Health Bill Should not Pit Women against Seniors

The health care issue is, one would think, too important for partisan games pitting one group against another. Especially when huge portions of each group are one and the same. But as Robert Pear and David M. Herszenhorn report in today’s New York Times, that seems to be happening.

In a day of desultory debate on sweeping health care legislation, senators appealed to two potent political constituencies on Tuesday, with Democrats seeking additional medical benefits for women and Republicans vowing to preserve and protect Medicare for older Americans.

The Democrats’ first amendment, offered by Senator Barbara A. Mikulski of Maryland, would require insurers to cover more screenings and preventive care for women, with no co-payments.

‘Women often forgo those critical preventive screenings because they simply cannot afford it, or their insurance company won’t pay for it unless it is mandated by state law,’ Ms. Mikulski said.

I met with my oncologist two days ago and decided to have a mammogram. It’s been two years since the last one. She and I agree that, having had breast cancer in 2006 and breezed through a mastectomy, and being fit and healthy overall, my particular situation suggests the potential benefits — catch another cancer early, gain another good decade or so of life — outweigh the risks.  This is what the whole thing is about: every woman is different, every woman should be allowed to decide, with her doctor, on screening and preventive care. The Mikulski amendment will insure that can happen, whatever one’s age and circumstances.

The first Republican proposal, offered by Senator John McCain of Arizona, would strip the bill of more than $450 billion of proposed savings in Medicare. The savings would curb the growth of Medicare payments to hospitals, nursing homes, health maintenance organizations and other providers of care.

‘The cuts are not attainable,’ Mr. McCain said. ‘And if they were, it would mean a direct curtailment and reduction in the benefits we have promised to senior citizens.’

Senators said that debate on the bill, which embodies President Obama’s top domestic priority, would last for several weeks and perhaps continue into January. A vote on Ms. Mikulski’s amendment has not been scheduled but could come Wednesday.

The health care bill would require most Americans to carry insurance. It would subsidize coverage for people with moderate incomes, expand Medicaid and create a government insurance plan, which would compete with private insurers. The House passed a similar bill last month.

Ms. Mikulski’s proposal was prompted, in part, by the recent furor over new recommendations from a federal task force that breast cancer screenings begin later for many women.

The Senate majority leader, Harry Reid, Democrat of Nevada, hailed Ms. Mikulski’s proposal, saying: ‘The decision whether or when to get a mammogram should be left up to the patient and the doctor. That decision should not be made by some bureaucrat, a member of Congress or someone they’ve never met.’

As health costs and insurance premiums rise, Mr. Reid said, ‘more women are skipping screenings for cervical and breast cancer, and doctor visits that can catch problems like postpartum depression and domestic violence.’

Votes on the Mikulski amendment will show whether Republicans “truly want to improve this bill or just want to play games, stall,” Mr. Reid said.

Ms. Mikulski said her proposal would ‘shrink or eliminate the high cost of co-payments and deductibles’ for women who receive screenings for cancer, heart disease, diabetes and other conditions.

Senator Kay Bailey Hutchison, Republican of Texas, criticized the proposal, saying it would ‘allow yet another government agency to interfere in the relationship between a woman and her doctor.’

No, Senator Hutchison, the government isn’t interfering in my relationship with my doctor, nor will it do so by insuring other women’s choices and coverage.

Republicans argued that the bill would be paid for on the backs of older Americans.

‘We are receiving incredible and overwhelming response from seniors all over America,’ Mr. McCain said. ‘They paid all their working lives into the Medicare trust fund, and now they’re in danger of having $483 billion cut out of it.’

Mr. McCain’s proposal would effectively cripple the bill, because Democrats are relying on savings in Medicare to help offset the cost of providing coverage to more than 30 million people who are now uninsured.

This senior would like to add a word to that “overwhelming response” Mr. McCain reports. I paid all my working life into Medicare (which, by the way, was not exactly a gift to America from the Republican party) and I want a decent health bill more than I want every penny of my Medicare coverage protected.

A lot of us have come to terms with the fact that the health bill we may get is a long way from the health bill we so fervently wanted. We are still hoping that something survives the attempts to sink it at any cost.

Senators Pitch to Women and Elderly on Health Bill – NYTimes.com.

Doctors making house calls? An old idea whose new time has come

Could house calls make a comeback? It’s already happening. The University of California at San Francisco, for one success-story example, started the UCSF-Mt. Zion Housecalls Program in 1999 with a philanthropic gift. Its original goal was to teach medical students about home care, but with the exploding need for primary care for homebound elders it has evolved into filling that need throughout San Francisco — while still teaching the new generation about house calls.

