Last night, President Obama made a pitch for preventive care in his address to a joint session of Congress on health care:
“And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies – because there’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.”
As a doctor who has held the hands of patients dying from totally preventable illnesses, I couldn’t agree more. The largest number of deaths in the United States are caused by two preventable causes – tobacco smoking and high blood pressure – killing an estimated 467,000 and 395,000 people respectively in 2005. The list goes on and on, including obesity, physical inactivity, and poor diet.
When I was working in the emergency room as a medical resident, it was heartbreaking to see a patient with poor routine medical care roll into the emergency room with a devastating stroke that could have easily been averted with regular office visits and blood pressure medication – both relatively inexpensive compared to the cost of caring for the stricken patient.
We’re not preventing enough deaths by the types of cancer screening tests mentioned by President Obama. One reason is the technology is still not good enough. We need to develop better screening tests that pick up problems early but don’t lead to an unacceptable number of unnecessary biopsies, procedures, and further tests. And not enough patients are screened. Only about about 60 percent of women get mammograms and about 50 percent of men and women get routine colonoscopies.
Lack of insurance coverage is certainly a big reason why some patients don’t undergo screening. Another reason is patient fear and misunderstanding. In order to educate the public about the risks of colon cancer and the benefits of screening exams, Katie Couric underwent a colonoscopy on national television in March, 2000. Three years later, researchers at the University of Michigan found that colonoscopy rates jumped by 20 percent across the country following Katie’s procedure, calling the rise the
“Katie Couric Effect.”
It’s almost 10 years later and we’re still not screening enough patients. Although the death rate from colon cancer has dropped in recent years – likely mostly because of screening efforts – colorectal cancer still strikes almost 150,000 Americans every year and kills about 50,000.
As a gastroenterologist, I have seen patients’ lives saved by the removal of polyps and early cancers found by colonoscopy. I have also taken care of patients whose colon cancers were found too late to save them. Over the years, I must have heard every excuse for ducking a colonoscopy. The top four (and my answers):
I have no symptoms (most colon cancers start small and have no symptoms until they grow larger.)
I have no family history of colon cancer (that’s true in about 70 percent of patients with colon cancer.)
I’m afraid it will hurt (that’s why we use sedation and, if needed, anesthesia.)
I can’t do the prep (we’ll figure out a way to clean out your colon that you can tolerate.
And even if you have a tough night, it sure beats chemotherapy.)For this week’s CBS Doc Dot Com, I follow Katie’s lead and undergo a colonoscopy with cameras rolling in an attempt to remind people that a screening colonoscopy can save your life. I had the benefit of a house call the night before by my office nurse, Debbie Fitzpatrick, who held the video camera and offered advice and encouragement as I had a taste of my own medicine: the colon cleanout solution. The colonoscopy was performed expertly by Dr. Mark B. Pochapin, director of The Jay Monahan Center for Gastrointestinal Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
For more information about the Jay Monahan Center,click here.
For more information about screening for colon cancer, click here.To watch my colonoscopy, click below:
Because some of his recent posts seem to have confused many of his readers (why is he so strongly against proposed healthcare reforms when he supports so many of its goals?), DrRich will state once again, for the record, his political philosophy.
DrRich is a classical liberal. This means he deeply values the concepts that guided America’s Founders; individual autonomy, property rights, freedom from restraint, free markets and limited government. He is deeply committed to the Great American Experiment, which is, to determine whether a nation conceived in personal liberty and dedicated to the proposition that all people are created equal can long endure.
He believes that healthcare is very, very important, and indeed, has dedicated his career and most of his life to healthcare. But it is not the most important thing. For our generation to abandon the Great American Experiment for the sake of healthcare, or anything else for that matter, would be a perfidious act against our posterity, and indeed a crime against humanity.
DrRich is in favor of healthcare reform, and is glad that serious efforts to reform healthcare are at last taking place. He even finds much to like in the proposed reforms now percolating through Congress, such as, provisions for health insurance to be made available to most, if not all, of the people who cannot afford it today; the provision for health insurance to be made available to all the people who are blocked from insurance today because of their underlying illnesses; and the provision to prevent insurance companies (if any continue to exist in their present form) from canceling policies of their subscribers who get sick. These are all very good things.
