Paul Krugman: The Waiting Game

Paul Krugman straightens out some of the misleading claims made about health care waiting times, access to care, and other issues in comparisons of the U.S. to countries with universal health coverage:

The Waiting Game, by Paul Krugman, Commentary, NY Times [Full column]: Being without health insurance is no big deal. Just ask President Bush. “I mean, people have access to health care in America,” he said last week. “After all, you just go to an emergency room.”

This is what you might call callousness with consequences. The White House has announced that Mr. Bush will veto a bipartisan plan that would extend health insurance ... to an estimated 4.1 million currently uninsured children. After all, it’s not as if those kids really need insurance — they can just go to emergency rooms, right?...

Mr. Bush['s] ... willful ignorance here is part of a larger picture: by and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada.

The claim that the uninsured can get all the care they need in emergency rooms is just the beginning. Beyond that is the myth that Americans ... lucky enough to have insurance never face long waits...

Actually, the persistence of that myth puzzles me. ...Fred Thompson ... declared recently that “the poorest Americans are getting far better service” than Canadians or the British... [H]ow can they get away with pretending that insured Americans always get prompt care...?

A recent article in Business Week put it bluntly: “In reality,... the American people are already waiting as long or longer than patients living with universal health-care systems.”...

[T]he Commonwealth Fund found that America ranks near the bottom among advanced countries in terms of how hard it is to get medical attention on short notice... [and] is the worst place ... if you need care after hours or on a weekend.

We look better when it comes to seeing a specialist or receiving elective surgery. But Germany outperforms us even on those measures...

In Canada and Britain, delays are caused by doctors trying to devote limited medical resources to the most urgent cases. In the United States, they’re often caused by insurance companies trying to save money.

This can lead to ordeals like the one recently described by Mark Kleiman, a professor at U.C.L.A., who nearly died of cancer because his insurer kept delaying approval for a necessary biopsy. ... [T]here’s no question that some Americans who seemingly have good insurance nonetheless die because insurers are trying to hold down their “medical losses” — the industry term for actually having to pay for care.

On the other hand, it’s true that Americans get hip replacements faster than Canadians. But there’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare (yes, that’s what they call their system) because it has more lavish funding — end of story. The alleged virtues of private insurance have nothing to do with it.

The bottom line is that the opponents of universal health care appear to have run out of honest arguments. All they have left are fantasies: horror fiction about health care in other countries, and fairy tales about health care here in America.

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Previous (7/13) column: Paul Krugman: An Unjustified Privilege
Next (7/20) column: Paul Krugman: All the President’s Enablers

Comments

[S Brennan]

Clearly, to the "Poodle press",

______________________________

A lie a day,

keeps decent health-care away.

______________________________

[A Harvey]

I see specialty centers in Finland, Canada and Thailand are doing hernia operations and other routine stuff, undercutting the multimillionaire surgeons here. So Americans are actually traveling outside the country to get their specialty care, not for convenience, but for price.

[Lafayette]

Oh! Wow! Democrat gray cells may be exciting themselves?

From the NYT: New Economic Populism Spurs Democrats.

Will wonders never cease ... ?

[Lafayette]

PK: a professor at U.C.L.A., who nearly died of cancer because his insurer kept delaying approval for a necessary biopsy.

You must excuse me, but I've lived in France much too long.

You see, it is quite impossible to imagine (here) that an insurance should decide what medical treatment is necessary or not and when. If they do, then they must assume the legal consequences.

It is up to the GP to decide who gets what and when. If the GP is exaggerating (which has been known to happen all to often) at least the consequence is not dramatic. And, of course, they are risking their license to practice.

Whereas insurance companies, what are they risking? Apparently only their bottom line.

[Lafayette]

In case this was missed when posted elsewhere, from BusinessWeek: The French Lesson in Health Care.

An excerpt:
In Sicko, Moore lumps France in with the socialized systems of Britain, Canada, and Cuba. In fact, the French system is similar enough to the U.S. model that reforms based on France's experience might work in America. The French can choose their doctors and see any specialist they want. Doctors in France, many of whom are self- employed, are free to prescribe any care they deem medically necessary. "The French approach suggests it is possible to solve the problem of financing universal coverage...[without] reorganizing the entire system," says Victor G. Rodwin, professor of health policy and management at New York University.

France also demonstrates that you can deliver stellar results with this mix of public and private financing. In a recent World Health Organization health-care ranking, France came in first, while the U.S. scored 37th, slightly better than Cuba and one notch above Slovenia. France's infant death rate is 3.9 per 1,000 live births, compared with 7 in the U.S., and average life expectancy is 79.4 years, two years more than in the U.S. The country has far more hospital beds and doctors per capita than America, and far lower rates of death from diabetes and heart disease. The difference in deaths from respiratory disease, an often preventable form of mortality, is particularly striking: 31.2 per 100,000 people in France, vs. 61.5 per 100,000 in the U.S.

You see, France is not just famous for its baguettes ... its first hospital dates back to the 14th century. They've had, at one time or another, all sorts of health care means -- from private to religious to state.

The present one is the fruit of a great deal of experience in the matter.

[Cyrille]

I've got some good news for you: you can do a great deal BETTER than France.
Because, you see, in France we see a lot of problems with the medical system. We may have more hospital beds but we reckon we don't have enough, for example.
Still, many of the problems are tricky and have no easy solution, so here is one way to make sure you get better:

You could replicate the system with just one difference: how you manage the "numerus clausus". That is, the number of people accepted to medical studies each year.
This has been managed in a very short-sighted way. You see, in France we are appalling at being anti-cyclical. So that, despite the fact that those studies take around 10 years to complete, the number of students was almost always decided based on the situation at the time. There was a huge number of new medical students around 1968 and therefore too many doctors in France for years.

Guess what, they had a very low numerous clausus until VERY recently. When I started my studies, the message from my father (a cardiologist) had always been that there were too many doctors in most of the country and that some of them were making patients come back without need, something I would never do, so I never thought I would become one.

I've got some news: those 68 students will retire soon. Meaning that doctors either shorten their consultations, or (for those having a licence allowing them to do so) raise their fees. I am 31 now and had I chosen to become a doctor I would have an open road ahead. But not too many regrets: it would also mean being on emergency call 3 nights a week...

A higher clausus in the past 10 years would have meant cheaper and better care. So yes, France has a FAR better system than the US, but if you don't like it all that much, feel free to do even better, it's possible. If you allow for more doctors, that is.

[Lafayette]

Excerpted from the NYT article above regarding policy discussions amongst the chattering Dems, and good talking points: But the latest populist resurgence is deeply rooted in a view that current economic conditions are difficult and deteriorating for many people, analysts say, and it is now framing debates over tax policy, education, trade, energy and health care.

So, let's see what we've covered in Mark's thoughtful posting of past commentaries on these subjects:

1) Health Care - Amply discussed and the point of this present thread.

But, Hillary is not about to take on the AMA and a rabid K-street lobby - only to be savaged again in mid-campaign for the presidency. Nope - fool me once, shame on you; fool me twice, shame on me.

The health care system is so much a prisoner of vested interests, it will have to be rebuilt from the bottom up. And, it is so lucrative for those vested interests, I don't see its reformation being practicably possible.

Maybe this could work: For the 15 to 20% who are without health care, provide a separate clinic-based service for those who need it, that is totally financed from both state and federal budgets. Within this parallel system, practitioner and pharmaceutical prices are mandated. And, no patient is turned away or care procrastinated.

Watch this catch on - then expand it upward with a French style system (that is financed by employee contributions as well). Employees chose the system they want, employer (insurance) based or the alternative described here.

2) Education & Professional Training - Discussed very little actually.

Students graduate with an average debt of between 15 and 20K$, and I guess we figure its "par for the course" (after all, the brats are spoiled silly anyway ...)

The point is, university is NOT the only educational need. Only 33% of the American population has a university degree, so what about the rest of them? Education/training, as the body bags coming back from Iraq attest to, is NOT free, gratis and for nothing. Maybe it should be?

Professional training in selected areas of skill-set shortfall (nursing, for instance) is one proposition.

Giving low interest loans is one idea, but how about writing off the debt once the degree is obtained?

And, why not give stipends to those pursuing a degree/training that is identified as a key skill-set requirement (like, again, nursing - but certainly a host of others.)

3) Tax policy (aka Income Fairness) - Discussed at length in these forums over the past. Anything to add? Of course, there is ... marginal income taxes on the exaggeratedly high incomes. But, what does "exaggerated" mean, exactly.