In an article in the San Francisco Chronicle, staff writer Victoria Colliver details some of the many advantages that such programs have.

June Hagosian’s brain tumor has made it difficult for the 77-year-old San Francisco woman to leave her house in recent years, keeping her mostly confined to her bed.

For someone like Hagosian whose medical needs require frequent doctor visits, that would usually pose a problem. But because of a program run by UCSF, the doctor comes to her. She has had to leave her bright yellow home in the Richmond District to go to the hospital just three times in the past seven years.

“This program has been so wonderful,” Hagosian said during a recent home visit with her physician, Rebecca Conant, director of UCSF’s Housecalls Program. “I wish everyone could have it.”

Conant, who had just 15 patients when she took over the program in 2001, is one of five part-time UCSF physicians who spend all their clinical time outside the office, traveling from home to home visiting frail and elderly patients. Housecalls currently serves nearly 100 San Francisco residents and has an eight-month waiting list.The Housecalls physicians visit patients whose conditions make it so hard for them to go to the doctor’s office that they might otherwise put off seeking medical care. By then, they would be so sick they would need an ambulance and end up in a hospital emergency room. The program takes patients regardless of whether they have insurance or an ability to pay, which separates it from private practices that offer home visits as a convenience but at an added cost.

UCSF’s 10-year-old Housecalls Program is an old idea that has gained new traction. Both the House and Senate versions of the health reform bills contain proposals to examine whether home-based care improves the health of chronically ill patients and saves the government money by reducing hospitalizations and ER visits.”There’s no question there is both a medical need and substantial cost savings to the Medicare program,” said Constance Row, executive director of the American Academy of Home Care Physicians.

The Department of Veterans Affairs’ Home-Based Primary Care program, which has been operating for more than two decades, has showed a 24 percent reduction in costs for those patients, and some studies suggest savings as high as 40 percent, Row said.

UCSF’s Housecalls Programs operates on an annual budget of $300,000, almost all of which is devoted to physician salaries. That’s an average cost of $3,000 per patient, which does not include the cost of hospital care when needed. Medicare spends a national average of $46,412 per patient over the last two years of life, when patients typically have several chronic illnesses, according to researchers from the Dartmouth Institute for Health Policy and Clinical Practice.

But new technology – the ability to X-ray patients using portable machines, conduct blood tests and provide other services using mobile devices – allows doctors to offer a much higher level of care in the comfort of the patient’s home.

Conant, an associate clinical professor at UCSF, said she uses mobile devices to aid in her patient care, but she finds home visits offer other advantages like allowing her to see patients’ physical environments, meet their caregivers and better understand what kind of care they need.

“Not only does that improve medical care, but it’s based in reality,” she said.

The UCSF program is not the only home-based primary care program in the Bay Area. Kaiser Permanente, for example, serves some 370 members in San Francisco as part of its 13-year-old Community Care Program, which is handled by physicians, nurse practitioners and social workers.

Reinstituting and reinforcing in-home care, considering the significantly improved care for patients and the reduced cost to the taxpayer, would seem a no-brainer. But brains are losing out to politics a lot these days.

via UCSF program shows house calls’ time returning.

Skip mammograms, quit breast self-exams, and maybe lighten up on 'defensive medicine' while we're at it

All those mammograms, self-exams and dutiful attention to catching breast cancer at the very first sign? Forget it. Might even do more harm than good.

As summarized by Associated Press writers Stephanie Nano and Marilynn Machione late Monday,
Most women don’t need a mammogram in their 40s and should get one every two years starting at 50, a government task forcesaid Monday. It’s a major reversal that conflicts with the American Cancer Society‘s long-standing position.

Also, the task force said breast self-exams do no good and women shouldn’t be taught to do them.

For most of the past two decades, the cancer society has been recommending annual mammograms beginning at 40.

But the government panel of doctors and scientists concluded that getting screened for breast cancer so early and so often leads to too many false alarms and unneeded biopsies without substantially improving women’s odds of survival.

“The benefits are less and the harms are greater when screening starts in the 40s,” said Dr. Diana Petitti, vice chair of the panel.

The new guidelines were issued by the U.S. Preventive Services Task Force, whose stance influences coverage of screening tests by Medicare and many insurance companies.

