Kulongoski makes plans to extend health care
Kari Chisholm
Yesterday, Governor Ted Kulongoski unveiled plans to extend health care to uninsured children throughout Oregon.
Gov. Ted Kulongoski said Tuesday he agrees with the recommendation of a seven-member board to expand health insurance coverage to most of the 116,000 Oregon children without it.He said he will propose a small amount in his next budget, which he will unveil Monday, to begin the next steps toward providing coverage for the other 460,000 Oregonians without it, while controlling costs and improving quality of care.
But he also said Oregon cannot reach those goals without more time — and a national overhaul that President-elect Barack Obama is weighing now.
In 2007, the Governor proposed funding the healthy kids plan through a tobacco tax - which was defeated by voters after cigarette makers waged the most expensive ballot measure fight in Oregon history. How does the Governor propose we fund it this time? From the O:
The state would pay for the expansion with a broader provider tax on hospitals and insurers, raising about $700 million during the next two years and leveraging more than $1 billion more in federal matching money.The governor said prospects are good for the expansion. "It's going to happen," he said.
The Oregon Health Fund Board, a seven-member task force the Legislature created to fix the state health care system, handed the governor a 162-page blueprint for reform, called "Aim High: Building a Healthy Oregon." The panel crafted its plan during the past year with volunteer committee help from doctors, hospitals, insurers and others in the health care industry and testimony from hundreds of Oregonians across the state.
Of course, this is far from the end of the road:
The plan warns the state must act swiftly to dramatically change its health care system or the average cost of family health insurance will equal the average family wage within five years."We can't continue to fund a broken system," said Eileen Brady, vice chairwoman of the board and co-owner of New Seasons Market.
Most features of the plan are devoted to transforming the state's $19 billion health care industry with the aim of containing costs, improving quality and promoting health. The state would create a nine-member Oregon Health Authority Board to oversee the overhaul.
The board would collect information on health insurance claims and hospital costs, establish best practices standards and measures for health care quality, and give consumers more information on the costs and quality of doctors and hospitals. The state would regulate doctor and hospital fees and the administrative costs of insurers.
Like the Governor, I agree that getting us to truly universal health care requires a national solution. That said, it's good to see that folks aren't just sitting around waiting for it to happen.
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connect with blueoregon
Nov 26, '08
The plan warns the...average cost of family health insurance will equal the average family wage within five years
Is this true or at least credible? Doesn't that imply that it's health care costs that are the problem? -- or in other words, more insurance is not a good solution and what we need instead is less expensive health care?
Nov 26, '08
"The state would regulate doctor and hospital fees and the administrative costs of insurers."
The above sentence caught my eye. In my day job I work with lots of folks in the health care industry, but I am not aware of any state statutory or regulatory authority which would entitle the state to regulate doctor or hospital fees, or insurance company fees or margins. What am I missing?
I embrace any program that will provide 100% coverage to all children everywhere regardless of situation, parental income, insurance, or whatever. The idea that every kid could be taken to a competent doctor or emergency room or hospital at any time for any medical condition and not face questions about insurance or parental responsiblity or whatever is a great idea. While single payer universal coverage is my "Holy Grail", full coverage for all children everywhere is a wonderful first step.
I do wonder how it will work, and who will pay for it.
Nov 26, '08
Special interests (both good and bad) are gonna have a field day with the OHFB proposal come January.
Nov 26, '08
Why not just fund it through an increased tobacco tax? There should be enough Democratic votes to simply pass it in the legislature, instead of going through that "ask the people to amend the constitution" nonsense like last time.
8:54 p.m.
Nov 26, '08
I am not aware of any state statutory or regulatory authority which would entitle the state to regulate doctor or hospital fees, or insurance company fees or margins. What am I missing?
We're talking about the legislature here - so they could create statutory authority.
Nov 26, '08
Funding such an important program on a declining revenue source doesn't make a lot of sense and maybe that is why Measure 50 was voted down by such a wide margin.
How about a simple $1.00 fee for every medical appointment, collected by the provider and remitted to the state once a month or once a quarter? How about a pre-paid children's medical card like the Oregon Trail card so a parent can choose the medical service the child needs rather than only having medical coverage, what if they need to see a dentist or need new glasses. Most medical providers have credit card machines these days, the health care provider gets paid without a lot of paperwork or waiting for payment.
We need to think outside the usual channels. The majority of children's needs could be covered for a $1,000.00 a year. Forget insurance and go consumer direct to provider and save the cost to get the best bang for the buck. No cash value on a card, it would be used only for medical providers. If the balance gets used, replenish it like they do the Oregon Trail card.
Some children have severe health issues and this system would not work for all of them. The idea is to get all children medical services when they need them and have the parents be able to take them to a medical provider for the medical services they need.
Simple and direct. Thoughts?
1:57 a.m.