Besides, the discussion are footnote-posts about "percentages" and how they are constituted. Percentages are the last question - the first is Why, then Who (income classes), How (which selection of taxes (progressive/regressive(VAT?)/flat) and, finally, How Much.

How about a provisional first-year budget estimate of a Democratic administration - where the windfall from a no-longer existing Iraq war is deployed elsewhere? It will show clearly where the revenues are to come from (bilk the super-rich!) and are to be expended (public services).

4) Trade - Uh, oh ... tricky waters. The US is binded into a treaty that make unilateral action a bit risky. Typically the issues of dumping and unfair trade go before the WTO. Hardly a "populist" venue, the WTO. The Dems can chatter about this all they want, but it is an international mind field - and the US is not coming from a position of solid admiration globally. (The US has profited HANDSOMELY from international trade for the past half century since WW2, and now they want to change the rules. That has NO hearing whatsoever as an argument outside the 3-mile limit.)

5) Energy - I've proposed a "Project Landing-on-the-Moon" type of program with considerable infrastructure renewal, that would be a modern "New Deal". For instance, since forsaking nuclear energy, we have sold our souls to OPEC (like the fools we can be) and they have us by the short & curlies.

So, putting smokestack scrubbers on the major polluters (oil-fired electricity generators) is one idea that will have a massive impact on reducing such pollution. New durable (non-carbon molecule based) energy sources, like government subventions for geothermic heating (available uniformly everywhere/everyday) is a new idea wildly fashionable in Europe. Windmill farms, but where - they are plenty noisy and an eyesore. Any other ideas? More so, any information regarding the "R-O-I" of durable energy sources?

And, what about staunching the flow of immigration. The Dems, after their recently Pyrrhic legislative victory in the matter, will need a viable response.

Any takers?

[anne]

"Being without health insurance is no big deal. Just ask President Bush. 'I mean, people have access to health care in America,' he said last week. 'After all, you just go to an emergency room.'"

What is interesting is that this has been the commonplace mean-spirited arch conservative refrain for several years, and it is never clear how such a refrain spreads so easily to become a commonplace among conservatives and why the mean-spirited quality does not quickly become too embarrassing to be continued.

There is a special courage and humaneness to Paul Krugman in continually pointing to such falsity and heartlessness.

[anne]

"The White House has announced that Mr. Bush will veto a bipartisan plan that would extend health insurance, and with it such essentials as regular checkups and preventive medical care, to an estimated 4.1 million currently uninsured children. After all, it’s not as if those kids really need insurance — they can just go to emergency rooms, right?"

Remember, because of Mark Thoma we have been able to repeatedly point to the intended sacrifice of American children that has been planned for months. I have repeatedly pointed to the budget for the coming year that will bring us another $44 billion in military spending, not counting spending for Iraq, while the President is battling to cut domestic social benefit spending preventing covering millions of eligible children with health care insurance.

The cost of health care insurance for millions of our children would be about $5 billion, as opposed to the the insane added cost for the military not including the cost of Iraq.

[anne]

http://maxspeak.org/mt/archives/003183.html

July 13, 2007

Mark Kleiman Kills The Waiting List Argument Against Single Payer
By Gar W. Lipow

Ezra Klein, Dean Baker, and a host of progressive bloggers over the years have given enormous numbers of statistical, and logical refutations of the idea that our system makes people wait less for treatment than single payer health. But one of things that makes Sicko so effective, is that Michael Moore is a story teller.

In that spirit, I think Mark Kleiman's story of how his own wait for health almost killed him pounds the "waiting list" argument into dust.

...I was diagnosed with cancer. I had fancy-dancy health insurance through my employer, which as it happens also owns one of the world's dozen best medical centers..
The diagnosis of cancer, based on symptoms plus the chest X-ray that should have been done several months earlier, was made very early in May. By then, I had dropped forty-some pounds, had almost no voice, couldn't walk more than 30 yards without puffing, and had a resting respiration rate of 20 breaths per minute.

But of course you can't treat "cancer." You have to treat some specific cancer. And you can't treat it until you figure out what it is.

That process took just about one full month, a month during which my chances of survival were dropping fairly steadily and the intensity - and therefore the side-effect profile - of the treatment that would be required if we ever got the damned thing figured out was rising in parallel. It would have taken longer- quite possibly fatally longer - if Al Carnesale, whom I'd known when we were both at the Kennedy School, and who by then was the Chancellor of UCLA and thus at some ethereal level responsible for both me and the hospital, hadn't sent a note to the guy who runs the entire UCLA medical area (hospital and medical school). The note politely hinted that it would be at least marginally preferable if my department didn't have to go through the hassle of recruiting a replacement. After that, things speeded up somewhat.

What absorbed that month? Mostly waiting....

[anne]

http://maxspeak.org/mt/archives/003183.html

July 13, 2007

...I was diagnosed with cancer. I had fancy-dancy health insurance through my employer, which as it happens also owns one of the world's dozen best medical centers....

After the chest X-ray, I needed to see an oncologist. I couldn't make an appointment until I had the approval of the insurance company for the referral. That took a few days. Getting on the oncologist's schedule took a few more days.

After the oncologist saw me, he wanted a bone marrow sample to send to the pathologists to figure out what the cancer might be. I couldn't make an appointment for the bone marrow procedure until the insurance company approved it. Then I had to wait for the bone-marrow extractor to have time on his busy schedule.

When it turned out that there wasn't enough marrow to test, I needed a lymph-node biopsy. More waiting for an insurance approval and more waiting for an appointment.

Having seen the head-and-neck surgeon who was going to do the biopsy, I couldn't have the biopsy right away because the insurance company wouldn't approve it as an in-patient procedure and there was queue for outpatient biopsy operating room time. Anyway, the guy who had seen me didn't have any time free on his dance card for the next several weeks, so he sent me to another surgeon to actually do the procedure.

When I showed up for the outpatient biopsy, the anaesthesiologist took one look at my chart and flatly refused to put me under for the procedure except in an in-patient setting, on what seemed like the reasonable grounds that otherwise I could easily die on the table. That meant, of course, more waiting for another approval and another appointment....

[Lafayette]

Interesting anecdotal evidence.

We know what the problem is, despite Republican smoke and mirrors. What's the solution?

More money? OK. Where? How?

More money into the present system is just going to end up in practitioners' pockets or corporate profits. That's the solution? Hell, that's part of the reason for the present mess!

(Anybody, watching "ER" -- that's what it is called over here -- KNOWS what the problem is. The program directors have hit gold by highlighting the mess.)

So, what's the solution? Come on, let's stop the moaning and start thinking. Pointing the finger never solved a problem - it just identifies the culprit.

Looking for the "quick fix" so we can go on to solve the next problem? No such thing, in this case. It's a long, complex way to an acceptable level of Health Care, so what's the first step on the road?

[anne]

"I can understand how people like Mr. Bush or Fred Thompson, who declared recently that 'the poorest Americans are getting far better service' than Canadians or the British, can wave away the desperation of uninsured Americans, who are often poor and voiceless."

No; I cannot understand the meanness and falsity. I simply cannot understand. I cannot understand how an increase in infant mortality through the South can be tolerated as Medicaid enrollments are slashed and services limited. I cannot understand how the governor of Georgia can tell a crying mother to call her congressman to complain about having her daughter denied due insurance and proper treatment for diabetes. The congressman of course blamed mothers for overusing the insurance system. The governor became hostile when pressed.

No matter, there is always begging.

[anne]

Of course, child health care insurance programs should be and can be fully funded and immediately. Of course, Medicaid can be and should be fully funded. Fund the auditing programs properly as well to guard against abuse, allow Medicaid and Medicare to negotiate drug prices as they already negotiate prices for other medical services.

What is lacking is the intent to insure proper health care to Americans, the rest coming from the general intent.

[anne]

Here is the direct reference to Mark Kleinman's scary and essential essay:

http://www.samefacts.com/archives/health_care_/2007/07/rationing_health_care.php

July 12, 2007

Rationing Health Care
By Mark Kleiman

[Please set down the direct references to the comments by George Bush and Fred Thompson, if possible.

George Bush - “After all, you just go to an emergency room.”

Fred Thompson - ... “the poorest Americans are getting far better service” than Canadians or the British... ]

[anne]

Here is an early reference on George Bush's present plan for the budget for the coming year and the modest alternative:

http://www.cbpp.org/6-21-07bud.htm

June 21, 2007

The Fight Over Appropriations: Myths and Reality: Most of the Growth Would Go for Military and Homeland Security; Increases Planned for Domestic Appropriations Are Small.
By Richard Kogan

[elvis]

“After all, you just go to an emergency room.”

