Tuesday, February 21, 2006

Health Care Cuts- More Governors Hurt the Poor

My last 2 posts have dealt with my belief that the US Governors and a few former Governors need to lead with health care reform from "the bottom up" since the current Bush administration including Dr. Frist has no intention of doing anything meaningful and the Dems at the federal level, with some notable exceptions like US Rep. Jim McDermott (D-Wash) and Sen. Tom Harkins (D-Iowa) , are not yet stepping up to the plate despite the upcoming mid-term elections. Why? Where is Dr. Dean? when I need him?

In my previous posts I reference Gov Rob Blagojevich (say his name bla-GOYA-vich) from Illinois, Gov Tim Caine of Virginia, and former Governors Dr. John Kitzhaber (Oregon) and Richard Lamm from Colorodo as shining lights in an otherwise dark environment.

There is cause for some hope but my partners blog on Stayin Alive last Thursday set my optimism back as did an article I read from the Miami Herald on Sunday. My partner Cervantes reported in his post entitled "Department of How could I have missed this?" that after the vicious cuts last year in Missouri's Medicaid program by Governor Matt Blunt who, as a devout Christian, cited the cuts as "morally correct" based on his belief that taxes should not be raised. Also Cervantes learned that the Missouri legislature under Gov Blunt's leadership also voted to eliminate Medicaid entirely by 2008! What!!!! The "show me state" sure showed us how cruel a Governor could be.

Then I learned on Sunday that in the great state of Tennessee, faced with a $650 million shortfall to pay for his state's Medicaid program, Gov. Phil Bredesen cuts 191,000 low-income people from the struggling health plan.That action and other cost-saving measures outraged advocates nationwide, who accused the Democratic governor and former healthcare executive of endangering the well-being of the state's poorest residents.
Similar criticism has greeted Bredesen's latest move, which is unmatched anywhere in the country: Tennessee is the only state that won't pay to cover a widely used class of anti-seizure medications for 560,000 poor adult Medicaid enrollees. In addition, Tennessee is the only state that won't cover these people for eight other types of drugs -- including fertility and weight-loss medications -- that the federal government allows states to purchase under Medicaid.''This is a public health crisis as far as I'm concerned,'' said Beth Coleman, executive director of the Epilepsy Foundation of Southeast Tennessee in Chattanooga.

Also vulnerable under the coverage ban are poor, mental-health patients who use the drugs to treat depression, anxiety, panic disorders, insomnia and tremors. Benzodiazepines also help control muscle spasms in cerebral palsy sufferers.

Meanwhile back to positive news , former federal Secretary of Health and Human Sevices (HHS) Tommy Thompson made some bold proposals last week in my home town of Philadelphia. "Many businesses provide health benefits, but if businesses want to put a brake on escalating costs, they should advocate for health-care coverage for the uninsured" Thomson told area business leaders at a seminar last week organized by the Deloitte Center for Health Solutions.

Thompson's proposal: Just as states require automobile insurance, states should require all people to have health insurance, organizing those not covered at work into a group. The state would request bids for a low-cost, no-frills package and then use some earned-income tax credits to bring the cost to an affordable level, subsidizing where necessary.
Finally, the federal government should pass a reinsurance program that would cover bigger losses than usual in a small business' health plan. Minimizing risk would encourage small companies to provide health insurance to their employees, Thompson said.

Well, it seems that former governors and former cabinet members have the luxury of speaking some sense andshowing some much needed compassion on solutions to the health care crises that is denied all but the most courageous sitting pols. I wonder why?

Friday, February 17, 2006

Lamm (former Governor) is a Lion on Health Care Reform

I failed to reference in my blog post of Feb 15 on Governors and Health Care an extremely important pioneer again, another former Governor, Richard Lamm of the great Centennial State of Colorado-also called the “Highest State” (mountains not pot)

Gov. Lamm is former three-term governor of Colorado (1975-1987) and now serves as Co-Director of the Institute for Public Policy Studies at the University of Denver www.du.edu/ipps where he maintains a vigorous teaching and speaking schedule. A real maverick Lamm is a lawyer, accountant, and novelist (“1988”). Lamm demonstrated rare courage-and controversy- while as Governor in 1984 he spoke up about physician assisted suicide. He also probably was the first public figure to use the “R” word = Rationing of Health Care required by the realities of US demographics.