But Susan Pisano, a spokeswoman for America’s Health Insurance Plans, an industry group, said insurance coverage isn’t likely to change because of the new guidelines. No changes are planned in Medicare coverage either, said Dori Salcido, spokeswoman for the Health and Human Services department.

Maybe, just maybe, a clearer look at breast cancer screening could be accompanied by a good look at a little of the other possibly unnecessary and extraordinarily pricey “defensive medicine” going on around the country. What a fine way that would be to hold down costs and save a lot of time and angst. In another recent article (November 5) published in the San Francisco Chronicle, Associated Press reporter Steve LeBlanc wrote of how the costs of “defensive medicine,” along with malpractice insurance and lawsuit awards, are adding significantly to the soaring costs of health care.

LeBlanc illustrates the issue with a story that rings sadly true:

Dr. James Wang says he tries to tell his patients when medical procedures aren’t necessary. If they insist, though, he will do it – not so much to protect their health as his own practice.

After being sued for allegedly failing to diagnose a case of appendicitis, Wang says he turned to what’s known as “defensive medicine,” ordering extra tests, scans, consultations and even hospitalization to protect against malpractice suits.

“You are thinking about what can I do to prevent this from happening again,” he said, adding that he did nothing wrong but agreed to a minor settlement to avoid a trial.

We have, LeBlanc explains, doctors battling malpractice premiums and lawyers saying malpractice suits discourage bad medicine — meanwhile, the costs of it all add up to some ten percent of health care expenditures.

We the public, healthy and sickly alike, are caught in the middle. Could we not somehow declare a truce? We’ll quit rushing to sue, lawyers back off from chasing ambulances, doctors go about the business of practicing medicine according to patient need rather than fear of consequences. Seems like a good idea to me, but I’m not holding my breath.

I’m also not having any more mammograms any time soon.

New advice: Skip mammograms in 40s, start at 50 – Yahoo! News.

End-of-life counseling stays in health care bill

Here’s a piece of very good news just in from Associated Press reporter Ricardo Alonzo-Zaldivar:

It’s alive. The Medicare end-of-life planning provision that 2008 Republican vice presidential nominee Sarah Palin said was tantamount to “death panels” for seniors is staying in the latest Democratic health care bill unveiled Thursday. The provision allows Medicare to pay for voluntary counseling to help beneficiaries deal with the complex and painful decisions families face when a loved one is approaching death.

The business of thinking ahead toward end-of-life decisions and making  one’s own wishes known through legal documents such as advance directives has long been encouraged by federal policies. But when coverage for talking things over with one’s doctor was incorporated into health reform it was quickly distorted by Republicans.  Sen.Charles Grassley led the successful campaign to strike it from the Senate bills. But saner heads have prevailed in the House.

“There is nothing more basic than giving someone the option of speaking with their doctor about how they want to be treated in the case of an emergency,” said Rep. Earl Blumenauer, D-OR. “I think the outrageous and vindictive attacks may have backfired to help raise awareness about this problem, which is why it’s been kept in the bill.” The legislation would allow Medicare to pay for a counseling session with a doctor or clinical professional once every five years. The bill calls for such sessions to be “completely” voluntary, and prohibits the encouragement or promotion of suicide or assisted suicide.

The counseling provision is supported by doctors’ groups and AARP, the seniors’ lobby. It was not included in health care bills passed by two Senate committees.

It’s alive! End-of-life counseling in health bill.

How public is your option?

Not very, in all probability.

According to current reports, only those whose coverage exceeds 12.5 percent of their income, only the smallest businesses, or those who aren’t covered by Medicare or VA programs… a very few onlies will have access to the public option. Still, the public option is less important than the reform bill itself. We may have reached the point at which the perfect is indeed the enemy of the good.

Early on in this process my friend Catherine Dodd, whose extensive health policy credentials include stints on Nancy Pelosi’s staff and as a Regional Director for the Department of Health and Human Services, advised an audience inundated with numbers and percentages and data to remember just one figure: “Nineteen point seven,” she said. It has taken an average of 19.7 years after one health reform measure failed to raise the issue again.

Many of us do not have another 19.7 years to wait for the next battle.

Boomers & the high cost of dying

As health reform slogs along, a few critical pieces are already gone for good — or for now, at least. One of the saddest is coverage for end-of-life conversations; one of the saddest elements of our culture in general and healthcare mish-mash in particular is the tendency to treat death as a curable disease. Timothy Egan, in a recent blog for the New York Times, makes an eloquent case for injecting a little reality into all this.