Nov 27, '08
Joel H.,
Re: Doesn't that imply that it's health care costs that are the problem? -- or in other words, more insurance is not a good solution and what we need instead is less expensive health care?
The short answer to your question is "no."
The longer answer is that you are posing a false opposition between what are interlinked phenomena.
First, note that the problem as defined is literally average insurance costs as a proportion of average family income. Insurance costs are determined by many things besides the costs of healthcare, a fact which is illustrated by nothing better than that different insurers are able at present to negotiate different prices from the same service providers. The averages disguise that.
Then we have to consider the distinction between the cost of healthcare and the price of healthcare. Under our current screwy set-up / non-system, these two phenomena are largely disconnected, for reasons that are substantially though not wholly rooted in the insurance system and in who and what it doesn't cover.
One important aspect of those reasons, payment on a fee-for-service basis, also has roots in the history of medical professional culture in the U.S. and is the product of a negotiation between providers (mainly doctors or groups of doctors, and hospitals) and insurers. Fee-for-service creates incentives to provide more services and to subdivide them. The good side to this is that necessary services for those with insurance are likely to be provided. The bad side is that many unnecessary services are provided and paid for. But more importantly, it leads to devaluation of illness prevention and health maintenance, and heightened focus on treatment after the development of clinically visible illness. Currently something like 80% of medical expenditures go to treatment and 20% to prevention and maintenance, where there's wide agreement that we'd get better population health outcomes if those proportions reversed, or at any rate shifted dramatically toward prevention and maintenance. (I'm a bit skeptical of a complete reversal simply because even with strong prevention the bare facts of aging and death will mean continuing need for treatments of some some sort eventually, though what the pattern would look like could be a lot different.)
Another large chunk, however, comes from inappropriate use of Emergency Department facilities and personnel and deferred seeking of care among the uninsured or underinsured that is directly attributable to lack of insurance. As insurance costs rise, it will lead to decline in employers offering insurance benefits and decline also in employees paying for them on the terms offered, which will tend to increase the problems of misuse of Emergency Departments for primary care and of deferral of seeking care until later and more expensive points in disease progression.
Of course, both a dramatic shift toward prevention and health maintenance, and eliminating the problems of inappropriate E.D. use and delayed care-seeking would contribute to "less expensive health care." But at least in cases of the latter two problems, more insurance is how we get to less expensive care. (For the former, it isn't the quantity of insurance but reform of insurance and compensation which is at stake.)
Universal health insurance would also make it easier to make the relationship between costs and prices more transparent, particularly with respect to hospitals and other institutional providers, where the fees for services are constructed in order to cover overhead costs including care for the uninsured.
The current set-up also has lots of administrative costs due to inefficient and redundant private bureaucracies, including insurance bureaucracies and provider and employer personnel required to deal with them. These would be most effectively cut with a single-payer public insurance system, but could be reduced by standardization through regulation.
The component of costs attributable to drugs is distinct & rooted in the structure of research as well as patent law and marketing spending by drug companies.
In both insurance and pharmaceuticals as well as large hospital companies demand for profits providing high return on investment, in a financial culture based on artificially inflated returns, contributes to high pricing rising faster than the overall rate of inflation.
There is also an element of rising costs that derives from development and use of increasingly expensive technologies.
Nov 27, '08
In Europe about 75% of children are born with the aid of midwives. In Oregon, which has better midwife services than most of the U.S. about 15% of children are brought into the world with midwives. The services provided by midwives are less expensive and have a better survival rate than doctors. Yet often because of regualtory problems and fear of competition from the doctors expectant mothers are denied this choice. A move to bring more midwives into the would be beneficial all around. Infants, mothers and the system all around.
Additionally doctors need to publish their prices so that consumers can compare them. Wherever, or from whatever group, or groups are discouraging doctors from publishing their price needs to be exposed. (I'm not sure this last sentence make sense but I'm sure some can figure out what I intended). Is it the AMA that puts pressure on doctors not to publish their prices, or someo other group? Then let the public know that this is what is going on so that it can be stopped.
Where's the press in all this? Absent as usual.
TLG
Nov 27, '08
Chris, do not forget to speak of the capitation system that actually rewards providers for denying care to patients. The less they treat, the more they keep.
Contributes to patients being forced to spend their money to get health help outside the treatment domain. Kaiser is ferociously aggressive in trying to force members to buy extraneous service to address issues instead of doing all necessary specialist work FIRST and then working collaboratively with a patient for a recovery regime. They have a layer of utilization nurses who identify frequency and then intrude upon those attempting to get appts with PCPS who are working collaboratively with patients to address complex or sequelae-laden health pictures.
They want us to spend our own money out in the community instead of making them afford us access to treatment and ancillary services within their system.
Ugly. But still was better care than I am getting now in the so-called open markets of the clinic where the hassle and dropped ball factors are very high and have a high price for those with chronic conditions.
9:40 a.m.