In 2003 Richard Lamm’s book on US Health Care was published The Brave New World of Health Care which reinforced his reputation as a recognized expert on US Health Care policy. In the book using extremely colorful but accurate language Lamm correctly concludes as many now have that our current US Health care system is unsustainable, unaffordable and inequitable. Lamm defines the problem for us including what he calls “living on the banks of the river -denial” such as huge unfunded liabilities we are leaving to future generations, and among other cogent observations the dilemma of what physicians want for their patient verses what society at large can possibly afford.(the individual good verses the common good-or "physicians serve their patients by spending other peoples money") An interesting section is “The Tale of Two Governors” where Lamm contrasts former Gov of Virginia James Gilmore who tried to intervene by requiring that a husband agree to re-insert a feeding tube to a wife in a vegetative state (Dr. Frist’s shameful game plan in the recent Schiavo case which received much national attention) verses the progressive policies of then president of Oregon’s state Senate Dr. John Kitzhaber who, in contrast to Gov. Gilmore, led the fight not to pay for excessive organ transplants under Oregon’s Medicaid law but instead use the dollars to maximize the coverage for medically indigent Oregonians.

Lamm’s Proposed solutions’ “Rebuilding the House of Health Care”

- Public Policy should pay for the statistically probable but not the clinically possible

- Managed competition geared toward correct the lack of purchaser power when individuals access the system empowering demand instead of supply side medicine

- Reducing individual expectations-overrating ourselves at the expense of others (the common good).

- Providing basic health care to all US citizens as good social policy through the legislature not through the courts as a “right”

-Expanding Health Care's Moral Universe-the imperative of rationing-tough choices between good and good

- Rethinking The Institutions of an Aging Society including rethinking entitlements, redrawing the ethics map, and controlling health care costs.

Richard Lamm closes his book by stating that the foundation of the house of health care is individual responsibility! (One would say almost a “republican sentiment”) He talks about ethics and duties of the doctor-patient relationship, the ethics and duties of the health insurance plan and the ethics and duties of the state and nation . And he makes the strong case that we do not necessarily maximize health by maximizing health care.

In my view Richard Lamm’s greatest contribution to this growing national debate was his early recognition of the imperative of rationing, intergenerational competition for health care resources, and the need for the nation to confront death and dying. In short, Lamm demonstrated enormous courage sometimes at great personal and political expense. Some call it backbone-I call it sheer courage- that of a lion!

Wednesday, February 15, 2006

Where are the DONKEYS on Health Care Reform?

We know where the Pubs are –no where-lost in time and space- But where are the Dems on Health Care reform? I recognize there is a lot of competition for the Health Care reform issue to get on the proverbial radar screen but it seems to me that progressive Democrats and Independents had better move without delay. We have only 9 months till the 06 elections and if these incumbent pols and hopefuls are reading the same polls I am the mainstream Dems are not saying enough about this issue either alone or as a minority party poised to become a majority.

One highly regarded health issues polling organization updated monthly-The Kaiser Family Foundation continues to report that, only after the war and the general economy, Americans say that health care is the most important problem for the Government to address. So why is it that the Dems aren’t yet feasting on this low hanging fruit?

Ironically the Dem party (DNC) is currently headed by a physician (Dr. Howard Dean) who is married to a physician who, when Governor of Vermont, made some tangible progress on Health care for Vermonters. That the kind of state where innovation can happen and Howard did it. Why we don’t hear much from him now on health care is a mystery?

The dethroned queen of US Health Care Reform Sen. Hillary Clinton (D-NY) mismanaged her first lady assignment in 1993 and since then has been like so many once burned an incrementalist rather than an advocate of bold reform.

I came to realize over the past few years that the creative players in this arena were not national politicians from any party but rather governors, former governors and in one case a former state senator who happens to be my friend.

Anyway while we wait for the formal Democratic position on Health Care from Dr. Dean and company let me commend you to the following.

Just inaugurated Virginia Governor Tim Kaine who delivered the less than energizing Democratic response to the recent Bush State of the Union Address (SOTA) referenced his own efforts, as Lieutenant Governor in Virginia, to provide health care for nearly 140,000 children who were not covered 4 years ago. In the SOTA response Gov. Kaine referenced a fellow Democratic Governor’s work on Health Care. It seems that Gov. Rod Blagojevich (D-Illinois)(say his name bla-GOYA-vich) believes that Health Care is a basic fundamental right and was successful in getting signed into law his landmark –first state in the nation- All KIDS plan that will provide every uninsured child in Illinois with affordable comprehensive health care coverage. In stark contrast to neighboring states this innovative Governor has also increased access to health care to not only children but Illinoisan Seniors through his “No Senior Left Behind” program and “I –Save Rx plan” the latter allowing Illinoisans to purchase american made pharmaceuticals from other countries for a fraction of the costs they would have to pay in the good ole US of A. Go Rod!

