Lenny said: How do we call for health care reform that takes in the breath of change needed?

The answer: The Oregon Better Health Act

Medical reform is very much needed to adequately address the demographical changes in this country. Along with the waning influence of the Bushes we're beginning to hear an increased murmur for substantial change in how national healthcare is provided. I expect to see universal healthcare as a big issue this coming election cycle. But I would also like to see some serious proposals put forth that would address end of life care such as that experienced by your aunt. Not to seem calloused, but way too much money and resources go into providing healthcare during the last several months of life regardless of the quality of the end stage. It's as if we've inexplicably committed ourselves to extending life even when the outcome is obvious, while we grudgingly spend a pittance on PM for children and young adults.

Just a thought.

Those who look at universal health care or single payer as a panacea ought to look closely at what is going on the UK. I just returned from a lengthy visit and the topic du jour on everyone's mind in the UK is "what can we do to salvage our health care system?" Wait lists have grown impossibly. "Elective" procedures (like cardiac stents) take several years, and routine checkups have multiple year waiting lists. The affluent are buying "top up" insurance that pays for NHS doctors to move them to the head of the queue in getting procedures done. The UK Parliament has no clear solution to these problems except to raise taxes ever higher. Those who want the US to go in the direction of the UK need to look closely at the UK. I don't want to go there. The Brits don't want to be there without "top up" insurance. The US can't solve its problems on the back of a Universal Health System as the UK amply demonstrates.

Jenni...some very good points about women's health care. Not so long ago it was standard practice that pharmaceuticals were developed by men with men in mine. Almost all clinical pharmaceutical trials exclusively used men as test subjects, with the resultant data being considered equally valid for both men and women. Hopefully, there is more balance now, or was until the Bushies assumed control.

mrfearless47...There are ways of making basic UHC work for everybody all the time. The system will have to be prioritized so that emergent and critical care patients have immediate care available to them, while elective procedures could be relegated to a list or private pay.

I found earlier today addresses the relative costs and benefits.

this lnk I found earlier today addresses the relative costs and benefits.

While the costs of the last few weeks of life can indeed be very high, there are many, many elders with chronic, incurable, eventually fatal diseases like dementia and congestive heart failure. They often reach a point where the constant presence of caregivers is a requirement, but they may live on for years. The costs are killer, and caregiver costs are not covered by most insurance plans or medicare. Not only is it an unpleasant way to spend your last years, but you and your family must find a way to pay.

Even though the patient may be bankrupting themselves, caregiving does not pay even close to enough to raise a family. Few people are choosing this as their work. With the incredible (as in, very difficult to believe) numbers of baby boomers approaching retirement and old age, this is really going to get ugly!

This, like solving global warming problems, is going to take years of planning to solve. Also like global warming, no one seems interested in starting the process.

When we get clear in our minds about what the purpose of a health care system is, then and only then will we be able to develop the answer to this question.

The purpose of a health care system is to provide health care. I am not being facetious or snarky. That may sound obvious, but apparently it is not.

When you apply for a new health insurance policy, what is one of the first questions you are asked? "Do you have any pre-existing conditions?" They ask this because the majority of health insurance plans (outside of one-payer systems such as medicare, of course) do NOT cover pre-existing conditions. This means that if you have diabetes, heart disease, asthma, or anyone of a thousand conditions (many of which are mostly age-related), you are SOL.

What good is a health care system that does not provide health care? That is a truly irrational situation, except that we are so used to it being that way that we don't question it. I am not sure whether it's like the elephant in the living room, where it's so huge that we don't want to acknowledge it, or whether it's been a part of the furniture for so long we don't even see it anymore.

If you are saying, " well, yes, but but but ...", then no matter how progressive you may think yourself, and no matter how dedicated you think you are to health care reform, you are not there yet.

This is going to require a basic but total shift in the way we view health care. We can post on blogs and talk all we want, but you know what? We are making this a lot more complicated than it has to be.

A health care system is there to provide health care. Period. Now let's create that. Why is that so difficult a concept to grasp?

KittyJ and others mix "Health care system" with "Health care funding system". It is very easy to do, and they have to be treated quite separately.