Nov 27, '08
Why not just fund it through an increased tobacco tax?
You mean besides the fact that doing so would be one of the most regressive funding schemes possible?
I appreciate why Kari prefers to frame the failure of M50 through the lense of Big Tobacco spending. But I know too many (on the Left) who opposed it's regressivity to find that anything close to an adequate explanation for why M50 was rejected by voters.
Nov 27, '08
I cringe each time I hear "tobacco tax" for the reason that there are countless of us out there who do not smoke, but use a LOT of tobacco ceremonially. It is very expensive to take care of our prayers as it is at current prices. Each time the prices hike and hike, and even more taxation is discussed, I recalculate what it will cost me to take care of my women at lodge next month; or acquit my responsibilities at other ceremonies.
I am a health educator too, and understand what we purport to intend to do with the taxes garnered. And thus far we have the example of the tobacco settlements to look to. I don't know of any state that actually did what they promised they would do with that money. Some did a little bit of it, ALL of them waylaid the millions sideways.
10:07 a.m.
Nov 27, '08
The single most affluent class of tobacco consumers - cigar afficionados, who could most easily afford a new tax - were strangely exempted by the Dems who wanted to fund children's health care with tobacco taxes.
But ignore that. Surely it must have been the tobacco lobby who pulled the wool over voter's eyes...
Nov 27, '08
Kevin: perfect case in point. I can promise you that those of us who buy that awful, loose-pack, bulk stuff from non-cigar shops (I used to buy my pipe baccy from Rich's and had a fondest relationship with their Tolkiensian, UK-trained "mix" Master, Steve) are low-budget on the edge smokers or high-volume non-smoking users. You will see homeless or very impoverished hand-rolling Top, but you will NOT see gainfully employed rolling Top. Drum maybe or some other higher shelf... You will see us Traditionalists making prayer ties with cloth and herb but NOT from some exquisite smoke shop or even top or middle shelf product. We do try to use organics to mix with our herbs for ceremonial pipe use. That is limited and special, and still completely outside your standard smoke venues.
Sooooo... I was not even aware, ignorant me, of the fact that one could except certain lines from this taxation. Very sad business, this. Let's let the big men have their self-congratulatory see-gar and tax the shit out of the pitifully/moronically (depending upon your purview - I feel my son is a self-defeating moron to be playing with this at his young age, and I am helpless to stop him) addicted or those with no financial clout/political acumen. Business asssss per usual!
Nov 27, '08
You Socialist wanna be's are so out of touch it is amazing!
Tax the Hospitals? Increase their rates even more is a solution? (think they won't?) Hospitals were just complaining this summer that the Feds aren't giving them enough for all thier "un-reimbursed" care as it is silly.
You still don't understand that the huge medical insurance rate increases are a direct result of Hospitals and Dr.s raising thier rates to compensate for millions in "un-remibursed" care as a result of tens of millions of Ilegal Aliens here that will not buy insurance and greedy Employers that do not provide it to thier exploited third world workers.
ALL the children? You ignore Illinois and their all the kids not really free care program. Over $1 Billion in new costs in the 1st year to Taxpayers, look at thier state defecit, and 60% did not qualify for Medicaid previously because they are Illegal Alien kids (Feds do not allow criminals to get regular health care, only emergency), not including Anchor Babies who do qualify.
Rand Corp. and Dr. Madeline Cosman, PhD. Esq. (as reported in Journal of Surgeons & Physicians,'05) estimate that at least 1/2 of Children nationwide without med insurance are Illegal Aliens.
The other 1/2 that can't afford med. ins. are competing with Illegals (ex. Del Monte Fresh, Smith's Frozen foods) that are thrilled to get min. wage at a job that used to pay an American at least double that, with Benefits.
Solution? All Employers must use E-Verify (free & 99.5% accurate, more accurate than the Credit bureau's we use). Result? Illegals can no longer steal a job, they go home, and Americans get paid as they should while Employers beg for them to work for them, as it should be. AND Hospitals get paid for their servcies and ins. rates stabilize. AND Americans with valid S.S.#'s pay more taxes as they earn more income via our progressive tax system.
Can you comprehend lower health care costs and increased tax revenue without any new expensive programs to us tax payers, can you?
Capitolism not Socialism, why we are the economic envy of the World still guys and gals.
Nov 27, '08
Dear someone calling themselves Rick Hickey: it's not fashionable for me to agree that you have a point about the burden upon social systems introduced in states where citizenship is not questioned when accessing emergency or clinic-based services. Meanwhile, uninsured Americans end up dumped onto county hospitals at the ends of long ambulance rides being turned away by high-end hospitals. It is still happening.
However: your rant sounds like a strictly xenophobic cry. Am I wrong? And do you think your overweening rage will win anyone to stand by your side from the putative "other side"? You enforce the standoff this way.
