Whither the Crisis? - Part 2 of a series on Health Care Reform

We are continually being told that we have a "health care crisis". According to President Obama, in his latest address to the joint session of Congress, the health care system is "at the breaking point." So, we need to ask ourselves if we really do have a crisis and, if so, what, exactly, is the crisis?

A crisis is a situation that requires immediate action in order to avoid catastrophe. We have seen the results, with this administration and the last, of a crisis-oriented administration. As President Obama's Chief-of-Staff, Rahm Emanuel, famously said, "Never let a good crisis go to waste." And this administration certainly hasn't. We have seen an $800 billion dollar "stimulus bill", rushed through Congress and passed before anyone had a chance to read it to respond to the "economic crisis." We saw the government take-over of 2/3 of our domestic auto industry in response to an auto industry crisis. The House of Representatives passed the Cap and Trade Bill before it was finished being written - a bill that, if it passes the Senate, will constitute the largest tax hike on the middle and lower classes in history, in response to the "global warming crisis." Taxes are being levied on sugary juice and sodas in response to the "obesity crisis." A crisis is a very convenient circumstance to rush a bill through Congress without giving the public watchdogs or even the Congress Critters time to analyze the fine print of the legislation and also gives convenient cover to spend a lot of money in order to avert the imminent catastrophe. President Jimmy Carter once said, ""When a president has authority to act unilaterally (as in a crisis), his leadership can be exerted. Otherwise, compromise, delay and confusion are more likely." In fact, when Carter was presented an "energy crisis", he declared fighting it, "The moral equivalent of war."

That is not to say that there are no real crises, but when the government attempts to rush a huge, expensive bill through Congress on the basis of a crisis, our antennae should go up and we need to be sure there actually is a crisis and that what we are doing is necessary to avert that crisis. We've all seen shoot-outs on Main Street in old Western movies. In the movies, the quickest draw always won. In real life, it wasn't like that. A quick draw and shoot with a pistol is wildly inaccurate. The real winner was usually the gunslinger that took time to aim and make sure he was going to hit his target. The trouble with much of our crisis legislation is that we don't take time to aim. We spray our shots wildly, thus wasting valuable ammunition and usually getting ourselves shot, anyway.

So, is the crisis in health care one of quality? You might think so, given some of the rhetoric coming out of Washington. We hear that we spend more on our health care than any other nation, but get less for it. I've debunked this notion in my previous essay, First, Do No Harm, posted on Sept. 12, 2009. We actually have the best health care system in the world and our numbers prove it. I'm not going to reiterate my arguments here, if you haven't yet, read my previous essay.

Another reason for the "crisis" that we hear is that there are a large number of people who have no access to medical care because they cannot get insurance. The original number we heard bandied around was 47 million Americans (out of approximately 304 million), or about 15% of the population. In the most recent speech to the joint session of Congress, President Obama revised that number down to 30 million, since 17 million of those in the higher number were illegal aliens. 30 million is still a substantial number of people uninsured, but is that the whole story? No. Actually, according to the US Census bureau, more than 9 million make more than $75,000/yr. and could afford at least catastrophic health care insurance, if they choose. Many of these people are young, single people who eschew health insurance because they are healthy and would rather spend the money on flat-screen TVs and iPods. Another 14 million people are fully eligible for government programs like SCHIP or Medicaid, but are not signed up. In fact, of the children who are uninsured, over 70% are eligible for SCHIP, Medicaid, or both. That leaves 7 million Americans, or approximately 2% who are chronically uninsured. Now, without a doubt, for those individuals and families, being uninsured is a crisis, but should we restructure the entire US health care system for 2% of our population, especially when 85% of Americans say that they are happy with their health care insurance? Are there other, and better, ways to cover these uninsured people? I argue that there are and I will discuss this topic in upcoming essays.