The health care version of the Iraqi-insurgent-taunt "Bring 'em on!"

You're doin' a heck of a job, bushie.

[elvis]

“After all, you just go to an emergency room.”
The poor man's gold-plated coverage.

I'm sure hospital's are exstatic over the president's confidence in them. Bring 'em on

BTW, isn't this also the Wal-Mart health care plan?

[anne]

http://www.whitehouse.gov/news/releases/2007/07/20070710-6.html

July 10, 2007

President Bush:

Let me talk about health care, since it's fresh on my mind. The objective has got to be to make sure America is the best place in the world to get health care, that we're the most innovative country, that we encourage doctors to stay in practice, that we are robust in the funding of research, and that patients get good, quality care at a reasonable cost.

The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room. The question is, will we be wise about how we pay for health care. I believe the best way to do so is to enable more people to have private insurance. And the reason I emphasize private insurance, the best health care plan -- the best health care policy is one that emphasizes private health. In other words, the opposite of that would be government control of health care.

And there's a debate in Washington, D.C. over this....

[spencer]

Can you post the Commonwealth Fund study?

[anne]

http://www.townhall.com/columnists/FredThompson/2007/06/26/duplicating_disaster

June 26, 2007

Duplicating Disaster
By Fred Thompson

Many Canadians have started coming to the US for treatments that they just can't get at home.

Now, top officials of the British National Health Service, often held out as an example of the kind of socialized medicine America should adopt, have acknowledged that they have similar problems. One in eight National Health Service hospital patients has to wait more than a year for treatment. Thirty percent wait more than 30 weeks.

Think about it. This is what we're supposed to copy? The poorest Americans are getting far better service than that. And there's nothing about Americans that would make us any better able to run a government health care bureaucracy than the Canadians or the British. In fact, we've got less practice at that sort of thing than they do -- and we might be a lot worse at it.

[btgraff]

Lafayette wrote: The French can choose their doctors and see any specialist they want. Doctors in France, many of whom are self- employed, are free to prescribe any care they deem medically necessary. "The French approach suggests it is possible to solve the problem of financing universal coverage.

Well, that is not far off from the Canadian system.

In Canada, most family doctors and specialists are self employed - on doctors in hospitals are not self employed. hospitals are effectively owned by the government because virtually all funding comes from government, or from other monies they raise through donations, lotteries, etc. - there are only a few small clinics that are run on a "for profit basis.

doctors are free to pick and choose their patients, and patients are free topick their doctors, except there is a shortage of doctors ( i spoke about this before) - the shortage is worst in small towns and rural areas where doctors don't want to go.

doctors are free to prescribe any care they deem necessary.

doctors have to take the government payment as full payment - they cannot "extra bill". aprt from extra items (dental care, drugs, getting a private room) there is no private insurance, although a recent supreme court decision in quebec is opening the door on this.

note that my experience is ontario, where 1/3 of canadians live.

[Detlef]

spencer,

This is the latest updated report.

[Isabel]

Commonwealth Fund study (last one, I think):

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678

[Isabel]

Detlef beat me to it ;-)

And this one, about primary care, is interesting, too:

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=508058

[Lafayette]

Bush: And the reason I emphasize private insurance, the best health care plan -- the best health care policy is one that emphasizes private health.

Where did lead-head see this? In a comic book?

Twice he was voted in, twice. Fool me once, shame on you; fool me twice, shame on me.

[Cyrille]

"And the reason I emphasize private insurance, the best health care plan -- the best health care policy is one that emphasizes private health."

I wonder if that's accidental. What does he mean by private health? That you, as an individual, will be healthy? Well, then you could certainly not conclude "In other words, the opposite of that would be government control of health care."

If it is supposed to mean "the best health care policy is one that emphasizes private healthcare", then wouldn't it be a way to put the idea in people's minds without stating it, because there is absolutely nothing backing it, whereas of course everyone wants to have a good private health?

[Lafayette]

C: ... whereas of course everyone wants to have a good private health?

Private doesn't mean personal. It means "non conventionné" in France. The opposite, "conventionné" means a doctor is "approved by the state for medical practice" or public service medicine.

Even France is having a problem with containing medical costs, even though doctors opt the public medical practice - where the price of their services are fixedby the state).

Bush was genuflecting to the Republican notion that state government public service is worse than private enterprise.
In the case of his crony administration, and if Katrina is any example ... he's right.

As regards health care insurance, however, he's dead wrong.

[anne]

http://select.nytimes.com/search/restricted/article?res=FA0E14FF345D0C758EDDA80994DA404482

November 26, 2002

John Rawls, Theorist on Justice
By DOUGLAS MARTIN

John Rawls, the American political theorist whose work gave new meaning and resonance to the concepts of justice and liberalism, died on Sunday at his home in Lexington, Mass. He was 81....

The publication of his book ''A Theory of Justice'' in 1971 was perceived as a watershed moment in modern philosophy and came at a time of furious national debate over the Vietnam War and the fight for racial equality. Not only did it veer from the main current of philosophical thought, which was then logic and linguistic analysis, it also stimulated a revival of attention to moral philosophy. Dr. Rawls made a sophisticated argument for a new concept of justice, based on simple fairness.

Before Dr. Rawls, the concept of utilitarianism, meaning that a society ought to work for the greatest good of the greatest number of people, held sway as the standard for social justice. He wrote that this approach could ride roughshod over the rights of minorities. Moreover, the liberty of an individual is of only secondary importance compared with the majority's interests.

His new theory began with two principles. The first was that each individual has a right to the most extensive basic liberty compatible with the same liberty for others. The second was that social and economic inequalities are just only to the extent that they serve to promote the well-being of the least advantaged.

But how could people agree to structure a society in accordance with these two principles? Dr. Rawls's response was to revive the concept of the social contract developed earlier by thinkers like Thomas Hobbes, John Locke and Jean Jacques Rousseau.

For people to make the necessary decisions to arrive at the social contract, Dr. Rawls introduced the concept of a ''veil of ignorance.'' This meant that each person must select rules to live by without knowing whether he will be prosperous or destitute in the society governed by the rules he chooses. He called this the ''original position.''

An individual in the ''original position'' will choose the society in which the worst possible position -- which, for all he knows, will be his -- is better than the worst possible position in any other system.

The result, Dr. Rawls argued, was that the least fortunate would be best protected. The lowest rung of society would be higher. Though inequalities would not be abolished by favoring the neediest, they would be minimized, he argued.

In later works, Dr. Rawls expanded his arguments to suggest how a pluralistic society can be just to all its members. His idea was that the public could reason things out, provided comprehensive religious or philosophical doctrines are avoided....

[anne]

Darn, I am sorry for the post was meant to be on the principles of taxation thread, but then Rawls easily makes sense here.

[Cyrille]

Thanks Lafayette. I realised that this is what private means in this context. My question was because he said private health -as opposed to private healthcare.

Maybe it makes no difference. I was wondering whether private health really meant anything, and if not, whether the change in wording was accidental or deliberate.

[Farrar Richardson]

Thanks, Anne, for the article on John Rawls. I am still slogging admiratively through A Theory of Justice. A few pages every evening. Meanwhile your article seems to be a good summary.

[robertdfeinman]

Several have mentioned above the apparent lack of empathy for those in immediate need by sitting politicians. The question is why?
Possible choices:
1. Ignorance of the true state of affairs
2. Sociopathic personality
3. Ideological bias (the afflicted bring it on themselves through some sort to of moral failing or, alternatively, it is "God's will".)
4. Willful denial of the facts (guilt suppression)

People in the first class can be educated as, for example, happened with several smug reporters when they actually went to New Orleans after Katrina.

People in the other three classes will not (or can not) change and they need to be driven around as one does a boulder lying in the road. This means actively supporting opponents, participating in electoral politics, demonstrating when appropriate and challenging incorrect statements when they occur. The complicity or unwillingness to be confrontational by the press has been a real obstacle to getting the word out.

For example the reporter in the interview on "Now" with Sonny Perdue pressed him once on his unwillingness to come to grips with the issue, but backed down when he pushed back. We have seen little of the kind of stance that wouldn't allow this to slide yet. There was the case of Jon Stewart a year or so ago and the recent actions by Michael Moore on CNN. In addition there has been Keith Olbermann, but he does it as an essay and not face to face.

One can hope that this might become a trend. But with media control in the hands of a handful of huge industrial firms it seems unlikely. Perhaps the blogosphere will get noticed enough to provide the corrective action.

[anne]

Farrar Richardson, thanks as well and notice the rest on the relevant review of "Theory of Justice" and "Justice as Fairness" on the principles of taxation thread.