BTW: I'm ignorant - what is an anchor baby? I assume you mean the billions of non-citizen women popping out children to make it so they can stay here? WHat about Elian Gonzales?
Nov 27, '08
RH - also fascinating, what is Capitolism?
Do you speak of state's rights versus federalism, perchance?
Just wondering.
Nov 27, '08
If they think they can fund health care by taxing tobacco and hospitals/providers then they have quite a reality wake-up call coming this session.
Nov 27, '08
Rw, I don't see any comment in my post calling for me to be classified as a Xenophobe, I have no fear of any race or ethnicity and did not mention any.
I didn't say anything about the E.R. care as know one should be left to die in the streets, but regular care is a different story and that is what I wrote about.
Win over the other side? Difficult for the Brainwashed to absorb but it is food for thought and a dose of reality and an Honest Solution to this big dilemma.
Elian was born by an American.
Anchor Babies? 500,000 - 750,000 a year, not billions.
I think Honesty and Solutions would help suffering Americans more than the Political agenda of too many Democrats- more expensive and corruptable programs.
Nov 27, '08
The open-vent rant against "illegals" as a/the primary reason our blah blah blah... you carried on at great length, kid. The irony is that people like you are too bellicose to stand next to.
I do not disagree with you.
I do not feel we should be a porous safe haven for every economic opportunist. I've seen them in all stripes up and down the SES, and I've seen way too many who had NO fucking regard or respect for us or feeling for America. In fact, a kind of cultural disrespect for us that requires me as an American woman to bend over and pretzel up for. WHen working in direct social and health intervention services, I do not question this, as my JOB is to reach people for their sake only and not think of any policy beyond that. And I do a good job. However, standing out here, right now, I see there are rainbow stripes of reality, and to label all ppl looking for opportunity as deserving and owed that here in the US is too broad brush for my taste. However, the spew you just dropped on this wonderful day was also too broadbrush and tinged with, yes, hate.
I am in agreement with you viz jobs - many jobs spoken of as too bad for a lazy American to stoop to doing... that's not true and never was. Just more bullshit from status quo commercialists as well as folks afraid to make distinctions that may have to be weighed out against racism and other isms we'd rather just deny within ourselves AND deny by using easy peasy broad paint brushes. Too hard to engage and work through the guilt of our past and so on and so.
Anyway: you ranted in a way that is not conducive to much more than a sidelong look.
Nov 27, '08
Capitolism not Socialism, why we are the economic envy of the World still guys and gals.
Anyone that envies our economy is sadly out of touch. Which isn't saying you're wrong!
Nov 27, '08
the final report[http://www.oregon.gov/OHPPR/HFB/] is interesting. Reading it might dampen some arguments above. the outline isn't the cliche liberal versus libertarian versus conservative football one might think.
Nov 27, '08
Read everything after my post, no discussion on how to give kids access to health care. Illegal aliens' tax tobacco, insurance companies, doctor and hospital billings.
Where is the discussion to getting kids health care go?
Do you think a buck would be too much to pay as a surcharge to cover kids? I see it as simple and sustainable. Did I read in the newspaper that tobacco tax revenue was down $22M last quarter and the state doesn't know why? Will it continue to decline, yes I believe it will - then what? Take away the kids medical coverage to raise the income level to qualify for it. They need a steady reliable revenue source. People can buy tobacco online, but they can't see a dentist or doctor online or get an X-ray.
What about saying to heck with insurance companies and self fund most kids with a prepaid health care card like the Oregon Trail card?
Am I nuts or are these viable options the legislature should consider next session. They have "x" amount of dollars and will need to spend them very carefully or more kids will end up with no health care then we have right now.
2:53 p.m.
Nov 27, '08
As usual, when Rick Hickey tries to present "documentation" for his bigotry he just ends up confirming his own prejudice. As an example, the source he cites for one of his more outrageous claims above also happened to be a source for the infamous Lou Dobbs claims about immigrants and leprosy - and has been thoroughly debunked.
So, today we can be thankful for groups like Southern Poverty Law Center and others who are dedicated to exposing the hatemongers for what they are.
Nov 27, '08
Thank you Daniel Pete. I was thinking I'm paranoid, imaginative and cannot smell the rank stench of crude xenophobia. Thought I was crazy.
I wish we could, here, escape the all or nothing approach from either pole of the conversation - neither seems to be a good answer for the universal collective; neither moves any towards a center where we can work on workable change. ... but it seems we cannot get anything more elegant than polarized ranting disingenuously labeled as "debate"!
Southern Poverty Law has done incredible work. God, I hope they find a hook to help them deal with this very issue. Bring some creativity and historically-couched passion to the thing.
How gutsy it is to talk about the unfair stack of law against those who cannot purchase representation in the courts OR in buying laws in the political and business process.
