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Thursday, September 10, 2009



Here we go folks... I'd bang my head against the wall, but I'm unsure about the quality of the health care I'd receive...

Again, I can barely turn on CNN in the mornings because I know someone is going to say something about health care that will make me absolutely livid. Someone will say "trigger option" one more time and I'm going to put my head through the TV in an effort to scream directly at Olympia Snowe that people need %*^&%! health care RIGHT NOW. Like this second. Like twenty years ago. Like ONE HUNDRED years ago.

The Power to Cloud Men's Minds....
The debate -- if you can call it that-- is so freaking contorted now that nobody knows what side is up. August was, if you believe the pundits, a total disaster of town hall brawls. People are out there shouting "Keep your goddamned government hands off my Medicare!"

Voices of reason and logic, like Robert Reich--a former secretary of Labor and now professor at UC Berkeley-- are being practically drowned out in the furor. Here's his explanation of the public option, clear and simple.

But summertime's over, babycakes. It's time for the big B.O. to take things in hand because frankly this bipartisanshit-- sorry, bipartisanship thang ain't working out.

The Character of Our Country
In case you missed it, the full text of Obama's address to Congress is here. (Video here) Thank God, because just as Obama was getting to the emotional peak -- "That large-heartedness – that concern and regard for the plight of others – is not a partisan feeling. It is not a Republican or a Democratic feeling. It, too, is part of the American character." my DVR cut off. Doesn't matter. Here's the rest.

You see, our predecessors understood that government could not, and should not, solve every problem. They understood that there are instances when the gains in security from government action are not worth the added constraints on our freedom. But they also understood that the danger of too much government is matched by the perils of too little; that without the leavening hand of wise policy, markets can crash, monopolies can stifle competition, and the vulnerable can be exploited. And they knew that when any government measure, no matter how carefully crafted or beneficial, is subject to scorn; when any efforts to help people in need are attacked as un-American; when facts and reason are thrown overboard and only timidity passes for wisdom, and we can no longer even engage in a civil conversation with each other over the things that truly matter – that at that point we don't merely lose our capacity to solve big challenges. We lose something essential about ourselves.

What was true then remains true today. I understand how difficult this health care debate has been. I know that many in this country are deeply skeptical that government is looking out for them. I understand that the politically safe move would be to kick the can further down the road – to defer reform one more year, or one more election, or one more term.

But that's not what the moment calls for. That's not what we came here to do. We did not come to fear the future. We came here to shape it. I still believe we can act even when it's hard. I still believe we can replace acrimony with civility, and gridlock with progress. I still believe we can do great things, and that here and now we will meet history's test.
Because that is who we are. That is our calling. That is our character.

Shape the future. The time to call or email your reps is now.

Contact your individual representatives and senators.
Look 'em up, folks -- call your friends in Montana, call your friends in Blue Dog states. It's time to make a squawk --to inform these Congress members that THEIR jobs are on the line. Email is cheap -- health care isn't.

If you're interested in the details of Obama's own plan, visit the White House site.


In this week's New York Times, Paul Krugman puts out a simple defense of the public option:

Most arguments against the public option are based either on deliberate misrepresentation of what that option would mean, or on remarkably thorough misunderstanding of the concept, which persists to a frustrating degree: I was really surprised to see Joe Klein worrying about the creation of a system in which doctors work directly for the government, British-style, when that has nothing whatsoever to do with the public option as proposed. (Forty years of Medicare haven’t turned the US into that kind of system — why would having a public plan change that?)


And about the National Health Service...

Much maligned in the news in the month of August was the UK's National Health Service. Eric's mom-- who also sent me a link to this very interesting, and not atypical, story about the NHS-- was out here for a visit last week and happened to be staying in a B&B with a physician from the UK's National Health Service. I'm grateful to her and to Dr. Stephen Shepherd for letting me reprint some of his thoughts on this health care debate.


Whilst visiting San Francisco in August 2009 a few thoughts occurred to me concerning the current debate in the US about the proposed changes to the US Health care system and comparisons with the UK's NHS.

In every country in the world there are basically only 3 ways of accessing health care.

The rich simply pay cash for whatever they want.

Those with health insurance received 'managed care'

The poor are thrown on the basic healthcare provided by the State

In the UK the NHS covers both the last two catagorys. The standard of care for ALL is equivalent to the managed care received by US citizens with insurance. A few people in the UK have private health insurance, usually as a perk of their job. In the past this allowed you to bypass some of the NHS queues. Nowadays, with the better financed NHS, private health insurance tends just to allow you to have private room, rather than share a 4-bedded bay, which is the norm in NHS hospitals.

The vast majority of hospital specialists or Consultants do most of their work in the NHS and do private work to supplement their NHS income. Private hospitals are not really set up for complex procedures and if you are seriously ill you are best off with the NHS.