[Farrar Richardson]

As Laf points out, even France is having problems containing higher medical costs. It seems like every year, there is a deficit in the health care budget, even though social security and the hospitals work like crazy to cut costs. Drs. can prescribe any treatment or medication they deem necessary, most without advance approval, but they are controlled after the fact by social security experts, and that helps keep the lid on.

Imagine - a French GP charges 22 Euros per visit, and the last time I saw an American GP five years ago, it cost me 75 Dollars. Even though the FX rate is 1.38 Dollars to the Euro, the purchasing power parity seems close to 1 to 1. Doctors are grumbling and we may face a real shortage down the road if they can't earn more.

I fear that we are going to have to get used to paying more here in France. Sarkozy is already sending up trial balloons, even though he has just given away about 15 billion in tax reductions for the rich.

In short, I'm glad I got my cancer cured five years ago, during the real golden age of French medical care.

Even is the US, I wonder if you can save enough through single payer and other efficiencies to reduce over all costs. At least medical care can be more equitably distributed.

[Holly w.]

"People have access to health care in America,” [Bush] said last week. “After all, you just go to an emergency room.”

Last year when NOW on PBS followed up on a previous story about high school kids doing environmental clean-up work around the Anacostia River in Washington, DC, they reported that one of the subjects, an 18-year-old boy who had received a college scholarship for his work, had died of cancer since their last visit. He'd been suffering frequent flu-like symptoms and repeatedly went to the emergency room for treatment, but the ER personnel were concerned only with his immediate problems rather than the continuing issues. Since he had no health insurance and no personal doctor, no-one recommended that this kid should get additional testing or observation of any kind. It seems to me that it's a real waste to lose someone so young and promising. Sure, he might have died anyway, but having to rely on the emergency room appars to have seriously delayed his diagnosis and treatment.

Is this what President Bush has in mind? I realize that the plural of anecodote isn't data, but this kid was one of 18,000 people in this country who die annually because of this kind of "access" to medical treatment.

[save_the_rustbelt]

"...the large majority of hip replacements in the United States are paid for by, um, Medicare...."

Medicare, which has pretty generous funding, is now proposing a 10% cut to physicians on reimbursement, which will put Medicare at below cost in some primary care offices.

Given the (technical and reimbursement) history, Medicare might not be a great template for national health care.

[spencer]

detlef -- thanks

[Lafayette]

C: My question was because he said private health -as opposed to private healthcare.

Oh.

Goodness, you have to be foreign to have picked up that error in English. But, you are right, of course.

Remember, this guy learned his mother-tongue of the back of a breakfast cereal box.

[anne]

"Given the (technical and reimbursement) history, Medicare might not be a great template for national health care."

There is a peculiar way of Republicans always finding a reason why any possible program that really helps people and has worked well for, well, decades has to be denounced with no suggestion that, well, the program might even ever be improved. What deceptive nonsense.

[anne]

As to the question of rising health care costs in France, as elsewhere, drug therapy has since the 1960s become a slowly but steadily larger part of medical spending with costs for drugs increasing more sharply after 1980 as an American change is patent allowance for drugs developed with public funds increases the relative number of patents controlled by drug companies.

Recent years have seen a spate of drug price increases and a more aggressive attitude by drug companies in raising prices. How much then of the French helath care cost increase is attributable to drug use increases and price increase?

[DILBERT DOGBERT]

The LA Times had an interesting article about a woman who died on the floor of the waiting room as staff ignored her. They even were mopping the floor around her. Others in the room were 911ing the situation but as the woman was already in the hospital they, the 911 operators, did not know how to respond.
Yes just jump in the car and go to the ER. You will get great care there. That is what I did when I had a heart attack last year. I got great care, but then I live in Palo Alto not the black community of LA. I am also insured and under medicare.

[anne]

What I do not know is how drug prices for, say, the most prescribed 50 drugs vary in 20 countries ranging in per capita incomes. Also, I do not know what effect on drug prices a limiting of production in India or Brazil or Thailand or South Africa of drugs meant for low income markets is having on drug prices in the low income market and beyond. What of drug availability in low income India? Lastly, what is the evident recent effect of a change in drug pricing begun by Roche and spreading to change for the value of a drug to a patient's well-being, making for a rationale for $100,000 yearly prescriptions.

[anne]

Dilbert, please set down a reference if possible so the anecdote can be examined and cited if more than just an aberrant incident. I might guess at the hospital, but hope I am wrong in the guess. Even so, why should such an incident occur under any circumstances? There needs to be a context.

[Isabel]

Talking about minorities and health(care), this is also interesting:

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=506830

(Sounds like the sub-prime mortgage story, BTW)

[ECONOMISTA NON GRATA]

American healthcare = Your money or your life...

It's that simple.

Let's see.... Ummmm.... The "greatest country in the world". They want to destroy "our way of life". What else...? Any suggestions....?

Free Universal Heath Care for all Americans. If you need to tax more, so be it. If you need to tax the rich and the middle class and the poor.... Too bad.... Take the profit out of the administration of healthcare. But most importantly...

CAMPAIGN FINANCE REFORM...!

Econolicious

[Lafayette]

Rawls: The result, Dr. Rawls argued, was that the least fortunate would be best protected. The lowest rung of society would be higher. Though inequalities would not be abolished by favoring the neediest, they would be minimized, he argued.

I mean no disrespect to the esteemed Mr. Rawls ... but this has very little relation with reality. It seems "utopian".

No one (that I know) choses their "original position" and few have even a choice of anything from there on to the final position.

I admire his conclusions, but I prefer to believe that the collective value that is "just" is that which esteems a "safety net" for all is more important than "maximum optimization" of the few.

We are "classed" from birth and its damn difficult to change one's destiny - going up or coming down. Still, it must be assured that all have the opportunity to better themselves, if only comparatively few succeed to do so substantially. There is no guaranty whatsoever that a child will do better than his/her parents - only a chance that such an outcome will happen.

Life's a lottery. But, some don't even get to buy a ticket to play.

[Lafayette]

ENG: CAMPAIGN FINANCE REFORM...!

You kidding? Choosing an elected official based upon principles, platform and ideas - rather than mindless sound-bites of character assassination, balloons and razzmatazz?

Hell no, José - that ain't the American Way ...

[Francis]

anne: MLK in LA County (again).

[anne]

Francis, thank you, I knew, without knowing, the moment I read the anecdote. But, can such an incident mean? How can we in any way contextualize this? Martin Luther King is as far as I remember the only hospital in the Watts region. Am I still right?

[save_the_rustbelt]

The feds and California have tried to close MLK (now Harbor) off-and-on for a decade, but local politicians protected it both for patient access and because it is a good jobs program in a depressed area.

The hospital has an incredible record but was never shut down.

[BJ Feng]

To say that the uninsured in this country aren't receiving basic services is wrong. This friend of mine recently got his girlfriend pregnant. Of course he never bothered to save money, but they were unconcerned about the costs. I was curious about this, so I asked about the maternity costs one day when I was over to see the new baby. They said they received prenatal care, went to the hospital to give birth, and on top of that, received diapers, baby food, and other items in a "new parent" package that was pretty substantial. Total cost? $0. It was through some government program, they couldn't name it, all they understood was that you went to this place and everything is taken care of.

Guess what? Someone has to pay for all those services because they cannot. So if you have money, or are insured, YOU have to pay. Medical providers have to make up for these losses somehow so they charge up the nose for those who can pay because they have to subsidize those who cannot pay. Insurance is also affected because the hospital or provider has to pay the bills and they're going to negotiate a rate with the insurance company that will keep the doors open. "If you don't give me at least this much, I'm out of business" and so those who have insurance end up paying for those who use the system for free. Everyone pretty much has access to health care, the only difference is that some don't pay and others do.

Many of these proposals call for giving everyone access to health care, but everyone does have access already. Now you can give MORE access to people, but then costs would rise and we would have to pay more.

I think the real debate is about whether we want to pay more so that everyone can have more access to health care. I also don't think preventive measures would make much of a difference because heart disease and cancer are the top two killers and they involve lifestyle choices. A doctor telling you to exercise more and eat less fat doesn't usually make much of a difference. My friend above also smokes, he's not going to quit because doctors have already told him and he's well aware of the dangers.

It's perfectly reasonable for people to decide they do not want to pay more so that everyone can have more access to health care. That is what the real debate is about.

[anne]

Thank you, STR. What I do not understand is why this particuar hospital, any hospital really, especially a hospital that should be considered so important to a community, cannot be improved, if indeed there has not been improvement. This is a hospital that trains medical students. Obviously I know little of the issues, but we should be puzzled, when or if problems persist so.