Nov 27, '08
Also, a sizable number of my native friends laugh long and HARD when they witness certain species of whites in particular going on like our friend above. YOu are going to protect WHOSE land from whom, guy? YOUR land, eh? Mmmmmm.... kay. Heh. Check out Sherman ALexie skewering sweetly on the Colbert - Dan P will like this one -- hah - a little perspective would be good while we are all jouncing around in our tight trousers talking about "our" country. Heh.
www.colbertnation.com/the-colbert-report-videos/189691/october-28-2008/sherman-alexie
Nov 27, '08
It doesn't help when you have Sioux historians saying "we're a people of conquest. We understand the concept of the 'rights of conquest' and the 'rights of the conqueror'".
You know, if it was so consciously justified, why was it against Spanish colonial law in the Americas to use the verb "conquistar"? Kind of like today. You can do "crusade", but you can't call it "crusade".
"Rights of conquest". That phrase has to be right up there with "personality orientated news format". How is it different than breaking into someone's house, committing rape, refusing to leave, then, after the fact, using the fact to claim "conjugal rights" as a defense? OK, the diff. is most courts don't accept conjugal rights as a defense anymore. So how screwed is it for native americans to say "we understand the rights of the conqueror"?
6:01 a.m.
Nov 28, '08
If the Sioux were a people of conquest then what would that make the Chippewa who conquested (prior to European conquest of them) something like half of the land historically claimed by the Dakota Sioux?
This all is way off on a tangent from the topic of this thread, but it seems to me that the sin of the caucasians was not in the conquesting. It was in breaking treaty after treaty after treaty and then having the unmitigated gall to coin a hypocritical pejorative like "indian giver."
Nov 28, '08
I find it high comedy that the only hx most ppl know about and so quote at all times IS that of Cherokee or Sioux Nations, the Plains and a few eastern woodlands tribes whose government structures were notable to visiting caucasoids.
There were definitely warring tribes. Hell, you should see the awful family to family smoke wars in indian country. It's real. That is human-level, thought. Wwarring on each other to get land, and doing it in ways that are structured for honor. Not sailing across the seas, genociding whole peoples, working them on plantations as slaves (that was a failed effort, and is why overseas african continent slave trade was required!).
Speak of the gentler coastal and river people who were wiped off the earth, the ones who did not make wars that spanned lands. Speak of the diversity of humanity that fell under infected goods and gun! Explore outside the few props you were handed as a gullible kid in school.
Ah, there are nations that had to sue for peoplehood under the endangered species act. There are tribes that cannot muster enough of their own to be a tribe adn so must band together with others fragemented to meet a threshold to be claimed as a whole!
Zara, interesting point, Kevin, the rationalizing causes me a kind of pain, yet I am grateful that someone takes a few minutes interest to really look and think and talk! Try looking at the fate of gentle tribes that did not do as the roaming, traversing VERY FEW any children and most adults know anything about. There is a reason certain tribes and their (perceived) ways were most bandied about - they served the interests of the conquesting rationales of those doing the genocides.
Scalping was invented by invaders; certain terms such as that you mentioned likewise. Conquering accidentally by disease occurred and on purpose - microbiological warfare. They are still maintained in huge ghettos, prison camp areas. And treaties are as of today being broken - lands that were allotted do not really exist; health and education and special needs supports do not exist or are not deployed as needed and requested; mineral rights and grazing rights mismanaged or being grabbed by coercion STILL; and treaties signed with non representatives of the tribes (try on the New Echota Treaty for size, signed in the dark of the night by a man who was not a representative of the CHerokee in OK....) good stuff and close to home.
Nov 28, '08
I rarely post here and now I remember why, there is no conversation here. It gets off topic and degnerates into nothingness.
Same as plotics, lots of finger pointing and accusations, its a lot like watching the legislature or the congress.
Nov 28, '08
So get in there adn generate topical discussion that is not just pissing-match or posturing.
12:29 p.m.
Nov 28, '08
Rebecca, it wasn't my intention to rationalize. Yet I can see where I did. It's virtually impossible to discuss the macro without resorting to some sort of sweeping generalizations that don't do full justice to anything on the micro scale.
A friend and former coworker is a member of a coastal branch of the Siletz tribes. I've never been able to imagine him or his people as waging conquest. Everyone at the workplace where I first met him jokingly referred to him as "The Bank of Siletz" because he was so giving, constantly loaning a couple bucks here or there - never saying "no" to the best of my knowledge. Indeed, I believe he first coined the term himself. Great guy whose giving nature isn't limited to finances. Most definitely someone I'd want watching my back in times of trouble. Come to think of it, I'm having a hard time thinking of many who I'd rather entrust my safety to if the S#!t hit the fan than good ol' Elery. A great big mountain of a man who always puts on a gruff act... but who has a heart of gold underneath it all.
12:38 p.m.
Nov 28, '08
"Will it continue to decline, yes I believe it will - then what?"