In the last days of her life, Annabel Kitzhaber had a decision to make: she could be the tissue-skinned woman in the hospital with the tubes and the needles, the meds and smells and the squawk of television. Or she could go home and finish the love story with the man she’d been married to for 65 years.

Her husband was a soldier who had fought through Europe with Patton’s army. And as he aged, his son would call him on D-Day and thank him – for saving the world from the Nazis, for bequeathing his generation with a relatively easy time.

That son, John Kitzhaber, knew exactly what his mother’s decision meant. He was not only a governor, a Democrat who served two terms in Oregon as it tried to show the world that a state could give health care to most of its citizens, but a doctor himself.

At age 88, with a weak heart, and tests that showed she most likely had cancer, Annabel chose to go home, walking away from the medical-industrial complex.

“The whole focus had been centered on her illness and her aging,” said Kitzhaber. “But both she and my father let go that part of their lives that they could not control and instead began to focus on what they could control: the joys and blessings of their marriage.”

She died at home, four months after the decision, surrounded by those she loved. Her husband died eight months later.

The story of Annabel and Albert Kitzhaber is no more remarkable than a grove of ancient maple trees blushing gold in the early autumn, a moment in a life cycle. But for reasons both cynical and clinical, the American political debate on health care treats end-of-life care like a contagion — an unspeakable one at that.

Kitzhaber, having seen the absurdities of the system — Medicare would pay hundreds of thousands for continuing treatments but not $18 an hour for an in-home caregiver to help her die as she chose — was among the thousands of us who were distressed to see the debate get sidetracked by misinformation and outright lies. He knows the truth: that changing the way we treat dying people is the only way real economies and compassionate reform will happen. He is not only a politician, currently running for a third term as governor of Oregon, the state that has shown us the way, but a physician. And he’s smack in the middle of the Baby Boomer generation. Egan cites the recent Newsweek cover article by Evan Thomas, “The Case for Killing Granny,” and its on-target line about this being the elephant in the room, “Everybody sees it, but nobody wants to talk about it.

John Kitzhaber, M.D., politician, and son who watched both parents die in a dignified way, cannot stop talking about it. His parents’ generation won the war, built the interstate highway system, cured polio, eradicated smallpox and created the two greatest social programs of the 20th century — Social Security and Medicare.

Now the baton has been passed to the Baby Boomers. But the hour is late, Kitzhaber says, with no answer to a pressing generational question: “What is our legacy?”

The Way We Die Now – Timothy Egan Blog – NYTimes.com.

Healthcare: Could We Get A Moral Commitment?

Is there a simple way to get universal healthcare in this country? In a word, yes. Or rather, in two words: moral commitment. If we were to make a moral commitment to what is, after all, only the fair, humane, equitable thing to do, author/reporter T. R. Reid told an audience at San Francisco’s Commonwealth Club today, there would be no problem.

Reid, a reporter for the Washington Post, documentary film maker and NPR commentator, was in town to promote his new book, “The Healing of America: A Global Quest for a Better, Cheaper and Fairer Health Care .” In it he tells the story of his journey around the world in the company of a painful shoulder, consultations about which were his introduction to personal encounters with health care systems of every sort. He also met with government representatives and policy makers across several continents.  It is an informative and highly readable (no pun intended, that’s just an appropriate adjective) book.

Reid outlined the four primary models of health care currently in existence on our small planet, each with different versions of who pays and who provides. In Britain’s socialized medicine model, health care is the government’s job and it does both. A “mirror image” of this plan is that put into place in Germany shortly after the country was established in the late 18th century, a “National Health System” in which the providers — doctors, clinics, etc. — are private but the payer — government — is public. Workers are covered through their employers. One advantage to both, Reid points out, is that everyone buys into preventive care. He told of British ads asking passersby if their feet hurt, and urging them to visit a podiatrist right away if so; “It’s free.” Or commercials featuring a coughing “Mum” and giving a phone number to call so a nurse may visit. “It’s free.” Each is aimed at diagnosing other illnesses early, and/or preventing the spread of disease.

The Canadian Medicare (that’s where Lyndon Johnson got the name for our elder care) system now copied by Australia, Taiwan and others would have had Reid waiting an long as a year for consultation and treatment of his shoulder. Although he proclaimed his pain to be a very present issue, it was not seen as an urgent need to the primary care doctor he consulted. It is this often extensive wait for non-urgent care that is most criticized (especially by Americans) about the Canadian system. But Reid got a Canadian answer to that. “We Canadians,” he was told, “don’t mind waiting, as long as rich Canadians have to wait as long as poor Canadians.”