[Lafayette]

BJF: I think the real debate is about whether we want to pay more so that everyone can have more access to health care.

Per capita expenditures in the US are four times that of other countries that have better Health Care Systems. And you are suggesting that we "spend more"?

Wow ... you a GP?

BJF: I also don't think preventive measures would make much of a difference because heart disease and cancer are the top two killers and they involve lifestyle choices.

Lifestyle? Yes, eating too much provokes heart disease, as does smoking. So, if preventive medicine can forewarn people of the consequence of their lifestyles and they change their ways, is not that a considerable benefit?

Unfortunately, for that to happen a national Health Care service needs clinics (not ERs attached to large private hospitals) that easily available to that part of the population that needs them most - those without insurance.

You are quite wrong in this notion. The World Health Organization classification of the US at 37th in their listing (of Health Care Systems globally) is due, in fact, to its lack of preventive medicine.

This criteria is so important that just after the US in the listing is Cuba, which has awful remedial care but quite a good preventive care mechanism. It is free and it is readily accessible - unlike the US.

[Cyrille]

"Remember, this guy learned his mother-tongue of the back of a breakfast cereal box."

Thanks for that, it brought a good hearty laugh even though I was just back from a cocktail where our CEO made an absolute disgrace of himself, truly appalling. Memo to self: must leave that company in a hurry.

"Rawls: The result, Dr. Rawls argued, was that the least fortunate would be best protected. The lowest rung of society would be higher. Though inequalities would not be abolished by favoring the neediest, they would be minimized, he argued.
I mean no disrespect to the esteemed Mr. Rawls ... but this has very little relation with reality. It seems "utopian".

No one (that I know) choses their "original position" and few have even a choice of anything from there on to the final position."

Well, I think you misunderstand "original position". It's not (in Rawls' mind) something you choose -or indeed something real, more a metaphor.
His point is that when deciding on ethics, you cannot take into account where you will stand. He goes on to describe this story about the veil of ignorance and calls being behind it the original position.

His metaphor is used to say that if we could bring ourselves to be in such a situation, then the ethics we would choose could be considered, well, ethical.

His conclusion that we would then choose the system maximising the happiness of the least happy is far from obvious actually -that's what we'd choose if we were highly risk-averse. But someone who likes risk would probably choose differently.

Still, this is a reasonably robust "ethical inequality". Go any further than that, and you know you are hurting someone. It won't give you an obvious answer in every situation, but it's a good starting point, a direction towards which to aim.

[Lafayette]

BJF: I think the real debate is about whether we want to pay more so that everyone can have more access to health care.

Per capita expenditures in the US are four times that of other countries that have better Health Care Systems. And you are suggesting that we "spend more"?

Wow ... you a GP?

BJF: I also don't think preventive measures would make much of a difference because heart disease and cancer are the top two killers and they involve lifestyle choices.

Lifestyle? Yes, eating too much provokes heart disease, as does smoking. So, if preventive medicine can forewarn people of the consequence of their lifestyles and they change their ways, is not that a considerable benefit?

Unfortunately, for that to happen a national Health Care service needs clinics (not ERs attached to large private hospitals) that easily available to that part of the population that needs them most - those without insurance.

You are quite wrong in this notion. The World Health Organization classification of the US at 37th in their listing (of Health Care Systems globally) is due, in fact, to its lack of preventive medicine.

This criteria is so important that just after the US in the listing is Cuba, which has awful remedial care but quite a good preventive care mechanism. It is free and it is readily accessible - unlike the US.

[anne]

Imagine the special kind of lunacy and meanness in deciding that cancer involves lifestyle choices.

[anne]

Ah, I should have included heart disease as well in light of the ideas that we must blame the ill for their illness and give over the idea that possibly their illness might have been prevented or limited by, say, medical intervention.

Rawls nicely argued, Cyrille.
Clever, Lafayette.

[save_the_rustbelt]

Anne:

MLK (Drew Harbor) is a classic case of local politicians and unions trying to control a local institution that requires very sophisticated management while operating under very difficult circumstances with a difficult clientele.

The hospital is probably better now that it was five years, which is not much of endorsement.

Sad.

[anne]

We need then to watch for discussions of Drew Harbor (I do like the name, MLK). I will look to the past this evening, since I think the hospital was discussed several times on public television.

[Jim Harrison]

Preventative medicine could drastically improve the medical cost picture. All we need to do is harvest all the insurance company executives and prepare a serum from their minced up bodies. Universal vaccination with the resulting product will inevitably lower the cost of medicine over the next several decades.

[evagrius]

BJ Feng;

Sigh.....The government program your friend's pregnant girlfriend had ( and has until the newborn is one year old), is known as Medicaid.
Pregnant women are eligible for pre-natal care and delivery (and post-natal services for one month after delivery) and the baby is eligible for medical care until one year of age under a special Medicaid program known as the percentage program. It does not count assets for eligibility, only income and this has to be under 200% of the Federal Poverty Level, ( about $27,000 for a single pregnant woman).
Your friend's income assets are not counted since they are not married.
Since she was eligible for this program, she was probably eligible for WIC, the special nutrition program for women and infants.
Your friend's girlfriend probably easily fit the income criteria.

Now....give it some thought. Was she working earning over the stated amount as yearly income or was she not?

[anne]

Thank you, Evagrius. This is a Medicaid program for which funds have been lacking in several Southern states at least.

[James Killus]

Tell me something BJ Feng, do you get as incensed about your tax dollars being used to torture randomly captured Afghani citizens and bomb Iraqi civilians as you get at them being used to fund prenatal care for pregnant women?

Just curious.

[anne]

Also, again, we have to pay more attention to international drug costs and associated factors. I have several times pointed out that international drug companies have since 1980 been the most pronounced profits driver of any corporate sector, and as a result leading the investment gains sector. This is a wildly profitable and powerful part of the health care industry, but with practices that were little noted before the 1980s and too little considered and understood since.

Think about having breached the $100,000 yearly prescription cost threshhold, and realize what drugs mean for health care budgets not only in America. What of drug costs in France and Switzerland and Sweden and Germany, all with powerful drug companies.

[anne]

Remember in France and Germany patients are not seeing the cost of drugs that health services are seeing, so are health services under pressure? If so, we need to pay attention to such pressure.

[BJ Feng]

Evagrius, my friend's girlfriend probably did qualify for both programs. She worked as an employee at In N Out, a fast food chain that pays around $9 an hour last time I checked. This particular friend is an assistant manager at Blockbuster and doesn't make much more than his girlfriend.

Anne - International drug companies are also the ones who have helped billions of people extend and improve their lives thanks to the drugs they created. Most of the profits they make go back into R&D to create new drugs that will help future generations, this seems a pretty good system to me as no other system seems more effective. Creating new drugs isn't easy, and each successful drug has to make back the costs of all the unsuccessful drugs that came before it, and do so before patent protection runs out. After the patent expires, the drug is available to be mass produced by all forever, which is essentially a "gift" from the inventing company. In this way, new drugs are continuously being created, and they all eventually become available to everyone for next to nothing (production costs). What's wrong with this? If anything, we should be thankful for all the drugs created by the international giants that are now generically available. Without those companies, the drugs would never have been invented in the first place, or not as quickly, and we would have no drugs.

Why are drug prices so high for Americans? Because we can pay! Poorer countries are charged much much less because they can't afford to pay as much, yet the costs have to be recouped somehow so the rich pay more to help the poor who can't afford to. Since many posters advocate this type of policy, I don't understand why they would be so angry when it's actually put into practice. Maybe because this time they are the rich and they're the ones who have to "pay their fair share".

[evagrius]

At $9/ hr she does qualify but barely. Her child will probably qualify until six or seven under different percentage programs and she might also qualify as a single parent. It depends. If she's living with her boyfriend the rules are more complicated.

As for drug companies, most of the profit isn't plowed back into R&D. It's plowed into advertising.

[Lafayette]

C: (In France) We may have more hospital beds but we reckon we don't have enough, for example.

I suspect, were a survey done, you'd find a larger instance of psychosomatic disorder amongst French patients than elsewhere.

It would be in keeping with the national mood presently. The French, along with the Americans, are the biggest pill-poppers in the world. Which is also an indication of mental condition, given that many of those pills are anti-depressants.

[Lafayette]

BJF: Most of the profits they make go back into R&D to create new drugs that will help future generations

This is conjecture on your part. I wouldn't be so swift to make it. See this, though the information is somewhat dated. I doubt that the situation has much changed nonetheless.

