as our average industrialized colleague.

The Netherlands (and Switzerland) comply with 2 ¾ of these rules. All citizens are in a single risk pool with a single schedule of benefits. Cost sharing is minimal. Financing is provided by regulated agencies. However, for-profit companies are allowed to compete with not-for-profit companies.

But the other two rules still apply in the Netherlands, making this brand of competition repellant to American insurance companies.

  • Insurers must sell at the same price to all applicants, regardless of age, sex, or health.
  • Just to be sure there is no cherry picking, the Dutch government taxes companies with healthier patients and subsidizes those with sicker patients.
  • All policies must include a comprehensive schedule of benefits at a regulated price. Companies compete on service only.
  • All policies have low deductibles and minimal out of pocket costs.
  • Administrative costs are low, 5%, compared to the US costs of 15% to 20%

It is not only the Dutch insurance companies that operate differently, consumers do as well.

  • All residents must buy insurance. No excuses.
  • Failure to pay the required premium may precipitate a tax on the offender’s salary, disability benefits, or retirement income.
  • Specialty care can be obtained only through primary care referrals.

What does this ostensibly competitive market look like? The top five plans in the Netherlands have 82% of the market. Most insurers still operate at a loss in hopes of gaining market share later. And 75% of health care is funded via the government. In the US, the figure is 45% and there is outcry about “socialized medicine” and “government rationing.”

It is quite the imaginative stretch to say our new health care bill puts us on par with the Dutch system.

Remember the three rules. The US has a long way to go before we can claim to be “going Dutch.”

References:

http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf

http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Jan/The-Swiss-and-Dutch-Health-Insurance-Systems–Universal-Coverage-and-Regulated-Competitive-Insurance.aspx

http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2009/Jan/The%20Swiss%20and%20Dutch%20Health%20Insurance%20Systems%20%20Universal%20Coverage%20and%20Regulated%20Competitive%20Insurance/Leu_swissdutchhltinssystems_1220%20pdf.pdf