KittyJ is absolutely correct: virtually anyone with a pre-existing condition cannot obtain reasonable-cost FUNDING for their health care. In Oregon, almost anyone can get FUNDING from the Oregon Medical Insurance Pool - OMIP, but it sure ain't cheap (my wife and I must both use it, and we pay $10K annually for our combined FUNDING. No, not a typo.) The FUNDING discussion must happen!

My post above concerns both: There will be a huge shortfall of actual CARE available for elders within just a few years because the occupation of Caregiver is not attractive. At the same time, the need for caregivers will be mounting very quickly indeed.

There is a serious problem for FUNDING as well. As the original post suggested, it is difficult for most of us to actually picture ourselves needing a walker or a caregiver, and that keeps most of us from thinking this through - many, many of us are destined to have a chronic, progressive, eventually fatal condition that will first strip us of almost every asset we own. No exaggeration. That, in my view, constitutes a FUNDING problem!

The system needs reform but I am very skeptical of a proposal to take dollars from Medicare and redistribute to others. Medicare is the only part of the US health care system that actually works as it should, and I say don't screw with success.

There are billions and billions of reasons why Repubs and their lobbying buddies oppose a national single-payer system, and those reasons have nothing to do with patient choice, quality of care or waiting lists. Let's see - there are the billions of dollars in profits made by medical insurance companies. Plus the billions of dollars in profits earned by the private for-profit hospital corporations. And don't forget the billions of dollars paid to the top administrators of "non-profit" (ha ha ha) hospitals throughout the US. And the billions of dollars earned by the drug companies.

A couple of comments - 1) the Oregon Better Health Act starts with a different premise than simply taking money from one program and redistributing it; and 2) today more than half the money spent on health care is from public dollars - money that not only belongs to all of us, we should be good stewards of that money and we should all get some benefit from that money.

This isn't just a funding problem. Putting more money into the system will not solve the health care crisis. And to describe Medicare as a program that 'works as it should' means that a program for the elderly and disabled should create a disincentive for providers to accept those patients, not pay for home and community based services that those enrollees want and would often prefer, and not pay for long term care. I want a system that's not going to run out of money in 2019, that is actually sustainable for this generation on Medicare and for future generations - but it means we have to talk about what is paid for and how we deliver services today.

Don't get me wrong, Medicare is an important program with the lowest administrative overhead, but part of the reason that Medicare's overhead is low is that Medicare is a single payer program with universal access for a defined population. You've removed the need for an insurer to check eligibility for a particular plan provided by an individual employer for a group of employees, for example. A lot of administrative overhead is spent trying to figure out who is eligible for what. I agree that the level of profit is a matter for public discussion, especially when we're talking about taxes paid by you and me.

What we end up with will be a little different perhaps than what's been done in the UK or anywhere else - we're talking about adding the grassroots, public voice to this debate and planning process. In order for the US to design (and then adopt) a system of health care that we all have access to, we'll end up with something that is unique to the US. We have a lot of data to learn from because almost all industrialized countries have some sort of universal program and they all have problems they are trying to solve.

The question is whether we'd rather be having a discussion about how long people wait for elective surgeries (UK and Canada as examples), or a debate about whether people get access to care at all (the US). Until we have universal access to health care we will not be able to identify strategies that will effectively control costs.

I think that we can discuss this in sections - 1) what is the core benefit - the floor below which no one should fall; 2) how do we deliver that core benefit in a way that is accessible, cost effective, high quality, uses best practices, etc; 3) how do we move money through the system in a way that provides incentives for me (us) to do the things that will improve/maintain my health and provide incentives for providers and the system at large to provide the services that have been shown to optimize health; and 4) how do we transition from the system we have today to the system we've designed - a transition plan.

If we can deliberate on 1, 2 and 3 we may actually find ways to determine what should be paid for and how we should pay for it. That is the means to cost control. I think Oregon is the place to do this.

Jenni - oddly enough, consider a D&C. After at least 10 visits to 6 different doctors I had a diagnosis of endometriosis after the birth of my daughter. My doctor told me at the time, that it may actually have been caused by retained placenta and that I would possibly have trouble conceiving again. She was wrong about that part anyway!

