- Last week’s figures on cost and coverage from the Congressional Budget Office (CBO) shifted attention to those health care reform initiatives that are less costly. One of these is the Healthy Americans Act sponsored by Senators Ron Wyden (Oregon Democrat) and Bob Bennett (Utah Republican). The Wyden-Bennett plan rules out a public option (insurance from the government), but requires an individual mandate (everyone must have insurance). It taxes health benefits, although there would be a $19,000 income tax deduction for a family of four.
- David Brooks has an excellent op-ed column in Monday’s New York Times on the Wyden-Bennett plan and, in particular, on the tax exemption for employer-proved health care.
- David Brooks argues that the current plans under construction in Congress are built on what’s currently in place. To illustrate the wrong-headedness of this approach, he quotes “health care costs guru” John Sheils: “The single most expensive option is to build on the existing system.”
- We all know from medical dramas on TV, ranging from Doogie Howser, M.D. to Scrubs, if not from personal acquaintances, that becoming a doctor is a grueling process. Dr. Pauline Chen has a column in the NY Times on a question that plagues doctors as they begin their internship or residency: “Do I have to lose my self in order to become the doctor I want to be?”
- Speaking of doctors finding balance, PBS has an excellent NOVA documentary called Doctors’ Diaries. It’s a little like The Up Series of documentaries that films the lives of 14 British children every seven years. Doctors’ Diaries follows seven doctors from their training at Harvard Medical School in 1987 up to the present. The producer, Michael Barnes, has written a behind-the-scenes description of what the filming process entailed.
Health care reform
Wyden-Bennett plan, Fundamental Democrat/Republican differences, Gawande on building from what we have)
The Medical profession
(Stress vs. balance for doctors, Doctors’ Diaries on NOVA)
Health care reform
In an interview with The Wall Street Journal, Senator Wyden argued that it’s far better to pass a bill with broad support from both Democrats and Republicans than to use the reconciliation option. Otherwise you’ll have members of Congress trying to repeal the plan as soon as it’s passed.
The Wyden-Bennett plan combines the Democrats’ desire to have everyone covered and the Republicans’ interest in relying on the markets and preserving consumer choice. The Healthy Americans Act is supported by 14 Senators. Many Democrats are skeptical, especially those with ties to labor unions.
On unions, Wyeth says:
Unions have every right to bargain for the best possible package …. “But nobody, be it a CEO or a labor [union] member ought to be getting what amounts to gold-plated coverage with the tax subsidies paid for by somebody who is a modestly compensated woman at a small business who doesn’t have a health plan.”
On the public option as a slippery slope to single-payer:
“A lot of the people who are for a public option want a single-payer system, and they haven’t minced any words about it. Bless their hearts, extra points for honesty. But that’s not where I am.”
On universal coverage:
[U]niversal coverage … is proving more of a cautionary tale than the inspiration Democrats would like to call it. “I’ve gone and met with the Massachusetts folks,” Mr. Wyden says, and “cost containment is the Achilles heel.”
Arguments for the tax-exemption:
The exemption is a giant subsidy to the affluent. It drives up health care costs by encouraging luxurious plans and by separating people from the consequences of their decisions. Furthermore, repealing the exemption could raise hundreds of billions of dollars, which could be used to expand coverage to the uninsured.
After the Congressional Budget Office numbers sent Senate committee members scrambling last week, you’d think they might consider the Wyden-Bennett plan, “which already has a good C.B.O. score, bipartisan support and a recipe for fundamental reform.”
If you did think that, you are mistaking the Senate for a rational organism. For while there are brewing efforts to incorporate a few Wyden-Bennett ideas, there is stiff resistance to the aspects that fundamentally change incentives. …
The left is uncomfortable with the language of choice and competition. Unions want to protect the benefits packages in their contracts. Campaign consultants are horrified at the thought of fiddling with a popular special privilege. …
But there is almost nothing that gets to the core of the problem. Under the leading approaches, health care providers would still have powerful incentives to provide more and more services and use more expensive technology.
We’ve built an entire health care system (maybe an entire government) on the illusion of something for nothing. Instead of tackling that basic logic, we’ve got a reform process that is trying to evade it.
But Atul Gawande made a strong case for building on the health care system we already have in a January New Yorker article called “Getting There from Here.” He first considers the fears that accompany the prospect of change and the arguments for overcoming those fears.
[W]herever the prospect of universal health insurance has been considered, it has been widely attacked as a Bolshevik fantasy–a coercive system to be imposed upon people by benighted socialist master planners. People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse–especially for those who already have dependable coverage and access to good doctors and hospitals.
Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.
And both sides, he says, have contempt for anyone who argues that we should build a new system around “the mess we have.”
The country has this one chance, the idealist maintains, to sweep away our inhumane, wasteful patchwork system and replace it with something new and more rational. So we should prepare for a bold overhaul, just as every other Western democracy has.
He then goes on to show that this is not how it happened in Great Britain, France, and Switzerland.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
He describes the fiasco of the 2006 Medicare reform, an entirely new system that produced chaos. “There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices.”
As one intimately familiar with the problems of the health care system — a surgeon practicing in Massachusetts — he concludes:
Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it.
There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have. …
Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.
The medical profession
She reports on a study from the Johns Hopkins University School of Medicine in Baltimore that interviewed doctors beginning their residency.
[These doctors] set themselves up for burnout by accepting, even embracing, what they believed would be a temporary imbalance between the personal and professional aspects of their lives. While the young doctors interviewed defined well-being as a balance between all those parts, many felt that their medical training was so central to their ultimate sense of fulfillment that they were willing to live with whatever personal sacrifice was required, even if it meant a temporary loss of a sense of self. …
[W]hen the imbalance persists for longer than initially expected, professional growth is not enough to sustain most young doctors. “The ones who are happier … are the ones who have held on to one or two things and have said, ‘I’m not just another resident. I play the guitar, I run races, or I go home to family.’ They don’t do these things to the same extent as they did before residency, but they do them enough to maintain a sense of self.”
Doctors-in-training hold out the hope that things will get better – after my internship, after my residency, after I’ve retired. The author of the Johns Hokpins study, Dr. Ratanawongsa, suggests that doctors need to include balance in their lives from the beginning of their training. Otherwise there’s the danger that doctors will leave the work force or become less effective.
“We are taught to put our patients before ourselves … but I also think there has to be some sense that I matter, too, at some point. … [W]e need time to reflect on who we are and where we are going. …
[D]octors will have a greater capacity to know their patient as a person if they know themselves. That kind of knowledge requires a sense of balance and an understanding of why they chose to become a doctor. It comes down to their capacity to be an empathic, caring and compassionate provider; and it comes not from their medical knowledge but from their soul. This is something we should never sacrifice, even temporarily.”