But, as regular readers will know, DrRich has recently strongly criticized these proposed reforms, and hopes they will fail. This has angered and confused some of his readers, who know that he has favored universal healthcare, comparative effectiveness research, and other aspects of the reform plan now before Congress.
DrRich has turned against this reform plan not so much because of what’s in the reform bill itself. As DrRich has pointed out, the actual words of the reform bill are entirely open-ended. This is why proponents of one view or another can find in the bill what they wish to see (death panels vs. no death panels, continued availability of private insurance vs. a poison pill for private insurance, etc.), and it’s why their arguments take on the cast of debates among Biblical scholars over the true meaning of some cryptic Old Testament passage.
Rather, DrRich’s objection to this healthcare reform is based on the context in which it is being advanced. And in recent months he has come to see the context as this: a broad dismantling (whether inadvertent or not) of the Great American Experiment.
This dismantling probably began earlier than the fall of 2008 when DrRich first noticed it. But last fall was when our Congress (the peoples’ representatives) first began the wholesale abandonment of their duties and of the Constitution, with their passage of TARP. TARP took $700 billion and presented it to the Secretary of the Treasury to spend as he saw fit, thus creating, arguably, the second most powerful government official in U.S., and certainly the most powerful unelected one, in a manner never conceived under our Constitution. This was followed by the government’s moves to begin consuming Fannie Mae, Freddy Mac, AIG, numerous banks and investment houses, and the auto manufacturers. And all of this was begun under a Republican administration.
While the Obama administration did not start any of this, they took the ball and ran with it, and to a degree that would have seemed impossible (to DrRich, at least) a year ago. They completed the acquisition of the car companies and other private and quasi-private institutions into the federal portfolio. They added yet another $800 or $900 billion onto the federal debt with the Stimulus Bill, and in the process our flaccid Congresspersons once again acceded to the idea that when the executive branch cries “crisis,” it is perfectly acceptable to pass a 1000+ page law into existence without even making a pretense of discovering what is in it.
Then there is the disturbing gathering of power by the executive branch. This includes commandeering control of the upcoming census by the White House, and just this past weekend, bringing the interrogation of foreign (and presumably domestic) terror suspects under White House control. (Under what circumstances do you suppose a Congressional Intelligence Committee would ever launch an investigation of the White House’s interrogation practices?) Perhaps more disturbingly are the 30+ unelected “czars” the President has named so far, individuals with potentially very big (but undefined) powers that at least threaten to impinge on the functions of Constitutionally legitimate government agencies and branches. These czars are not approved, or even vetted, by Congress (our representatives) – and at least some of them look to DrRich like very scary people, whose avowed political philosophies are collectivist, anti-capitalist, and dismissive of the Constitution.
So when the healthcare reform process began, yet again, with the presentation of a 1000+ page bill and the exhortation to pass it immediately – don’t bother reading it – on account of the dire crisis confronting our healthcare system, DrRich had seen enough. When that “pass-it-quick-it’s-an-emergency” strategy failed for once, and people began reading the monstrosity and reacting to it (as the Constitution provides that they may), and when in response our leaders accused them of being fascists, terrorists, mobsters, and other disturbing things, DrRich had seen enough. When DrRich read big parts of the reform bill himself, and realized that it is an intentionally ambiguous document whose effect will be to turn over the re-shaping of our entire healthcare system to appointed functionaries, czars, and other unelected bureaucrats, DrRich had seen enough.
DrRich has never been a conspiracy buff. He has always believed that sustaining for any length of time a conspiracy any more extensive than, say, cheating at bridge, would be impossible. He has always considered the right-wing nut-jobs who think the opposition secretly wants to convert the United States to a Marxist utopia to be, well, nut-jobs. But if the governmental activities we’ve seen over the past six months are not a concerted effort to end, once and for all, the Great American Experiment, then they are at least an inadvertent effort to do so. DrRich wants this to stop.