Then we'll all enjoy the rather large savings in public health cost due to smoking, which was the reason tobacco was cited as the most obvious source to pay back the public health care dollars being spent on smoking related illness. (As Chuck Butcher points out reliably, however, the costs associated with alcohol use are even higher; a similar tax should be placed on alcohol sold in the state).
Nov 28, '08
Okay, so tobacco and alcohol consumption are taxed out of existance but what happens when people live longer and suffer the diseases of age?
That too is off topic, sorry.
How can all Oregon children have health care? That was the original topic. I have thrown out a couple of ideas, but there must be more ways to as they say "think outside the box." A big surcharge on insurance & hospitals will only result in higher cost and more people dropping insurance and higher hospital bills for the remaining insured patients. That seems counter productive. Hawaii has full coverage for all children for seven months and had to discontinue it. Too many people who had private health insurance for their kids dropped it and signed up for the free kids health insurance program.
Sometimes the best intensions go bad.
Discussion?
Nov 28, '08
Okay, so tobacco and alcohol consumption are taxed out of existance but what happens when people live longer and suffer the diseases of age?
That's a very relevant question given past funding schemes for children's healthcare coverage here in Oregon. All the more relevant because recent studies appear to show that in fact smokers cost society less precisely because they don't live as long and thus tend not to incur a wide swath of expensive geriatric ailments and diseases.
How can all Oregon children have health care? That was the original topic.
Within what constraints? The politically easy (in relative terms)... or the politically progressive? I don't believe they are necessarily one and the same. The politically easy would be to once again ignore the socio-economic stats as well as the new research and once again try to pin the tail on tobacco addicts - except, of course, those sainted cigar smokers in their BMWs and Mercedes because, by gawd, they have meaningful political access and thus play by a fundamentally different set of rules.
Nov 28, '08
Yay for Kevin.
Yes.
Nov 29, '08
Back on the original subject. In Europe about 60% of all medical costs are for nurses and a study that was done some time ago suggest that nurces could do more in the U.S. if regulations were repealed that prevent them from doing so. While that would not necessarily lower costs in the short run, it may do so in the long term because nurses tend to spend more time with the patients and collect more detailed information thus leading to better care.
TLG
Nov 29, '08
Robotically intoned: Back on Topic, SIR. Nurses are making high wages and have strong unions intent upon pressing that upward. My world is populated with loads of nurses as my friends. The bottlenecks in the education system is creating a stiff upward pressure on nursing salaries, deep unhappiness with their jobs is creating another upward pressure (hate to say it, ALL of my nurse friends complain terribly about their jobs and whine about pay as high as 40 dollars an hour [considered only a median wage in the wages offered in this market] as not being compensation enough for their stressors)- and as these older nurses retire, it's going to skyrocket. THIS from a much-qualified and much-desired senior nurse who also does administration.
So TLG, further empowering nurses in OUR culture will do WHAT for the ones who cannot get access to care? Public Health Nursing is still highly-paid compared to other work in that field, but only those with a calling will go there, as it can be half of what others make in the profession.
We have to alter the power structure to give physicians less power to intimidate and punish nurses given their role in our system of having to write them up when they make mistakes or break safety regimes, something that happens extremely frequently according to my key informants who have to do this. It's stressful, and doctors are indeed allowed to pretty much act as they care to, while nurses can be reprimanded for not charting against miscreant doctors. Pretty intense work, no wonder high wages and climbing. They feel protected if you press them for the truth of that matter - they know nurses are so desperately needed it is rare any of them will lose a job. BUT - the power and control business is not balanced. That's how it is in OUR culture. Something has to change for all of these vaunted new ways to be successfully implemented, if nurses' stories are taken to be true.
Nov 29, '08
rw I did mention that regulations need to be repealed, but not knowing those regualtion specifically I just broadly suggested it. That might give nurses the independence to work without the pressure the doctors put on them.
I doubt that blogging about it will get anything done.
TLG
Nov 29, '08
TLG - "I doubt that blogging about it will get anything done".
Non sequitur.
Was that a slam?
At whom?
Surely not at yourself. That would be silly. Now, tell me this, since I've heard several of you frequent flyers say, "Blogging won't make any difference" in the past few days --- what are you doing up here, what is the utility of a blog? I've assessed it is merely a place to waste some time, do some arguing and occassionally trade a funny or a pat on the head to each other. It's a place to bleed off energy.
Civiletti said he treats it ONLY as a place to post comments he know the media will see. So it is he stays focused on a specific bullet point he wants media to see.
The rest of us clearly have given little thought to, nor do we apply much discipline regarding the actual function of blogging in general and this blog in specific.
Kari's mandate says it is just a place to gather up online and talk.
So, again: not sure what the function of your comment was? A positive entree to telling folks what you are personally doing to help bring change about? Or simply an observation that this is bluster and noise?
Either is valid.
10:54 a.m.
Nov 29, '08
Nurses in general and Nurse Practitioners in particular are underutilized here in The States, IMHO.
