Health Reform Update Quickie

Most of the talk these days is about financial reform, ethics, and oil, but that healthcare bill is percolating through. NYT recently took a look at how Texas feels about it. In brief, they hate it because it costs too much.

Nurse: So. What gets me is that a lot of objections seem to be from “small government” types, whose general attitude is that the markets handle things in the best way on their own without interference. and when we’re talking about healthcare, there are a few problems with this– including that it’s clearly not working. costs are through the roof, outcomes aren’t improving, safety is a constant issue, and the system rewards choosing billable procedures over best practices.

Lawyer: And maybe, if people were shopping for healthcare services themselves, the market might take care of it. But they aren’t shopping for medical services — insurance companies are. And many of them aren’t shopping for insurance companies — their employers are. So the people setting the criteria are not the people using the services, and the people using the services end up having very little choice — hence, no market forces making it work.

Nurse: I seem to recall a Gawande essay in the new yorker about the town with the highest per capita health care costs being in texas?  I would argue that healthcare is a basic human right and that the government should be protecting it as they do life, liberty, and property– but this is more controversial.

Lawyer: I mean, none of our great old documents say we have a right to healthcare. But how about the right to life? And how about international human rights agreements? I will quickly be out of my depth if we start talking about international law, but let me leave it at this: among developed countries, we’d be doing pretty badly even if everyone did exactly what this new law says.

Nurse: To the argument that providing insurance to all the uninsured is way too expensive, I say that’s short-sighted. Ask any health care professional: chronic diseases that are poorly controlled are both extremely common and extremely expensive. When these patients are uninsured, they are treated in crisis only, and the cost of this care is out of control when compared to ongoing primary care– which typically, people do not seek without insurance.

Lawyer: Exactly. People are looking at the price tag and comparing it to zero, not comparing it to the alternatives. It’s like having a job where you absolutely need a car to get to it, and looking at a used Honda and saying “that costs too much,” when the other choice is a brand new BMW. You have to buy one — so comparison shop. Don’t just let your jaw drop at one price in isolation.

Sure, lots of things I believe in are genuinely open to the criticism that the government shouldn’t be spending money on that. The problem is, the government is going to pay for all this stuff anyway, and they’ll pay less, and people will be healthier, if we make the outlay.

Next time someone tries to argue otherwise, I will ask them if they want to repeal EMTALA. (That’s the law that requires emergency rooms to treat anyone who shows up needing treatment.) If you’re in an accident and you don’t have (a) your checkbook or (b) your insurance card with you, would you like the hospital to just leave you bleeding in the hallway until you prove you can pay?

Otherwise, emergency rooms will treat people who need it. And without insurance for preventive care, more people will need it.

I have a feeling we’re preaching to the choir here. Can I get an amen?

Obama and same-sex partner visitation

So we’ve all heard about Obama’s memo mandating hospitals to allow same sex partners to visit and make decisions for each other if that is their wish. I wonder if this will make a difference– patients have already had the right to designate anyone they choose (who is of age and of sound mind) to make their decisions for them, but I know (even though I am somehow still incredulous) that these wishes are sometimes not honored for same-sex couples. And I also know that there are hospitals where partners have been refused the right to visit, even when one of them is dying. I can’t imagine refusing someone that right, but I know it happens. When I worked at HRC, in the healthcare project, one of our recommendations was to carry a copy of all your POA paperwork with you, always, for just this reason. I hope that this step generates some awareness and helps to end some injustice. I just cannot understand– what does anyone, even someone who doesn’t believe in homosexuality, gain from denying a dying person’s lover the chance to say goodbye? We are committed to caring for our patients– so let’s CARE, at least a little! Ok, off soapbox. Thanks, prez!

(see also:

Here it is. Obamarama.

Lawyer: I went through the transcript with a highlighter to mark places where he actually said something concrete. I got to page 3 before I found anything.

Nurse: Overall, I think he’s doing a good job with this– it’s actually politically quite a tightrope between being too vague and making concrete promises that have to be shifted in some way later, and this always bites you in the ass. That said, it’s kind of disapointing to see how safe the approach is. While I recognize that it is largely impossible to enact sweeping dramatic change in a democracy which is beholden to so many interested parties, I wish it wasn’t. There are so many roots of the problems we have with healthcare delivery that are not addressed in this proposal– in a way, we are treating symptoms instead of making smart lifestyle choices. But I suppose that’s inevitable. Sigh.

Here are the substantive points he made, one by one:

1. We’d better build on what we have, rather than trying to build a whole new system.
Lawyer: Agree!

Nurse: Reluctantly agree out of pragmatism, not true belief.

2. This plan has three basic goals.
a. More security and stability for people who have insurance
b. Insurance for people who don’t have it
c. Slow the growth of health care costs

Lawyer: He doesn’t say much about how (c) is going to happen…

Nurse: And indeed, a lot of the most promising ways to do that are not possible in what amounts to a conservative (in the true sense of the word) reform effort.

3. Insurance regulation:
a.companies can’t deny coverage for preexisting conditions or drop/water down coverage when you get sick.
b. No arbitrary limits on how much coverage you get
c. Limits on out-of-pocket charges
d. Routine check-ups and preventive care must be covered

Lawyer: I mean, yeah.

Nurse: Right, this should be obvious. It’s not, but it should be. Even if this was the only thing that changed, we’d be better off.

4. Rather than out-right legislating what insurance companies must do, we will make these above reforms requirements for joining the health insurance exchange. Companies will want to join it so that they can compete for new customers. The exchange will give customers bargaining leverage.