Reforming healthcare is important, very important. But reforming healthcare is not worth abandoning the foundational precepts of the most exceptional country the world has ever seen.
We can reform our healthcare system effectively and equitably, in a way that specifically preserves and strengthens those foundational American precepts. (DrRich has described how elsewhere.) At one time DrRich thought current reforms could possibly be turned into a first step in that direction. Now, thanks to the context in which these reform proposals are being advanced, he sees present efforts at healthcare reform as an irreversible step in the opposite direction, and possibly a final step from which we are unlikely to ever recover.
First we must decide what kind of society we are to be – and that’s the real “discussion” we’re having now – and then, and only then, can we decide how we are to reform our healthcare system.
And this is why DrRich will make his paltry efforts to try to stop it.
“There are few people who are not ashamed of their love affairs when the infatuation is over.”
– François, Duc De La Rochefoucauld
The end of an infatuation is always rather sad – we have many expressions for it, “the bloom is off the rose” comes to mind. Falling out of love is often a moment of maturity, a moment of coming out of an illusion – never wholly welcome.
We have had many decades of uncritical, wholesale adolescent-style adoration, heartbreak and hate towards our politicians. We have been capable of sustaining illusions and uncritical thought with support from a similarly dazzled media. This has been done for years on both sides of the aisle. This kind of idealism says that we have finally found the man (party) who will (choose one) solve our problems, understand us, have complete integrity, be able to function in a trustworthy and honest fashion. This idealism comforted us by putting some in black hats and some in white. The comforts of certainty, zeal and clarity, even if untrue, are hard to resist. How long we can sustain this with any one politician or party depends on the filter we have, and how much attention we are paying. This is how crushes are sustained, in romance and in politics.
There are signs on the ground that we are beginning to grow up. We are beginning to understand that the corruption, self-interest, special interests and spin exist symbiotically on both sides of the aisle. With the deeply personal debate on health care and its associated reform costs, our need for honesty and successful policy to save our country is suddenly more important to us than the comfort of bedtime stories. This is political maturity.
What are the signs of this? Take for example, the publics’ realization that our representatives have not read a bill in its entirety. This conversation did not even occur as little as ten years ago – we assumed a level of expertise by our elected officials, or we didn’t care, but somehow, and this is the point, the illusion was maintained. In retrospect, I would imagine few bills were ever read page by page – and that the fact that they are not now is nothing new. What is new is that we now care about this. What is new is that we now see that legislation has a direct impact upon us. What is new is that we realize this congressional neglect shelters corruption in the form of deals, earmarks and policy that the public would not support if there was transparency. And we now see that there is transparency not provided by a beneficent body of elected officials or trusted news sources, but rather there is transparency because of the internet. It is unprecedented that we can summon chapter and verse of any bill onto our own computer – almost in real time.
This is a game-changer.
We are now (as voters) in a position to demand that legislation (including I daresay health-care reform) occur in incremental, transparent, understandable terms that voting citizens can vet themselves. Not thousands of pages of nearly incomprehensible gobbledygook. Anything short of that has become unacceptable, in part because we are also now able to contact our representatives at a moments notice. In years to come, we will now look back and see the final lipstick-on-the-collar moment in our relationship with Congress as the ramming through of the unread, un-vetted Stimulus Package.
The bloom is off the rose. It’s time for a new kind of politics: a mature, unprecedented realism.
Politicians should dismiss the public as “not ready for this” at their own risk.
“When patterns are broken, new worlds can emerge.”
-Tuli Kupferberg
*This blog post was originally published at Dr. Wes*
There has been a lot of talk about the way in which a public health insurer would compete against private ones. As the President put it recently:
People say, well, how can a private company compete against the government? And my answer is that if the private insurance companies are providing a good bargain, and if the public option has to be self-sustaining — meaning taxpayers aren’t subsidizing it, but it has to run on charging premiums and providing good services and a good network of doctors, just like any other private insurer would do — then I think private insurers should be able to compete. They do it all the time.