I proudly disclose that my favorite politician and friend is former State Senator from California John Vasconcellos who just retired from a legendary 38 year career in California state politics where he earned the title “Dean of the California State Legislature”. Perhaps known best nationally for his coverage by Gary Trudeau in the Doonesbury cartoon series because I guess his idea to promote legislation based on the concept of self-esteem seemed funny in the 1980s Well I wasn’t laughing then and I sure am not laughing now. John was and still is of course correct. A healthy self-esteem is indeed the basis for a healthy and vibrant society. After retirement last year John has launched a radical new vision of government know as his Politics of Trust Initiative which can be visited and explored on www.politicsoftrust.net .While all the details of the Health component of this initiative are not yet constructed John assures me that Holistic Health will be it’s centralizing principle. John says, that “each of us arrives with an inherent capacity for wellness and self healing with support from Holistic Health modalities as needed. I’m personally helping John and invite you to also.

My final recommendation to you comes from the Beaver state of Oregon whose state invitation motto is “we like dreamers”. In a bold move former Governor Dr. John Kitzhaber, who having served as Oregon’s Governor between 1995 -2003, announced just last month that he would not make a re-run at the Oregon governorship but instead chose to devote his life to his passion- Health Care Reform. Launching The Archimedes Movement (“give me a lever and a place to stand and I can move the earth”) Another physician-politician, Dr. Kitzhaber made significant progress on Health Care while in office but his current rhetoric and plans are much bolder and visionary in scope and reflect a genuine sense of urgency. He calls health broadly defined as “the first rung on the ladder of opportunity –the cornerstone of a democratic society allowing people to fully participate to be productive and to take advantage of the opportunities of upward mobility that lie at the very heart of the American Dream”.

These are not just platitudes. Dr Kitzhaber presents solid plans based on sobering social,economic and political realities.For example he projects a shocking $65 trillion dollar unfunded Medicare entitlement when the baby boomers retire while our congress is preoccupied with a 5 trillion dollar Social Security gap. He correctly states that Health care is the fastest growing cost for individual families and businesses eroding wages thus posing a significant barrier to economic stability and growth. He predicts freightening implications for the stability of the US currency since health care is rapidly becoming the single major driver behind our exploding national debt. Unlike many others, Kitzhaber is not an incrementalist but rather, recognizing we are rapidly running out of time, is calling for a Revolution “not of violence but of vision, not of arms but of ideas”. “This is a pending crisis of huge proportions",he says, "that demands immediate serious and bipartisan attention of the United Stated Congress”. He offers Oregon as bottom up pressure on the nation on this issue now.

Here are Dr Kitzhaber’s #3 specific objectives

-to strip down our current system to its bare bones so that we all can see and understand its contradictions and inequities=illumination

-to offer a straightforward vision of what our system should look like. Among the issues Dr. Kitzhaber is interested in is the expensive technology dedicated unnecessarily to inevitable consequences of aging. The failure of the free enterprise model of US health care which is based on "categorical eligibility" rather than universal coverage. While he is not endorsing a Canadian style single payer system he is proposing more “public” Medicine like public education as a social good.

-to describe a direct action plans to spark the kind of national debate we so desperately need

I strongly urge you to visit his new website at www.archimedesmovement.org for more details about this remarkable man and his vision.

I’ll close by saying “Go forth pols of all stripes. Your country is calling you right now. Affordable quality health care is important to all of us and our children and our grandchildren. We’re watching and waiting. Don’t even think of letting us down. That would simply be unacceptable" -ral

Thursday, February 09, 2006


Mr President- I am a Doctor but more importantly I am a citizen of a country that I love .I feel it is my patriotic duty, Mr. President, to insist that you cease your and Doctor Frist's cruel and draconian cuts in health care immediately.

Mr. President in your State of the Union Address (SOTA) just 9 days ago you stated and I quote "Our government has a responsibility to help provide health care for the poor and elderly and we are meeting that responsibility" Mr. President -Your actions this week strongly belie your words.

The Seattle Times reported yesterday that you signed a measure yesterday that trims Medicaid and Medicare spending over five years, but you said Congress must make bigger changes as baby boomers retire.The bill you signed aims to trim $39 billion out the of budget over five years, partly through small cuts to Medicaid, Medicare and student-loan subsidies.In addition, the budget proposal that you submitted to Congress on Monday for the budget year that begins Oct. 1 seeks to trim Medicare spending by $35.9 billion over five years.