The key to the NHS is the General Practitioner or GP (Primary Care Physician). Your GP will refer you for both NHS and Insurance referrals, but will provide the bulk of your care. Most chronic diseases in the UK are dealt with by the GP, who will know you and your past history and will tailor your healthcare for you personally. Primary Care is very strong in the UK.

Now to deal with a few points:

Rationing: all healthcare is rationed, except for the rich. In the UK most treatments are covered by the NHS and your doctor is free to prescribe any drug or treatment that is marketed in the UK. The exceptions are new expensive treatments whose clinical effectiveness are assessed by an independent body called the National Institute for Clinical Excellence (NICE), before they become widely available on the NHS. In the US health care is rationed by the Insurance companies managed care system, or by your ability to pay. I understand it is not unknown for people to die in the US as they lack the money to fund their treatment. I leave the reader to decide which is the better system.

Waiting Times and Choice: in the past the wait for routine procedures could be measured in years, but since the advent of Tony Blair's Labour Government a lot of money has gone to improve matters. As a GP I can use the new Choose and Book computer system to book appointments during a patient's consultation, at a time and date of their choosing. Most routine appointments will be within a month. It is unusual for the wait for surgery to be more than 3 months. If your GP thinks you may have cancer, there is a rapid access system which gets you to see a Specialist within 2 weeks and any definitive treatment started within a month.

Quality: British doctors are trained to the same standard as those in the US and foreign graduates wanting to work in the UK must have a good standard of English and meet the clinical standards set by the various Royal colleges that supervise training in the UK.

Income: when the NHS was set up in 1945 many doctors feared that they would be out of pocket. This has proved to be far from the case. Most GPs earn £120000 from the NHS with very little from private work. Experienced nurses earn from £20-30000. Hospital Consultants earn around £100000 from the NHS, but their additional private income can vary from zero to £100000+ according to their speciality and/or personal choice.

Innovation: the charge that the NHS discourages innovation and invention just makes me laugh. The route to being a hospital consultant is through research. All hospital consultants only get their position once they have done some research and continue to do so once in post. British drug companies are amongst the best in the world and around 40% of current treatments had their origins in the UK.

I admit to wondering what lies behind the opposition to President Obama's health care reforms. I suspect that many Americans realise that sorting out your healthcare system will inevitably lead to other social reforms.

The NHS is a small part of a whole raft of social benefits that make up the British Welfare State.

Benefits are provided if you are unemployed, sick, disabled or caring for someone who cannot care for themselves. Everyone gets an old age state pension from 65. The elderly are one of the main beneficiaries of the NHS. Should you need residential or nursing home care as you get older then the state pays for that and allows you to keep significant personal assets.

The poor and other disadvantaged groups are not left to fend for themselves on the streets. Local government in the UK has a statutory duty to provide social housing for all who need it, together with social services care. The homeless are not left to roam the streets, but are housed in hostels, where they have their own lockable room. These hostels provide temporary accommodation until the local authorities can find somewhere permanent, usually in the form of a one or two bed apartment.

This extensive welfare system is the result of the Socialist Government of 1945 and is the result of the report carried out by Beveridge in the later years of WW2. It is important for Americans to remember that the UK, and Europe in general, is far more left wing than the US. The main British right wing party, the Conservatives, are much more akin to left leaning Democrats. The Labour Party is a left wing party that has moved a little more to the right under Tony Blair. Some of the views I have read from Republicans would have no place in British politics, except in our extreme right wing parties like the British National Party (BNP), who are viewed with contempt by the majority in the UK.

The downside of course to the Welfare state is the cost. Income tax in the UK starts at 20% and rises to 40% on any income in excess of £38000.

On mainland Europe the Social care systems are more generous than the UK, but their income tax rates are higher. In the US it seems you provide very minimal benefits, but have low income tax.

In the UK we have gone for the middle ground between the two.

A UK style system would almost certainly lead to the US middle class losing their mortgage tax relief, as happened in the UK. Perhaps this is the main reason for the opposition?

Benefits in the UK are aimed at providing a comprehensive safety net with benefit levels set to allow you to survive and stay in your own home. No one would choose to stay on benefit as even a modest income will give a better quality of life. For instance, except in times of recession, most people made unemployed would have found a new job within a month. The UK is still a net importer of employees.

A few people do slip through the net, especially in London, but people begging on the street is unusual in the UK and often they are people who have great difficulty engaging with any form of authority. Strenuous efforts are made by many state and charity groups to engage with these individuals.

Remember even these people have the right to see a GP and access all parts of the NHS. I have worked for a practice that provided services targeted at the homeless.

I am shocked whilst in the US, the richest country in the world, to see such affluence along side such abject poverty.

I would like to remind the US: 'No man is an island.'