After some consolidation, the industry overall is doing quite well profit-wise - given that "average" profits are between 10 and 12% long-term for most industries.

[Lafayette]

anne: What of drug costs in France and Switzerland and Sweden and Germany, all with powerful drug companies.

They are in continual battle formation with the French authority that "regulates" drug prices.

Far, far more medication in the US is found "across the counter" than in France, where such retailing is forbidden. You must have a doctor's prescription and it must be filled by a licensed pharmacists. Which makes pharmacy also a lucrative profession.

At the utmost, you will find aspirin retailed in France. Having said this, it is my own personal experience that cold remedies found stateside are far more effective than those sold in pharmacies here in France. Go figure why.

There's another side to this argument, however, and it is an important one. France's health care is orientated towards prevention, perhaps even more so than remedial intervention.

This means that getting to see a doctor is not only easily accessible to most of the population (including rural areas) but the cost of seeing a GP is very low. (I've mentioned it already several times in this forum - it's about $25, most of which is paid for by the national health care system.)

Compare this with your system stateside, anne, and you will understand why France is Number 1 and the US is Number 37.

NB: The WHO study, done in 2000, was clearly biased towards preventive medicine in its compilation of base data. Because it too believes that an ounce of prevention is worth a megabuck of cure.

[Lafayette]

Lafayette: Which makes pharmacy also a lucrative profession.

I forgot to mention that France operates some sectors of its health care system according to a medieval formula called "numerus clausus", which means a restricted number and refers to the practice of setting a quota for the number of persons/professions of some category.

For instance, both pharmacies and public notaries are limited by the number of people within a given statistical geography. This tends to limit competition and increase individual revenues, as can be expected. It should be done away with, for instance, by allowing lawyers to transact property or elaborate wills. Or, for supermarkets to sell some drugs, even with an attendant pharmacist.

But when it comes to "reforming France", I suspect this will be one of the last antiquated rules to go.

NB: In researching "numerus clausus" I came upon this interesting paper that relates how the mechanism is pretty much alive and well in sectors that we might have never imagined. Enjoy.

[Cyrille]

Yes, France consumes far too much medication. This is another field in which we must find a way to improve. Especially since, when not strictly indicated, pills tend to have negative effects.

I am glad that psychological trouble is reasonably accepted and that you can get cheap treatment for that -I made use of that at some point of my life and it helped a lot. But anti-depressants without talk therapy is just a waste, if not worse. When I needed them, I was very keen to reach the stage when I could stop, and was happy and proud when I did. Far too many people go the opposite route and try to have the prescribed forever.

There's a lot to be improved in the French healthcare system, and healthcare culture, but that just baffles me even more to see that many people are trying to not change the US one, which is far worse still.

[Lafayette]

JK: do you (BJF) get as incensed about your tax dollars being used to torture randomly captured Afghani citizens and bomb Iraqi civilians as you get at them being used to fund prenatal care for pregnant women? Just curious.

Bizarre curiosity, JK. When you cross apples and oranges, do you get mango as a fruit?

Have you a rebuttal that is not "ad hominem"? Just curious.

[Farrar Richardson]

Anne asked -
"Recent years have seen a spate of drug price increases and a more aggressive attitude by drug companies in raising prices. How much then of the French helath care cost increase is attributable to drug use increases and price increase?"

I couldn't begin to quantify this, but will supply a few anecdotes and impressions.

As Laf has noted, the french regulatory authorities resist.

My limited experience has shown a cost about 50% higher in the US than in France for certain well known medications. Of course this difference varies with exchange rates. The govt is making increasing efforts to encourage the use of generics rather than branded meds. The latest change is to make the patient apply for reimbursement for branded meds, rather than processing them through the national automatic payment network.

I sometimes think that Drs. encourage consumption of meds, to make sure the patient is getting his and the state's money's worth. Anecdote: A few years ago my doc noticed a mild excema (sp?) on my legs which I had never noticed and which never bothered me. Without asking me he prescribed a cream for it, which I have never used.

A reminder here; the French system does not cover everything for everybody. The poor are covered at nearly 100%. Serious illnesses are covered at nearly 100%. Ordinary problems are covered at about 60%-70% (I think, I'm too lazy to go look at my regular monthly statements).
The rest is made up by private complementary insurance, the price of which keeps rising - now about 1600 Euros per year for my wife and me, both of us over 65.

Ordinary dental coverage is very poor. Optical is not too good either.

The insurance companies claim that the rising cost of meds is the main culprit in the premium increases, but it is sometimes difficult for the patient to see the connection because the total cost of essential drugs is automatically paid by the nationwide network, provided one has complementary insurance. If you don't you must pay the 30% 40% out of pocket. Since we have complementary insurance, I just walk into a pharmacy, present my state issued Carte Vitale, and my prescription, and walk away with the meds. So there is no direct and clear incentive to limit consumption of meds which might be considered non-essential, although the govt. regularly prunes the list of certain "comfort" meds, and others considered ineffective.

As Laf wonders, perhaps the French are subject to psycho somatic illnesses. Everyone who has read "A Year in Provence" remembers the pharmacy scene with clients filling their shoping bags with meds. On the other hand, I have met a lot of older people who would refuse to even see a Dr until they were almost on their death beds. These are rapidly disappearing, usually at ripe old ages.

[Farrar Richardson]

I am just beginning to dig into Rawls "A Theory of Justice", and so far it seems very difficult for me to draw that veil of ignorance over my eyes in order to get into the initial situation. It occurs to me as I read this thread that health care issues might be the most nearly ideal area in which to apply Rawlsian principles, the reason being that disease can strike rich and poor alike, and no one can ever know whether (s)he wil br struck by some serious illness. (the forgoing needs quqlification, of course). But my main point here is that, those entering the debate are already covered by a veil of ignorance to a certain extent. We don't have to imagine it.

Why then do we have such problems reaching consensus on solutions. There are, of course vested interests and idealogies which get in the way, but perhaps we are also applying inappropriate, utilitarian reasonaing.

Vague musings - just trying to get outside the box.

[Farrar Richardson]

Good point from Cyrille that Rawls's principle has more appeal to those who are risk averse. Rawls attempted to deal with risk in the pages I read last evening, but I didn't understand it very well. Too much math. I'll go back and try again.

[anne]

Interesting and helpful descriptions, but while I have read of the supposed French "enjoyment" of drugs I have also read the same of Americans and Germans and Japanese. What we do not know is how the cost of drugs is effecting national health care systems, though we know quickly rising drug prices and increased proportional use is an American problem.

[anne]

As for American drug development, a significant majority of drugs are only developed to maintain patent control or to closely imitate serviceable drugs. I could not be more enthusiastic about research and development of drugs, but there is endless emphasis on development that is to no effect other than patent control and costs to market drugs are much of the price of development. Notice the work of Marcia Angell that Mark Thoma and Paul Krugman have referred to.

says...

http://www.nytimes.com/2004/09/14/health/policy/14conv.html?ex=1252900800&en=fe413194a662c12b&ei=5090&partner=rssuserland

September 14, 2004

A Doctor Puts the Drug Industry Under a Microscope
By CLAUDIA DREIFUS

WASHINGTON - In many ways, Dr. Marcia Angell is an unlikely muckraker. A pathologist by training, she is the former editor in chief of The New England Journal of Medicine. She is also a senior lecturer at Harvard Medical School.

But just days short of her 65th birthday and her first Social Security check, Dr. Angell is taking on the American pharmaceutical industry with a new book, "The Truth About the Drug Companies: How They Deceive Us and What to Do About It" (Random House)....

Q. Why produce an investigative book on the pharmaceutical industry?

A. Because everyone knows that prescription drug prices are sky-high. Americans pay far more for our drugs than people in other countries. The drug companies say, "We need high prices to cover our staggering research and development costs, and if you do anything to squeeze our prices, it will stifle innovation." The book was written to examine that argument.

Q. The pharmaceutical companies say their prices are steep because they spend somewhere in the neighborhood of a billion dollars per drug bringing them to market. Did your research support this assertion?

A. A group of economists - mainly funded by the drug companies - came up with the widely quoted figure on this. They said that it cost $802 million to bring a drug out. They, however, were looking at the most expensive drugs to develop: new chemical compounds developed entirely in house. Most new drugs aren't that at all. Most are what people call "me too" drugs, which are slight variations of older drugs already being sold.

According to these economists, the real cost of bringing out those rare original drugs is actually around $403 million. But they doubled it by factoring in how much money the companies might have earned if they'd invested that $403 million. Moreover, the economists did not figure into their total the many generous tax breaks these companies receive for doing research and development. This is a highly inflated figure.