My longtime (20+ years) family doc brought on a Nurse Practitioner about 15 years ago because she was so wildly popular that she just couldn't keep up with the demand. I think I've been seen by the doc maybe half a dozen times and she was consulted by the NP maybe another half dozen times since then. The Nurse Practitioner handles everything with great competence and has my complete trust, as does the doc who delivered both of my daughters.
But most noteworthy, from a strictly medical point of view, the NP has personally handled all of the most major medical issues I've dealt with. Ruptured disc in lower back diagnosis and referral to specialists, seasional affective disorder diagnosis and treatment plan, hyperthyroid diagnosis and referral to a specialist, assorted and sundry prescriptions. All handled solo by the NP. But she can only do that, legally, working under the auspices of a credentialed doctor. If she's typical of NPs then I'd certainly be open to NPs being able to practice on their own.
Nov 29, '08
I wonder how many patients a doctor must see in a day to pay their overhead. Some of the hospitals have walk in clinics in high rent strip malls, why not on hospital property? What happened to the Minute Clinics in drug stores? I thought they were a great idea, but there is only one left in the Portland Metro area.
Why not allow the health care providers to set up trailer clinics on school grounds and fund staff. What about staffing the or schools with EMT's. These people are highly skilled emergency response providers. They save lives every day and night in terrible situations. If they can do this, why not have them in schools too? They wouldn't run into anything more critical in schools than they do on the highways.
Our current medical delivery system is sorely broken. I have a friend in Canada, and believe me they are not much better off. They have as many citizens without a personal physician as we have uninsured. Their options are to sit for days in an ER or go back day after day to a walk in clinic for care. They do no have enough hospital beds and patients can spend an entire hopsital stay in a bed in the hallway. The big difference is cost. Canada is the second highest taxed society in the G7, but no one loses their home and retirement savings to pay unexpected medical bills. Our insurnance premiums go up and up, and our insurance pays less and less.
But . . . what about the original question, how to cover the kids? Why not a prepaid health provider card like the Oregon Trail card? Would it work and make care available and turn parents into educated price shoppers to maximize their childs care benefits? There is a cost to the back office, insurance billigs and state paperwork to file. Cut out some of the overhead and provide more direct services.
Nov 29, '08
My wife and I haved worked as nurses a combined 40+ years. We both stopped working in acute care because our increasingly corporatized system is dangerous for patients and for health care workers, not because doctors were terrible ogres who intimidated or punished nurses. Most of the doctors I worked with were honorable and hard working. The pressures they endured were unbelievable.
Hospital nursing was once a very satisfying job that afforded time for caring for people; it has become a factory job. Let's see you who imply that nurses are overpaid last a week at it.
We need single-payer, non-pay-or-die health care now, for the sake of patients as well as nurses.
Single payer systems can be set up to create policy boards that require outcome-based research, thereby continuously refining medical practice in ways that raise our poor current outcomes and decrease costs at the same time. They can also create job environments that allow nurses to thrive instead of desperately seek alternative employment.
There is a huge difference between a nurse and a nurse-practitioner.
Nov 29, '08
NPs DO have their own practices, independently, in the US. However, you state correctly that the culture sees them only as physician-extenders. THis is the basis upon which I accomplish all provider credentialing of NPs... it's rare that I must handle documentation on a Nurse who is being used in what is now an RN capacity - triage and slightly higher than MA duties.
CNMs function with full and unfettered privilges as a function of their specialty - all other NPs have potentially-ornate limits on the scope of what they may do in the hospital and other settings. And so, like PAs, are almost only used as physician extenders.
NPs rarely have their own clinics in Oregon - are a huge source of the medical care out in Indian Country if people are not required only to attend a clinic/hospital. Public Health nurses were known to regularly drive the countryside of the tribal lands - the kids ran away to avoid them -- and in major urban centers that may be the only care you ever see if you are poor. I myself LOVE NPs, love the relationshippy way they do things. And as an older teen in SF, alone, a free clinic NP was the only health care I ever had. I've loved them ever since.
NPs are underutilized in the US as a result of regulatory business that is hooked to politics. It is politics only, ultimately. Humble opinion, multiple angles of directly-gathered info.
WE'd do better to diversify and propogate the community clinic system again -- MDs still oversee PAs and NPs, and some actually get in trouble and have their licenses sanctioned b/c they use these mid-level providers to boost profits, but do not maintain the required supervisory and medical officer oversight. Lots to be said about the culture and efficacy of nurses.
Nov 29, '08
Harry - you will notice that when I spoke of the nurse reality, I am quoting the endless complaining of most of the nurses I know. I only have two or three nurse friends who do not go on about the dramas and difficulties of their jobs.... and I use the proviso "if their accounts are to be taken at face value".