Dr Stephen Shepherd, GP

Ashby de la Zouch, Leicestershire


Final words from the Grand Fromage
Watching the funeral of Ted Kennedy last week, I couldn't help but be overwhelmed by how much there is left to do-- and from the top of Ted's list: the "cause of my life", which he outlined in an article for Newsweek last month. As usual, he doesn't just bemoan the opposition they face, but looks at the possibilities.

Incremental measures won't suffice anymore. We need to succeed where Teddy Roosevelt and all others since have failed. The conditions now are better than ever. In Barack Obama, we have a president who's announced that he's determined to sign a bill into law this fall. And much of the business community, which has suffered the economic cost of inaction, is helping to shape change, not lobbying against it. I know this because I've spent the past year, along with my staff, negotiating with business leaders, hospital administrators, and doctors. As soon as I left the hospital last summer, I was on the phone, and I've kept at it. Since the inauguration, the administration has been deeply involved in the process. So have my Senate colleagues—in particular Max Baucus, the chair of the Finance Committee, and my friend and partner in this mission, Chris Dodd. Even those most ardently opposed to reform in the past have been willing to make constructive gestures now.

I long ago learned that you have to be a realist as you pursue your ideals. But whatever the compromises, there are several elements that are essential to any health-reform plan worthy of the name.

First, we have to cover the uninsured. When President Clinton proposed his plan, 33 million Americans had no health insurance. Today the official number has reached 47 million, but the economic crisis will certainly push the total higher. Unless we act now, within a few years, 55 million Americans could be left without coverage even as the economy recovers.

All Americans should be required to have insurance. For those who can't afford the premiums, we can provide subsidies. We'll make it illegal to deny coverage due to preexisting conditions. We'll also prohibit the practice of charging women higher premiums than men, and the elderly far higher premiums than anyone else. The bill drafted by the Senate health committee will let children be covered by their parents' policy until the age of 26, since first jobs after high school or college often don't offer health benefits.

To accomplish all of this, we have to cut the costs of health care. For families who've seen health-insurance premiums more than double—from an average of less than $6,000 a year to nearly $13,000 since 1999—one of the most controversial features of reform is one of the most vital. It's been called the "public plan." Despite what its detractors allege, it's not "socialism." It could take a number of different forms. Our bill favors a "community health-insurance option." In short, this means that the federal government would negotiate rates—in keeping with local economic conditions—for a plan that would be offered alongside private insurance options. This will foster competition in pricing and services. It will be a safety net, giving Americans a place to go when they can't find or afford private insurance, and it's critical to holding costs down for everyone.

We also need to move from a system that rewards doctors for the sheer volume of tests and treatments they prescribe to one that rewards quality and positive outcomes. For example, in Medicare today, 18 percent of patients discharged from a hospital are readmitted within 30 days—at a cost of more than $15 billion in 2005. Most of these readmissions are unnecessary, but we don't reward hospitals and doctors for preventing them. By changing that, we'll save billions of dollars while improving the quality of care for patients.

Social justice is often the best economics. We can help disabled Americans who want to live in their homes instead of a nursing home. Simple things can make all the difference, like having the money to install handrails or have someone stop by and help every day. It's more humane and less costly—for the government and for families—than paying for institutionalized care. That's why we should give all Americans a tax deduction to set aside a small portion of their earnings each month to provide for long-term care
There have been lots of tributes to Ted Kennedy of course, but I remember this one as especially lovely, from last year at this time, when Ted Kennedy appeared at the Democratic National Convention. But perhaps even more moving was Senator Robert Byrd's tribute:

I had hoped and prayed that this day would never come. My heart and soul weeps at the loss of my best friend in the Senate, my beloved friend, Ted Kennedy.

Senator Kennedy and I both witnessed too many wars in our lives, and believed too strongly in the Constitution of the United States to allow us to go blindly into war. That is why we stood side by side in the Senate against the war in Iraq.

Neither years of age nor years of political combat, nor his illness, diminished the idealism and energy of this talented, imaginative, and intelligent man. And that is the kind of Senator Ted Kennedy was. Throughout his career, Senator Kennedy believed in a simple premise: that our society's greatness lies in its ability and willingness to provide for its less fortunate members. Whether striving to increase the minimum wage, ensuring that all children have medical insurance, or securing better access to higher education, Senator Kennedy always showed that he cares deeply for those whose needs exceed their political clout. Unbowed by personal setbacks or by the terrible sorrows that have fallen upon his family, his spirit continued to soar, and he continued to work as hard as ever to make his dreams a reality.

In his honor and as a tribute to his commitment to his ideals, let us stop the shouting and name calling and have a civilized debate on health care reform which I hope, when legislation has been signed into law, will bear his name for his commitment to insuring the health of every American.

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