When I had my son, I began to hemmorage a couple weeks after giving birth. They gave me a D&C to stop the bleeding and I've been perfectly healthy ever since.

No doctor ever gave me that as an option before that point. Had I not had to get one after my son's birth I never would have known! I've since found that many women have had simillar results after using non-abortion D&C's as a treatment option.

I wouldn't doubt the constant attack on a woman's right to choose has squashed any efforts to show that their can be very possitive effects from a non-abortion D & C. God forbid research could prove that this procedure can actually be beneficial to women's reproductive health in any way.

In order to have the discussion Archimedes asks for above, we need to face the fact that some degree of rationing of care will be necessary. In defining a "core benefit" as the floor through which no one will be able to fall, we also have to decide where the ceiling will be as well. Much of this involves a discussion about end of life care and how much we are willing to spend to keep grandma alive. I speak from the experience of (a) being married to a physician who has been dragged into deal with moribund patients on countless occasions just because the family couldn't let go and hounded the doctor to "do something" (so they order expensive tests whose results will cause them to do nothing additional) and (b) as the son of a father who insisted to his dying day on receiving every possible medical treatment that Medicare would pay for regardless of its value in providing him with either a longer or better life. Had they offered him a heart transplant, he would have gone for it even though he would have died on the operating room table.

So as long as we debate what "floor" we need, we also need to discuss the "ceiling" as well. And there is no way to discuss either without discussing "rationing" and having a serious conversation about end of life care.

Although I agree with several of his points, mrfearless's comments demonstrate some of the challenges in restructuring US health care. The word "ration", along with "socialized" medicine, and "end of life" care for grandma will no doubt be used to spark hysteria among the masses, with the end result that nobody can move toward a solution. Of course, "no movement" is very good news indeed for the insurance companies, investors, health care executives and drug companies.

Although it is interesting to discuss health care policy on an intellectual level, my personal opinion is that the status quo system will have to collapse more or less completely before there is any real movement toward a single payer system. Too bad, but that's the reality of US politics, which are driven almost entirely by money rather than common sense.

BlueNote talked about "no movement" being good for insurance companies, investors, health care executives and drug companies. Isn't AARP all of those?

Lookie Here

After reading the big red and black "We love you Gordon Smith" advertisement that AARP placed in the Oregonian this morning, you won't find me saying anything nice about AARP today.

Bluenote writes: "The word "ration", along with "socialized" medicine, and "end of life" care for grandma will no doubt be used to spark hysteria among the masses, with the end result that nobody can move toward a solution."

I'm not trying to discourage a healthy debate by using scarewords. The reality of the US Health Care system is that in order to reform it in any meaningful way we have to figure out how to address the issues that have caused it to spiral out of control. Any serious student of the American health care system sees the drivers of our out-of-control health care system as (in no particular order): poor lifestyle choices, lack of personal responsibility, outrageous pharmaceutical prices, overuse of expensive technology, litigation costs, end of life care, unwillingness to accept death as a natural outcome of life. There are pervasive cultural issues that have to be overcome. To me, there are a couple of areas where legislative changes at the federal level could reduce the cost of medical care and insurance for the same. This would be a repeal of the 1997 law that permitted big Pharma to advertise to end users. Track health insurance costs before and after that went into effect and you will see some dramatic spikes in the data. Cause/effect? I don't know, but it sure would be worth a try to see if we could remove a significant line item from big Pharma's budgets - advertising. The second change would be tort reform. I'm all in favor of binding arbitration for alleged cases of medical torts. This would reduce the practice of defensive medicine, which would reduce the overall cost of delivering health care including the cost of liability insurance that is factored into the cost of every procedure in medicine, which would reduce the pressure on insurers to cover those extraneous and unnecessary tests and procedures. I doubt that this would be enough to free up revenue to increase the coverage for the uninsured, but I think most would be surprised by how much those two elements -- and the cascade of cost effects they have -- increase health care outgo in this country. The US isn't ready for a massive overhaul of the health care system because, as BlueNote correctly points out, all the various scare words will be trotted out against the reform. On the other hand, I do believe that there are ways of incrementally changing the existing system that would reduce costs significantly.