The Washington Post reported on Tuesday that even the usually favored National Institutes of Health(NIH)-the nation's lead agency in the hunt for the causes, treatments and ways to prevent diseases -didn't get a raise, receiving flat funding of $28.6 billion. Account for inflation, and that's really a cut, argued Dr. Robert Eckel, president of the American Heart Association. In inflation-adjusted terms, Bush's budget would cause a nearly 10 percent drop in spending in medical research since 2003.Some NIH divisions will lose money: $40 million from the National Cancer Institute, and $11 million from the diabetes institute, at a time when Type 2 diabetes is skyrocketing. The NIH this year will spend $8 per American researching heart disease, the nation's leading killer, an amount the heart association decried even before spotting a planned $21 million cut for the National Heart, Lung and Blood Institute.

Some programs you proposed for elimination are those that families have intensely lobbied Congress to enact:
-Universal newborn hearing screening, a $10 million program that helps states provide those tests for poor families, usually administering them before babies leave the hospital. Detecting hearing loss early helps ensure that babies get appropriate services so they learn and develop properly.
-The largest study of U.S. children ever performed. In January, mothers-to-be were to begin enrolling in the National Children's Study to track 100,000 children from mothers' wombs to age 21 to see how the environment _ everything from mother's diet to toddler TV to pollution influences child health. Scientists hoped the first births in the study would point toward some preventable causes of such problems as premature birth, asthma and autism. Ordered by Congress and supported by both medical groups and the chemical industry, scientists already have spent $60 million in tax dollars preparing the study, with waiting lists of families hoping to participate.But NIH budget documents direct researchers instead to close the program down by year's end.

"This is an affront to America's children. It will really hurt children today and for decades to come," said Dr. Alan Fleischman of the New York Academy of Medicine, who chairs the study's federal advisory committee.

Mr President-The late Rev. Martin Luther King Jr. (whose wife's funeral you attended this week) said "Of all the forms of inequality,injustice in health care is the most shocking and inhumane"

Mr. President and Dr. Frist- I know we do not have unlimited resources to spend on health care but you are harming your fellow citizens right now with your actions despite your SOTA speech rhetoric. Most despicable of all are your actions against our nation's innocent children. Yet, Mr. President, I stand ready to help.

Tuesday, February 07, 2006

Waste not, want not . . .

This report in Health Affairs by Jonathan Skinner, Douglas Staiger, and Elliott Fisher is a pretty hard slog and won't help you wake up in the morning, so read it at your own risk, but it's definitely instructive.

They took a second look at some earlier analyses that had found that, while the average cost for treating Medicare beneficiaries after acute myocardial infarctions (that's AMIs, basically heart attacks in English) increased by $10,000 from 1984 to 1998, average survival increased by one year. So it looks as though the increased expenditure on new medical technologies is worth it. Most people would pay 10 grand for a year of life. However, it turns out that the relationship between spending in different regions of the country, and outcomes, is negative, i.e. the more spending on people with AMI in a given region of the country, the sooner they die. What gives?

I'll skip the complex analysis and cut to the chase: the improvements in life expectancy, which largely ended in 1996 anyway, are mostly due to inexpensive interventions: aspirin (yup, my old friend acetylsalycilic acid, known to the ancients) and drugs such as beta blockers and ACE inhibitors which are now available as generics. Immediate ways of restoring blood flow to the heart, using drugs or angioplasty, can also help where indicated.* But regions where the tendency is to spend the most had worse survival. One reason seems to be that in those parts of the country, people tend to see many different specialists, who aren't necessarily communicating with each other very well, so people get confused, contradictory, and uncoordinated care. The important takeaway lessons, in my view, which seem to be more or less those of the authors although they are less direct, are two:

  1. We can get as good, or better results than we do now by doing less, and spending less money, but we need to do things right;
  2. Just putting cost constraints on top of the present non-system won't work, because it won't necessarily lead to a more effective allocation of resources. We need a much better coordinated system, in which care is coordinated by doctors who know their patients and can keep track of their needs and the services they get; and standards for effective, appropriately conservative care based on evidence can be promulgated and followed.

The best context in which to accomplish those goals is universal, comprehensive, single payer national health care. That's what I say, anyway.

*Of course, heart attacks can be prevented by eliminating tobacco use, proper diet, exercise, emotional tranquillity, and all that good stuff, but that's for another day.