The fact is that for the last two decades the drug companies have been hugely profitable. Last year there was a little wiggle downward, but in 2002, the 10 biggest American drug companies had a median profit of 17 percent of sales compared to a median of 3 percent for the other Fortune 500 companies. In the 1990's, profits ran between 19 and 25 percent. Prices are high to keep profits high.

Q. Exactly what are these "me too" drugs you argue against?

A. They are minor variations of old drugs already on the market. Sometimes a company creates a "me too" drug as a way of extending a patent on an older one. For example, AstraZeneca created Nexium to replace the virtually identical Prilosec when its patent was about to expire. By putting out these me-too's, the companies can get new exclusive marketing rights on what are essentially the same old drugs.

Other companies come in with their own me-too's because markets are expandable. It's been shown that when you advertise one me-too drug, you increase the sales of all of them.

Q. Why do you have a problem with this?

A. The prevalence of the me-too's really says an awful lot about the lack of innovation within the pharmaceutical industry. If you look at the new drugs marketed over the last six years, 78 percent weren't even new chemical compounds. They were just new combinations or different formulations of old drugs. And 68 percent were classified by the F.D.A. as unlikely to be improvements over drugs already on pharmacy shelves.

At the same time, there are shortages of some important drugs that the pharmaceutical companies aren't much interested in making because they are not as profitable as the me-too's. But the companies don't have to turn out needed drugs, if they are not lucrative. And they don't.

Q. How much of the high cost of drugs is the result of marketing and sales expenditures?

A. The companies spend over 30 percent of their revenues on marketing and administration....

[anne]

Sorry; but that was me on Marcia Angell, though my computer does not think so. Notice, carefully, however the important points made in the interview.

Farrar Richardson wonders are the difficulty of discourse derived consensus on political issues, and I am inclined to believe the problem is far more significant in America than France or through western Europe. A really important question that I will think about for quite a while, though I am immediately struck by the limited extent to which what are the formal news outlets for large numbers of people, possibly most people, allow for rounded discourse on issues.

[anne]

Farrar Richardson, these references may help but reading a little at a time and arguing along with John Rawls works. The core question being how to have open discourse with the sense that justice arrived at will mean more fairness....

http://www.nytimes.com/books/01/06/24/reviews/010624.24schneet.html

June 24, 2001

What's Fair Is Fair
By J. B. SCHNEEWIND

JUSTICE AS FAIRNESS
A Restatement.
By John Rawls.

....

http://www.nytimes.com/books/first/r/24rawls.html

Justice as Fairness
By JOHN RAWLS.

....

http://www.nybooks.com/articles/10296

February 24, 1972

A New Philosophy of the Just Society
By Stuart Hampshire

A Theory of Justice
By John Rawls

[anne]

Another perspective on waiting:

http://www.nytimes.com/2007/07/17/opinion/l17medicare.html

Medicare and Disability

To the Editor:

“Some Chronically Ill Adults Wait for Medicare to Arrive”:

Medicare is not just health insurance for older Americans. Seven million Americans under age 65 have Medicare coverage because of severe and permanent disability. But once deemed “disabled” by the Social Security Administration, people under 65 must wait 24 months for Medicare to kick in.

The wait is tragic: disability strikes, employment and health insurance ends, and people find that they are suddenly uninsured at the very time that they need health care more than ever.

Like chronically ill people in their early 60s waiting for Medicare eligibility, people with severe disabilities in the Medicare waiting period forgo life-sustaining care.

Our recent study, published by the Commonwealth Fund, found that these uninsured people go into debt to pay for care, beg for charity care or raise funds from family and friends to get care. More often than not, they eventually are turned away when seeking care and go without.

Congress should end the shameful waiting period.

Robert M. Hayes
President, Medicare Rights Center
New York, July 12, 2007

[evagrius]

On Medicare and Disability.

It is true that Medicare only kicks in two years after a disability determination but, meanwhile, one can be eligible for Medicaid.
However, Medicaid is not "free". It is only "free" for a single individual if that individual has an income of less than $600/ month, ( $1100/ month for a family of four).
Any income above that $600 is considered available for medical expenses.This is known as "share-of-cost" and is month-to-month.

So...the irony is that one is declared disabled, becomes eligible for Medicaid and, eventually Medicare, and receives Social Security Disability payments. If one is "fortunate", those payments may be under the Supplemental Security Insurance payment, (SSI), level which makes one eligible for "free" Medicaid, ( I believe SSI payments are roughly $750/ month). However, most diabled people have worked for quite a while and usually receive Social Security Disability Insurance paymets, ( SSDI), above the SSI level. This means that they do not receive "free" Medicaid. They are then eligible only for the "share-of-cost" Medicaid.

Such are the labyrinthine ways of government provided health care for disabled individuals.

[Chaim]

This article may be of interest, or serve as a counterpoint, to those who "care" about "health"/illness and how the "debate" is framed:

http://www.patchadams.org/hospital_project/positions.pdf

Re-Designing the US Health Care System: Think Universally, Design Locally
by Dr. Susan Parenti

Concluding Quote:

"The statistic is cited, over and over again, that in the richest country in the world, nearly 48 million Americans do not get health care.

We say that in the richest country in the world, 300 million Americans do not get health care. Yes, of these 300 million, many people do get into the disease management bureaucracy, as they have insurance. But what is happening inside the medical system is no longer care; the 567,000 licensed doctors are not permitted to doctor; the 2.4 million nurses are being thwarted at nursing. The culture of health care in America is being morphed into something else.

When hospitals and clinics are businesses, and doctors/nurses become business people, who will we then turn to for health care?"

[Farrar Richardson]

Anne -
Divine surprise! Increase in spending for medication for the year ending May 31 was only 1.6% (adjusted). If I remember correctly, this is mainly meds through pharmacies, and does not include meds through hospitals or clinics, which would probably be the more expensive kind.

This relative success is probably due to the big effort to push people toward generics, and possibly to a campaign to stop prescription of anti- biotics where not indicated, i.e. viruses. Also a fairly long list of ineffective meds were removed from the reimbursable list.

I have not found previous years for comparison yet. If your French is pretty good you may want to go to
http://www.ameli.fr/l-assurance-maladie/statistiques-et-publications/analyse-des-depenses/index.php
and browse around neighboring pages.

[BJ Feng]

The article should be seen as a serious fault with our doctors and the way they prescribe drugs rather than an indictment on the drug companies which are out there to make as much profit as they can (by the way, excess profits creates huge incentive for new companies to enter the market which is why we have so many biotech startup companies, a good thing).

Instead of bitching, Dr. Marcia Angell should be using her time to create a database of equivalent drugs, and figure out a cost/benefit analysis that would advise doctors when they should be using the more expensive drugs, and when they should be using generics instead. The AMA or similar large group of doctors could try to find consensus on those analyses. That way, doctors would have a database to figure out which drugs to prescribe as they do not have the time to keep up with all the new inventions and drugs coming out.

Of course, this would take a lot of time and effort, it's much easier to attack the drug companies than for "concerned" doctors to come together and do work. Bitching is easy, work ain't.

[anne]

Farrar Richardson:

"Divine surprise! Increase in spending for medication for the year ending May 31 was only 1.6% (adjusted). If I remember correctly, this is mainly meds through pharmacies, and does not include meds through hospitals or clinics, which would probably be the more expensive kind.

"This relative success is probably due to the big effort to push people toward generics, and possibly to a campaign to stop prescription of anti-biotics where not indicated, i.e. viruses. Also a fairly long list of ineffective meds were removed from the reimbursable list...."

Stunning, absoutely stunning, when increases in drug prices here have not been less than inflation since the early years of Bill Clinton's Administration, when there was presidential pressure to hold down price increases or be subject to helath care reform measures.

[anne]

As the Clinton years wound down drug price increases quickened, from 1999 on the increases have been dramatic, but my father taught me that the restraint on drug companies in the early Clinton years showed that the companies had a large large pricing latitude that minimally effected profitability. We understood that drug companies were fine investment in those early Clinton years when analysts were falsely moaning as analysts repeatedly do.

Of course, the gains in prices of drug company stocks at the close of the Clinton Administration was also stunning and so enjoyable. Drug company stocks were gaining 50% and more while a bear market was taking hold.

Quite a business and quite a market.

But, Farrar Richardson gives us a wonderful insight of what may be done in terms of limiting drug price increases which of course there has been no Administrative interest in here at all.