The third common reason we hear for the "crisis" is that health care costs are rising too rapidly and they have become a burden on our economy. Certainly, health care costs have risen far faster than the general economy over the last couple of decades. They've risen almost as fast as the advances in medicine have. There are a number of reasons for this and I'll address this issue in another essay. According to President Obama, the rising cost of health care depresses the economy of the country and the individual economies of our citizens. In his State of the Union address, President Obama claimed that a bankruptcy occurred every 30 seconds. That is false. There is not even a bankruptcy every 30 seconds in the US, let alone one caused by high medical care costs. In actuality, while people who go bankrupt often have unpaid medical bills, few people (<1%,>because of medical expenses. Almost all hospitals and physicians will allow patients to pay on an installment basis and will not contact credit bureaus if the patient is making regular payments. As Thomas Sowell says, “In a country where everything imaginable is bought and paid for on credit, why is it suddenly a national crisis if some people cannot pay cash up front for medical treatment?”

So, is there a crisis in our health care system? Do we really need to rush a bill through Congress in order to avert an imminent disaster, or do we have time to rationally study and discuss and debate these issues? There is no doubt that health care is expensive, though we cannot expect Mercedes health care for the price of a Yugo. But there are many free-market solutions that do not involve a government that has an unbroken history of bringing in programs at higher cost and more inefficiently than anticipated.

In actuality, there is no more of a crisis now than there was a year or two or three ago. The only crisis for those who are trying to rush this through is that the American people may get wind of what is in the bill. I addressed this in my essay, Honest Barack’s Used Car Lot (posted Aug. 25, 2009.) The situation is too important to be rushed through or relegated to government control.

In my first health care essay, I used the oft-cited medical phrase, Primum non nocere – First, do no harm. We must keep that in mind as we discuss health care reform.

First, Do No Harm – Reforming Health Care (Part One)

I had originally thought I’d write an essay covering my opinions on the problems in health care and my opinions on how we can reform the system. I quickly realized that such an essay would run many pages and no one wants to wade through that. I’ve decided, therefore to do this in installments. This essay is the first of a planned series on the subject.

Introduction

I don’t know that there is anyone who thinks that health care doesn’t need reformed. The straw man that President Obama posits, that those who oppose his brand of health care reform want the status quo, is just not true. The problems are complex and defy simple, or quick, solutions. The issue requires careful study, sober contemplation, and multi-faceted solutions rather than quick solutions based on political expediency and interest group politics. Unfortunately, serious attempts to comprehensively address these issues are in short supply in Washington these days. In this series, I will attempt to address some of the problems we face and will suggest some potential solutions for those problems.

My Qualifications

Simply put, I am a member of the health care industry. I have been a physician for 23 years, working both in primary care and as a specialist. I have worked for the government when I served in the U.S. Air Force and am now in a private practice. I currently am a radiologist and nuclear medicine physician in Grand Rapids, Michigan. I am a shareholder in one of the largest single-specialty private practice groups in Michigan. I work in several hospitals and a large private medical group. One of the hospitals in which I work is a large, level I trauma center that has the 13^th busiest emergency department in the United States. It is also within the top 10 in the United States in the number of joint replacement surgeries and heart surgeries performed. I am on faculty at the Michigan State University medical school and teach medical students and residents.

My father was a small-town family physician for almost 40 years. He was a true cradle to grave doctor who delivered babies, made house calls, and was on-call 24 hr./day.

One problem that I see with health care reform is that there is a dearth of practicing physicians among the reformers. Most of the people on these committees are politicians, businessmen, or physicians who have not seen the business end of a stethoscope for years. In a field that is growing and changing as quickly as medicine, someone who has not practiced for several years has no conception on how health care has changed. Ask any physician and they will tell you that the practice of medicine 10 years ago is almost unrecognizable today.

So, as far as my qualifications go, they are informed and limited by my daily life as a physician. I don’t claim to be an expert on the insurance industry, the hospital industry, or the pharmaceutical industry. This paper, therefore, shouldn’t be seen as a comprehensive solution, but as a piece of a much larger puzzle.

Primum, non nocere

I will begin with a premise of which I am absolutely convinced, and that is that the United States health care system is, by far and away, the best in the world and it isn’t even close. Our physicians, nurses, and ancillary personnel are better trained than anywhere else, our equipment is better and more plentiful, and our facilities are second to none. It is no accident that our medical schools and residency programs are filled with students from around the world. It is also not merely blind luck that almost every significant medical advance in the last 30 years has come from the United States.