I find it complicated to make sense of it when I see how much volatility and risk I've endured in public health HIV work in direct services, interventions, needle exchange etc... as well as in my dinky bureaucratic job. For wages that sometimes do not pay all the bills for basic life. So I have trouble sometimes listening to the insistent whinging - so get out then, if it's so terrible and that high pay you get simply does not remunerate for the terrible conditions you say you exist in. I know nurses making ninety bucks an hour and ... well... sigh.
So this is nice to hear from Harry who speaks of the joys of nursing and does not dramatize the us and them of nurse and doctor. Frankly, until my current desk, I had a way different opinion of doctors. Right now I am getting my "Dark Side of the Picture" experience after having had mostly really great experiences for some five years with docs in this one niche. I'm seeing some pretty ugly and arrogant uses of position, and some cheesy lies and manipulation on the part of defensive staff. I'm definitely getting a new watermark and a different view on those decent and hardworking men and women who rage at the Regulatory folks b/c they hate the process we oversee. :)
Nov 29, '08
RN - registered nurse, not subject to credentialing, and the self - insured's bury the malpractice on them still. Not an independent care provider of any kind in any setting, but is the bedrock of patient safety in the acute care setting, is the chaperone and tertiary presence in a clinic. These nurses watch round the clock and catch errors in charting, meds, procedures. Heavy responsibility and little power or status, overtly speaking.
NP - advanced practice nurse - nurse practitioner. Self insureds are slow to report as required, yet. Able to open own clinic, some states allow without intrusive or direct MD/DO oversight. Many public health and indian health clinics function totally on the services of NPs and there is only a cursory MD/DO presence to legimitize the competent and responsive care being provided by the Nurse. Many communities and strata of populations would have NO medical care if there were not NPs out there doing it.
Time to quit playing games and ratify the work the nurses/NPs really are doing - and give them the autonomy and respect they really deserve.
Nov 30, '08
When it comes to paying for a better health care system, authors Donald L. Bartlett and James B. Steele say best in their book “Critical Condition”: “To be sure, the market approach is unbeatable in most segments of the economy. Competition among multiple producers that turn out goods and services leads to innovation, better products and lower prices. The concept works flawlessly when the commodity is cars, furniture, cereal, doughnuts, computers, clothing, gasoline, or any other consumer item.
The glaring exception to the theory is health care. The very core principle of the market system, that companies will compete by selling more products to everyone, is actually the last thing the health care system needs. The goal should be to sell less, not more — that is, fewer doctor visits, fewer diagnostic tests, fewer hospitalizations, fewer consultations with specialists, and fewer prescription drugs.”
We're already paying twice what others pay, and getting less. The question is when will we wise up.
Nov 30, '08
I read a germane article this morning. Mass. has dictated that all shall be insured, whether via Medicaid or employment-paid coverage. Thousands who had no coverage before were covered, but now there are minimum four month waits to see a PCP. The reason - PCPs are paid less under insurance contracts than Specialists, and patients are denied Specialist care if they do not have a PCP. Reason - PCPs are leaving that sector of health provision in great numbers, and thus far, no substantive research beyond what we do know of the structure of capitation as well as all other insurance payment schemes viz PCPs.
Problems for the newly-insured (I experienced this of course): they typically had more issues "stored up" needing to be addressed than those privileged to be insured over time. PCPs ONLY have a maximum of fifteen to twenty minutes typically even for new patient appointments. ONE problem per session, metered care. Long waits for appointments. And so these folks come into the system when finally their turn comes, more ill, with more illnesses, and with greater urgency as well, as they do not have a belief or an expectation that they will not again be lost to followup as a result of yet another shift in health policy.
The shortage of PCPs is causing a rise in visits to the ED for primary care. Why? Medicaid pays for it. Yes, we have a history of high ED use for those who are uninsured. However, many of us "out there" simply go without any care whatsoever, as we still try to protect our vulnerable credit profile by NOT ending up in an ER or going to a doctor we cannot hope to pay full price out of pocket for a broken limb or other acute care. We go without here, and doctor ourselves. Once Mass assured that all will be covered, those who might have stayed home and were not those vaunted "ER abusers" the "welfare people" haters love to drag up... well, if they were unable to access a PCP or get any appointment, they do now go for care where they can go.
<h2>SO: it is good to make a mandate. But a mandate must be backed by dollars. We already experience a tight market viz providers available to service the population. The Mass. situation is NOT just PCPs refusing to see Medicaid patients (a growing phenom - refusal to see Medicare elderly and Medicaid patients, in this, a time of growing joblessness and inevitable reliance upon state-based support to get families through these times). The structures of private insurance contracts mimic those of federal/state payment structures in shape. A PCP must work two full days to earn as much as a specialist will earn in one procedure. Hence, the growing national movement to develop a new model of the integrated-services medical home to get the PCP off the treadmill and substantially increase quality of life and care for all in that relationship - patient, family, provider, clinic staff.</h2>