Sunday, February 05, 2006


As a doctor I have always believed that freedom was literally a health issue. By that I mean that people(s) who are free psychologically and politically literally breathe freer and deeper. Emma Lazarus's poem at base of The Statue of Liberty "yearning to breathe free" got me thinking about the topic many years ago. I haven't done exhaustive research on this topic but I am hoping among our readers you might point me to some studies. Anyway our freedoms are under attack right now. And many progressive bloggers for example fear being shut down or shut out economically. That is why I reposting Jill's post from her blog today on http://brilliantatbreakfast.blogspot.com. "Jill" raises questions about corporatiztion of the internet and the freedom of speech of bloggers. Here it is-
If you believe that blogs like this one are going to be allowed to continue forever, guess again. Because the internet is just another government-created program that conservatives and their corporate masters are looking to privatize. And once that happens, companies like Yahoo! and Google and AOL/Time Warner will decide what you see. It will no longer be up to you.Here's their first step:
Companies will soon have to buy the electronic equivalent of a postage stamp if they want to be certain that their e-mail will be delivered to many of their customers.America Online and Yahoo, two of the world's largest providers of e-mail accounts, are about to start using a system that gives preferential treatment to messages from companies that pay from 1/4 of a cent to a penny each to have them delivered. The senders must promise to contact only people who have agreed to receive their messages, or risk being blocked entirely.The Internet companies say that this will help them identify legitimate mail and cut down on junk e-mail, identity-theft scams and other scourges that plague users of their services. Thy also stand to earn millions of dollars a year from the system if it is widely adopted.AOL and Yahoo will still accept e-mail from senders who have not paid, but the paid messages will be given special treatment. On AOL, for example, they will go straight to users' main mailboxes, and will not have to pass the gantlet of spam filters that could divert them to a junk-mail folder or strip them of images and Web links. As is the case now, mail arriving from addresses that users have added to their AOL address books will not be treated as spam. Yahoo and AOL say the new system is a way to restore some order to e-mail, which, because of spam and worries about online scams, has become an increasingly unreliable way for companies to reach their customers, even as online transactions are becoming a crucial part of their businesses."The last time I checked, the postal service has a very similar system to provide different options," said Nicholas Graham, an AOL spokesman. He pointed to services like certified mail, "where you really do get assurance that if what you send is important to you, it will be delivered, and delivered in a way that is different from other mail."But critics of the plan say that the two companies risk alienating both their users and the companies that send e-mail. The system will apply not only to mass mailings but also to individual commercial messages like order confirmations from online stores and customized low-fare notices from airlines. "AOL users will become dissatisfied when they don't receive the e-mail that they want, and when they complain to the senders, they'll be told, 'it's AOL's fault,' " said Richi Jennings, an analyst at Ferris Research, which specializes in e-mail.As for companies that send e-mail, "some will pay, but others will object to being held to ransom," he said. "A big danger is that one of them will be big enough to encourage AOL users to use a different e-mail service."In a broader sense, the move to create what is essentially a preferred class of e-mail is a major change in the economics of the Internet. Until now, senders and recipients of e-mail — and, for that matter, Web pages and other information — each covered their own costs of using the network, with no money changing hands. That model is different from, say, the telephone system, in which the company whose customer places a call pays a fee to the company whose customer receives it. The prospect of a multitiered Internet has received a lot of attention recently after executives of several large telecommunications companies, including BellSouth and AT& T, suggested that they should be paid not only by the subscribers to their Internet services but also by companies that send large files to those subscribers, including music and video clips. Those files would then be given priority over other data, a change from the Internet's basic architecture which treats all data in the same way.This Tuesday the Senate Commerce Committee will hold a hearing to consider legislation for what has been called Net neutrality — effectively banning Internet access companies from giving preferred status to certain providers of content. The concern is that companies that do not pay could find it hard to reach customers or attract new ones, threatening the openness of the Internet.You can bet that these telecommunications companies will be shoveling huge amounts of cash into the campaign coffers of the Senate Commerce committee.

Wednesday, February 01, 2006

Bush Lays a Health Care Egg in SOTU speech

Our President ,as I suspected he would, laid a huge egg on health care issues last night in his State of the Union Address. If the democrats don't make an omelet and feast on this one they really are missing a huge oppotunity.

Mr Bush outright lied about advancing health care for the poor and uninsured. And he briefly rushed through a few issues like electronic medical records, health savings accounts and health insurance portability for those who switch jobs. (Later on in the speech the president did mention HIV and medical malpractice reform)

But Mr. Bush failed to address possibly the #1 issue that concern americans. Having Dr. Frist by his side all night just added to irony of the tragedy of failing to propose meaningful reform.

Remember. Our US Health Care System is rapid real-time meltdown.