The fourth model cited is the out-of-pocket model, which Reid illustrated with a story of climbing a mountain in Nepal to seek shoulder relief. At the top of the mountain, in an extremely simple one-room building with its four walls painted in four different colors, the doctor explained his payment was generally in whatever the patient could afford. Someone relatively well off might pay in funds, others in whatever they had. Many of the patients could pay only by painting the facility, the doctor said; they seldom had the same color of paint, and thus the many-hued room.

“We have them all,” Reid told a hushed audience: Native Americans and veterans have the British/NHS; over-65, the Canadian Medicare; working people, Germany’s system. But 40+ million Americans have medical care equivalent to Afghanistan or Angola, and tens of thousands of Americans die every year because they cannot afford medical care.

One audience member called Reid on that issue, saying hospitals were required to treat people who came to them, but he was not backing down. True, he replied, if someone is actively dying or about to give birth, hospitals cannot turn him or her away. But for cases (such as one cited at the beginning of The Healing of America) of lupus, or diabetes, or in countless other instances, the inability to pay for necessary care causes ongoing pain and death for thousands.

Other audience questions raised the illegal immigrant issue. In most countries, it simply would not be an issue, he said. Citing Britain as an example, he said “you get (care) whether you’re a citizen or not.” Reid also said the public option is a non-issue elsewhere, because “you don’t need it.” And he threw in another few illustrations that argue for reform: In Britain, you have to cover everyone, you have to pay every claim, and you have to pay every claim fast. In Switzerland, if a claim is not paid within five days, the next month’s premium is free. In Germany you have a choice of well over 100 insurance companies; if you don’t like one, you simply switch to another.

Having set out to answer the question of how other countries provide health care for all of their citizens, Reid said he then turned to the why. Why every other wealthy, industrialized, developed country in the world has universal coverage and the U.S. does not. Others have it, he said, because “they think it’s fairer, equitable, humane, just — and these are moral issues. Health care reflects a country’s moral values.”

It was clear that Reid, like most in his audience, sees the U.S. as having moral values. “If we had the political will,” he commented, “other countries could show us the way.”

But the author was pessimistic about the possibility of universal care coming out of the current reform efforts. Asked how it might somehow come to the U.S., he said it could well be the way Canada’s plan came about; “we might get it state by state.” The Californians listening might have taken heart. Twice that state has passed single payer plans, only to have them vetoed by their governor. Reid suggested that other states might also be ready to implement statewide health coverage.

As to his painful shoulder, its current status was not given. Presumably, it will be necessary to read the book to find out.

Health Reform Geezer Gap

At least one more old geezer — we are legion — is fed up with the Medicare generation getting all the blame for opposing health reform. James Ridgeway writes in his Unsilent Generation blog today that

This health reform debate is about substituting a phony intergenerational war for what ought to be class war – pitting the old against the young, instead of pitting the rich against the poor, or the corporations against the little guy. There WILL be cuts to Medicare, and everyone says this has to happen to keep Medicare from going bankrupt before younger people get to use it. But in fact, if pols were willing to cut the profits of insurance and drug companies, there would be enough for everyone–we could have Medicare for all.

Which does certainly cut to the chase. Ridgeway cites his own earlier writing that applied Dean Baker’s chutzpah definition to today’s economy.

The classic definition of “chutzpah” is the kid who kills both of his parents and then begs for mercy because he is an orphan. The Wall Street crew are out to top this. After wrecking the economy with their convoluted finances, and tapping the US Treasury for trillions in bail-out bucks, they now want to cut Social Security and Medicare because we don’t have the money.

I am still with President Obama on paying for reform through elimination of waste and fraud, though that’s obviously not going to happen overnight and not going to pay for it all by a long shot. But Medicare’s going to survive, as will most Medicare recipients although we are all terminal. The moments of truth will come when the bargaining is over and we learn what the trade-offs really cost. That is, whether Big Pharma and insurance industry negotiations trump the public option, and other details still near and dear to many hearts.

So many trillions, so many sectors looking to save their own skins — or their own trillions, as the case may be — can boggle the mind quickly enough to send Jane Q. Public desperately in search of simplification, and blaming a generation is easy. The Medicares don’t want to lose their benefits, the Boomers worry that there won’t be enough for them (a legitimate worry, in fact) and the people who need health care get lost in the shuffle. Ridgeway fills in a lot of blanks. Check it out.