[anne]

Then, at just the time when we are experiencing pronounced increases in drug expenses, France is effectively limiting increases expenses and no doubt with no adverse health care effect and no matter all the supposedly wild pill loving French ways. I am impressed.

Another matter of significance, is the extent to which drug company general advertising and directed advertising to physicians moves patients to expensive drugs of no more efficacy than generics. Physicians such as oncologists, by the way, can directly sell drugs they prescribe to patients. Cancer drugs are especially expensive. There has been article on article in the New York Times on direct advertising of drugs to physicians and the effectiveness, and physicians groups are trying to set limits to physician-drug company ties.

[anne]

Responses to Paul Krugman's column are at the New York Times, along with comments by Krugman, and there is considerable thoughtful appreciation including appreciation by physicians.

http://krugman.page.nytimes.com/b/a/258280.htm

July 16, 2007

Let Them Go to the E.R.

Rich, Washington, D.C.: Funny thing about that hip replacement item: A friend of mine with very good insurance has been waiting for a hip replacement for almost two years. He went through multiple delays while getting approval to do a procedure that was more current and appropriate for his condition. Even when the insurer was rejecting this, it was not possible for him to get the replacement done in a particularly timely manner. Granted this is an anecdote, but it reflects the current state of our health care system. The red tape often is more likely to come from an insurance company and it's mostly about wearing people down and discouraging them from using their coverage, rather than delivering appropriate care.

Paul Krugman: In the health policy wonkosphere, it's called "rationing by hassle." My understanding, also, is that your friend's delay won't be counted as such in the statistics: only the wait in scheduling the surgery, not the wait in getting approval to do the operation, counts....

[anne]

Thinking of tragedy and medical costs, I wonder how what is going to be an astonishing cost for soldiers and civilians returned wounded from Iraq will be recorded among other health care costs. What might be the effect? Just this day, I am reading of 13,000 wounded returned American contractors. These are the physically wounded civilians, though there are the psychologically wounded as well.

Along with the costs for our physically and psychologically wounded soldiers, I would expect this to add to hundreds of billions of dollars in care.

Linda Bilmes writes of such costs, and I must look.

[anne]

http://www.news.harvard.edu/gazette/2007/02.01/99-vets.html

January 26, 2007

Terror War Could Strain Veterans' Health, Benefit Systems: U.S. unprepared for impact of returning soldiers.
By Alvin Powell

[Linda Bilmes counts $282 billion as the low cost long term estimate for medical care of wounded soldiers alone. I realize, I do not know what this means. There are the disability costs as well. Then, there are the contractor employed civilians.]

[Lafayette]

Chaim: When hospitals and clinics are businesses, and doctors/nurses become business people, who will we then turn to for health care?"

There are options.

The Japanese are working on an AI (artificial intelligence) robot, ambulatory, that can be programmed for nursing and minor levels of surgery.

Or, the world is already discovering super-clean, super-equipped, super-doctored clinics in Bangkok, that are super-cheaper than stateside.

Or, doctors in New Delhi will operate remotely via hi-speed links and robotic surgical devices.

The Harvard Medical School will have franchised itself to Schang-hai, Rio di Janeiro and Budapest.

The American doctor will have disappeared ... to live in a chalet in Zermatt or on a yacht in St. Tropez. To get "really good" medical attention in the US, it will be preferable to speak Hindi.

Go figure. Your immagination's the limit.

[elvis]

BJ Feng said:
Most of the profits they make go back into R&D to create new drugs that will help future generations, this seems a pretty good system to me as no other system seems more effective.

There was a book I read 2 years ago (written by a former editor of the New England Journal of Med) which revealed that drug companies include all their advertising expenditures in with "R&D". In fact, I believe advertising exceeded actual research. The actual basic research is carried out by universities which recieve funding by you and me.

Why are drug prices so high for Americans? Because we can pay! Poorer countries are charged much much less because they can't afford to pay as much,
Goodness, let me open my wallet a little wider, then. Canadians can't afford to pay as much as we do? I think it's pretty clear why we pay more--lobbyist made sure of that.

[anne]

Elvis:

"There was a book I read 2 years ago (written by a former editor of the New England Journal of Med) which revealed that drug companies include all their advertising expenditures in with 'R&D'. In fact, I believe advertising exceeded actual research. The actual basic research is carried out by universities which recieve funding by you and me."

The revolution for drug company profits but not for research came in 1980 when the companies were allowed to patent drugs developed with public funds and from research conducted in public facilities.

[anne]

http://www.nybooks.com/articles/17244

July 15, 2004

The Truth About the Drug Companies
By Marcia Angell - New York Review of Books

Every day Americans are subjected to a barrage of advertising by the pharmaceutical industry. Mixed in with the pitches for a particular drug—usually featuring beautiful people enjoying themselves in the great outdoors—is a more general message. Boiled down to its essentials, it is this: "Yes, prescription drugs are expensive, but that shows how valuable they are. Besides, our research and development costs are enormous, and we need to cover them somehow. As 'research-based' companies, we turn out a steady stream of innovative medicines that lengthen life, enhance its quality, and avert more expensive medical care. You are the beneficiaries of this ongoing achievement of the American free enterprise system, so be grateful, quit whining, and pay up." More prosaically, what the industry is saying is that you get what you pay for.

Is any of this true? ...

[anne]

http://www.nytimes.com/2004/09/06/books/06masl.html?ex=1252209600&en=1accf3fe4a08f287&ei=5090&partner=rssuserland

September 6, 2004

Indicting the Drug Industry's Practices
By JANET MASLIN

THE TRUTH ABOUT THE DRUG COMPANIES
How They Deceive Us and What to Do About It
By Marcia Angell, M.D.

Dr. Marcia Angell is a former editor in chief of The New England Journal of Medicine and spent two decades on the staff of that publication. If much of that time was devoted to reviewing papers on pharmacological research, it must have been spent in a state of near-apoplexy.

Her new book is a scorching indictment of drug companies and their research and business practices. "Despite all its excesses, this is an important industry that should be saved - mainly from itself," she writes....

But over all, Dr. Angell's case is tough, persuasive and troubling. Arguing that in 1980 drug manufacturing changed from a good business into "a stupendous one," thanks to changes in government regulations. She adds, "Of the many events that contributed to their sudden great and good fortune, none had to do with the quality of the drugs the companies were selling."

In the past, drug discoveries made through government research remained in the public domain. Beginning in 1980 those breakthroughs could be patented, even if their research was sponsored by the National Institutes of Health. As a consequence, Dr. Angell says, patent shenanigans have reshaped the drug business, as have the recent government regulations that expedite direct-to-consumer drug advertising. "Once upon a time, drug companies promoted drugs to treat diseases," Dr. Angell writes. "Now it is often the opposite. They promote diseases to fit their drugs."

Consider the consumer who exclaims, in Dr. Angell's words, "Omigosh, this Clarinex ad makes me realize I have hay fever!" According to her book, this individual is being snookered in several ways. First of all, there is the drug itself: she calls Schering-Plough's Clarinex a "me too" variant of the same company's popular allergy drug Claritin. But Claritin's patent expired in 2002, so the new version has been heavily marketed.

Dr. Angell maintains that while Claritin was approved as a hay fever remedy, Clarinex is an improvement only because it has been approved for the treatment of both indoor and outdoor allergies. "It was approved for the additional use only because the company decided to test it for that use," she says.

And why all the advertising? ...

[elvis]

anne, thanks for the links/articles.

[BJ Feng]

Why shouldn't they advertise if it will help sell more drugs? Again, the fault is with the way prescriptions are handed out by doctors, the "quick-fix" solution preferred by Americans, and the American legal system in this area.

Advertisements wouldn't be effective if doctors did their jobs and prescribed only necessary medicines using a cost/benefit approach. But doctors also face medical liability. If the patient asks if they need a certain drug, and the doctor knows that there is only a 1% chance the drug will be of any benefit, the doctor still will prescribe the drug because of the enormous liability he faces if he doesn't and the patient dies. The first thing a trial lawyer will ask is if there is anything the doctor could have done that they didn't do to prevent death. Juries don't seem to care about probabilities and cost/benefits, they only understand that the patient died, and might have been saved if only the doctor did something else. This kind of after-the-fact, Monday quarterbacking has to stop or doctors will just prescribe everything they can to avoid being fingered if the patient dies later.

It's also easier for patients to ask for a pill to lower blood pressure instead of exercising more and cutting calories to do the same. That is their right, but they should have to pay for that. Exercising and eating less "costs" more to the patient than taking a bunch of pills. Only higher drug costs can shift the balance of the pill vs. healthy living choice people face. Giving free health care would further encourage people to take more pills, not less.