He makes a good point. But we don’t have to talk about this in theory – we can look at existing state insurance programs to see how they operate.
In states prone to natural disasters like hurricanes, the market for private insurance has become increasingly uncompetitive. Several state governments have responded by setting up public insurance programs to sell coverage to property owners in their states. They operate something like private insurance companies – collecting premiums, maintaining reserves, and, importantly, buying reinsurance in the event of a catastrophe that exceeds what they can pay for themselves.
The New York Times reports that a number of the state insurers are thinking of doing something that a private insurer would likely never do: dropping their reinsurance coverage. It could save hundreds of millions of dollars a year. But it would expose them to billions of dollars in risk – that they likely would be unable to pay. The Times calls it “running naked through storm risks.”
Why can they do this?
I suspect that in the event of a bad hurricane that depleted their reserves, these insurers believe they can turn to the state or federal government to cover their losses. They are acting as if they already have a sort of “free” reinsurance from the government. Or, to use a modern expression, they are assuming they will get a bail out if something bad happens.
What it means is that these companies aren’t running anything like a private insurer. By not accounting for the cost of a catastrophe, they aren’t dealing with the real insurance risk they are taking. As long as a disaster doesn’t happen they save money. But when (not if) a major hurricane hits, they will be swept away in the storm, leaving the state and federal government – and the rest of us – with the bill.
“It’s typical of governments today to not be willing to make the hard decisions that are necessary to face up to the true risks and the true costs of the policies that they’ve undertaken,” said Robert Hartwig, president of the Insurance Information Institute, an industry group.
The Times says there are some efforts underway to formalize this sort of “implicit guarantee” from the government. That might be a step in the right direction if it forces everyone to grapple with the extent of this risk.
But what we see with these kinds of insurers is one of the important ways in which public insurers really aren’t the same as private ones.
*This blog post was originally published at See First Blog*
Dear President Obama,
I am in favor of Health Care Reform and I agree with you that universal coverage and eliminating the abuses that both patients and doctors have suffered at the whim of the for-profit insurance industry must be curtailed.
But I also want you to fix Medicare. Medicare is so bureaucratic that expanding it in its current form would be the death knell for primary care physicians and many community hospitals. The arcane methods of reimbursement, the ever expanding diagnosis codes, the excessive documentation rules and the poor payment to “cognitive, diagnosing, talking” physicians makes the idea of expansion untenable.
May I give you one small example, Mr. President? I moved my medical office in April. Six weeks before the move I notified Medicare of my pending change of address and filled out 22 pages of forms. Yes, Mr. Commander in Chief…22 pages for a change of address. It is now mid-August and I still do not have the “approval” for my address change.
I continue to care for my Medicare patients and they are a handful. Older folks have quite a number of medical issues, you see, and sometimes it takes 1/2 hour just to go over their medications and try to understand how their condition has changed. That is before I even begin to examine them and explain tests, treatment and coordinate their care. Despite the fact that I care for these patients, according the Medicare rules, I cannot submit a bill to Medicare because they have not approved my change of office address.
I have spent countless hours on the phone with Medicare and have sent additional documentation that they requested. I send the forms and information “overnight, registered” because a documented trail is needed to avoid having to start over at the beginning again and again. I was even required to send a signature from my “bank officer” and a utility bill from the office. Mr President, I don’t have a close relationship with a bank officer so this required a bank visit and took time away from caring for patients…but I certainly did comply.
I am still waiting to hear from Medicare. At my last call they said they had not received yet another document, but when I gave them the post office tracking number, they said it was received after all. They could not tell me when or if they will accept my address change.
I have bills stacking up since April and I just found out that they will not accept them if they are over 30 days old. I have cared for patients for 5 months and will not receive any reimbursement from Medicare. The rules state I cannot bill the patient or their supplemental Medicare insurance either.
Believe me, Mr. President, I commend you for taking on such a huge task. Please also know that Medicare reform is needed along with health care reform.
A loyal American ,
Internal Medicine (aka: primary care) physician
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