Detractors will point to lower life span in the United States, as compared to other countries, but not account for the high rates of obesity, heart disease, and violent (primarily vehicular) deaths in the United States as compared with most of the rest of the world. These are not health care issues as much as lifestyle issues. As the late syndicated columnist, Mike Royko said

Let us talk about medical care and, one of the biggest problems we have. That problem is you, my fellow American. Yes, you, eating too much and eating the wrong foods; many of you guzzling too much hooch; still puffing away at $2.50 a pack; getting your daily exercise by lumbering from the fridge to the microwave to the couch; doing dope and bringing crack babies into the world; filling the big city emergency rooms with gunshot victims; engaging in unsafe sex and catching a deadly disease while blaming the world for not finding an instant cure.
You and your habits, not the doctors, are the single biggest health problem in this country. If anything, it is amazing that the doc’s keep you alive as long as they do. In fact, I don’t understand how they can stand looking at your blubbery bods all day.

According to the Center for Disease Control, the average life expectancy for white females in the United States born in 2005 is 80.4years. That of white men is 75.2 years. Average life expectancy for an African American female born in 2005 is 76.5 years. Do we really think that African American females receive better health care in the United States than white men? According to the Department of Health and Human Services, the group with the highest life expectancy in the United States is Oriental women, with a life expectancy of 85.8 years. So, according to those who use life expectancy as an indicator, Oriental women receive the best health care of all. The fact of the matter is that health care has little to do with life expectancy.

Another statistic that is often trotted out by detractors of the US health care system is that of the infant mortality rate. But again, as they say, there are lies, damned lies, and statistics. Infant mortality is defined as the death of any child who was born live and who dies before one year of age. One of the problems is what constitutes a live birth? An article in US News and World Report, published in 2006, sums up the problem this way:

First, it's shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don't reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country.

Some countries will not count any birth as a live birth if the baby is pre-term (38 weeks.) In fact, Russia and other former Soviet Union countries would not count a premature baby as having been born alive until it had lived for 7 days. Japan and Hong Kong both report a very high rate of stillborn infants to live births, almost certainly because those infants who die shortly after birth are being reported as stillborn rather than an infant death.

In the United States, 50% of all babies born at 25 weeks survive because of the extraordinary care we provide. Elsewhere around the world, it is rare that any attempt is made to care for these infants. They are more likely to die within minutes to hours after birth and be listed as a stillbirth or a miscarriage.

During my residency, I spent three months at Boston Children’s Hospital. I remember reading chest x-rays from the neonatal intensive care unit and remarking on how many children had a rare congenital heart disease (I don’t remember now which one.) My attending reminded me that the disease was exceedingly rare, but that Children’s Hospital was the only place in the world that offered the potential life-saving surgery for these babies. And it wasn’t just this one heart disease. It was a number of different conditions. During my three months there, I saw children that had been flown in from Canada, Mexico, Brazil, Portugal, France, and Saudi Arabia, just to name a few. Now, if one of these infants died, this would count against the United States statistics since that is where the death occurred. And Boston Children’s, while one of the finest pediatric hospitals in the United States, certainly isn’t unique. There are a number of pediatric hospitals in the US that perform similar services.

Probably a better indication of the quality and accessibility of health care is cancer survival rate, which is almost entirely due to differences in detection and treatment. The 5-yr. survival rate (those patients still alive 5 years after detection) for breast carcinoma in the United States is 90.1%, in Europe, it is 79.0%, and in Canada, 82%. For prostate carcinoma, the 5-yr. survival rate in the US is 99.3%, in Europe it is 77.5% and in Canada, it is 87%. In fact, for every cancer, the US 5-yr. survival rate is higher than that of Europe and Canada. For all cancers, no country in the world has better cancer survival rates than the US.

As far as quality of care, accessibility, and innovation, there is nowhere in the world that can equal the United States system of health care. Whatever else is done to reform health care, the reformers should adopt one of the first lessons taught in every medical school – Primum, non nocere. First, do no harm.