Lawyer: I think this is a sound approach. Better to make people want to do things your way than to try to force them. Anyway, it worked with the whole drinking age thing. As long as it actually works. And insurance companies do actually participate. And follow the rules. Anybody know how this is actually going to function?

Nurse: It’s a tasty carrot. Mmm. carrots.

5. Tax credits for individuals and small businesses who can’t afford insurance, based on need.

6. Immediate low-cost, minimal coverage for the currently uninsured.

Lawyer: Um… details?

Nurse: Provided by? And covering. . .? People who can’t pay are still given care, but they are generally bankrupted by it. Maybe we are just getting around that.

7. People will be required to carry basic health insurance (just like auto insurance.) Businesses required to at least chip in. (Hardship waivers.)

Nurse: This at least makes sense, if we are going in a insurance-based model (See my previous post for a little discussion on that).

8. (wait for it…) Yes, there will be a public option available as part of the insurance exchange. (As one of many options.) CBO estimates that fewer than 5% of Americans would choose this option. The option will be self-sufficient, relying on the premiums it collects.

Lawyer: Wow, that low estimate makes me super-nervous.

Nurse: I think this is an essential part of the plan, not just in what it will actually do, but in the message it says. I do worry that it won’t truly be self-sufficient because people who elect it may have reasons not to buy private insurance or may find it too expensive. Depends on how the rest of that regultion reform plays out.

Lawyer: That’s too bad. Because people seem to be saying that it’s going down the crapper.

9. This will be paid for by cutting wasteful spending we already have, rather than expanding the deficit. If the projected savings don’t happen, we’ll cut spending, rather than adding to the deficit. Medicare trust will not pay for it.

Lawyer: Sounds good in theory. But I have a feeling that substantial savings will take a long time. I mean, longer than four years. Because our spending is really wasteful, yes, but we can’t just snap our fingers and quit doing that.

Nurse: And this is one place where we really need a cultural shift to fix it. A cultural shift involving how physicians and patients conceive of thorough care, and how malpractice suits are both perceived and actually used. Which leads into the next issue.

10. We’ll have some sort of panel to reduce defensive medicine. HHS is going to handle it. (vague, fuzzy, proclomations.)

Lawyer: I want to hear more about this! Ring ring, hello, Kathleen? Can we talk?

Nurse: Again, this is a deeply rooted cultural issue, in a way. I think we need some good evidence-based practice here– which means we need some research.

Lawyer: cf. Stimulus Bill.

Nurse: I have heard vaguely about studies which show that high-tech intervention can actually be harmful rather than helpful– as in using electronic fetal monitoring, which has been shown to cause unnecessary c-sections with no better outcomes, yet it’s become a standard of practice. HHS, can you work on this angle??

11. Poor Teddy Kennedy! This was his dying wish!  Also, as he said, this is a moral issue, not just a policy issue.

Lawyer: Aww. Shot to the heart.

Nurse: Ok. Cool.

12. People thought we were socialists back when we invented social security and medicare, too, but can’t we all agree now that we need those things and they were a good idea?

Lawyer: JEEZ, thanks Obama, I’ve been trying to tell people that for a while now.

Nurse: well, what’s wrong with socialists? And another thing: he talks about requiring insurance to cover preventive care, but I think we could make huge progress by going a step further and offering incentives for preventive care. Maybe that would just be smart business for an insurance company, I don’t know– but i think it would help!

Lawyer: Mmm,  more carrots. Carrot cake. I have to go…

We WILL talk about the Obama speech.

But not right now. Torts starts in 10 minutes and I didn’t even get to watch the speech yet, let alone think about it, due to that phenomenon about which I’d been warned, but had not really yet understood: the first year of law school.

But one of my professors was nice enough to reschedule my only Friday class this week, which means my 3-day weekend starts in… an hour and twenty-five minutes. So watch for it.

In the mean time, I’m going to go follow the example set by our upstanding members of congress and heckle my professor during lecture. We’ll see how that goes over. Professor Engstrom, if you happen to read this: I don’t actually think you were lying in class.

let’s talk about death!

Not to preach to the choir, but let’s talk about this ridiculous coinage, “death panels.” almost brilliant– who’s in favor of death panels? the problem is, whatever a death panel is, it was never part of the Obama health proposal.

the proposal was to allow doctors to be compensated for time that they spend counseling patients on end-of-life options. there is not, and never was, any type of “panel” involved. so we can dismiss that part. and the death? well, yes, there is death. and there always will be. but discussing options for how to manage it is NOT the same thing as denying care to old people, or allowing people who might get well to die instead.
indulge me a minute– i am not a critically ill person, and i haven’t had a very close family member deteriorate and die in front of me. but i have seen, very much up close and personal, a lot of patients and families go through this. sometimes, patients or their families have made their wishes very clear all along– do everything, including ventilators, IV nutrition, and shot-in-the-dark risky surgeries, for a glimmer of home. that is a choice, and there is no proposal on the table that will eliminate it. I have also seen families whose clearly stated wishes were to withhold aggressive treatment  in the care of terminal illness. This is also a choice, and a difficult one, but often a good one. What’s really at stake here, though, are the people who have not ever stated clear wishes, or perhaps even considered them. These are people who would benefit from a thorough, honest conversation with a medical professional. They need to know that sometimes people put on ventilators never get off, that they may be sedated but still in pain, that they can get pressure sores despite excellent care, that they may have tubes in their rectum and bladder and nose and throat, keeping them alive. Not to talk them out of it, but to make sure that they know what could happen. I have seen a 90 year old person elect to have aggressive surgery only to die in the ICU after 30 minutes of CPR. I have seen an end-stage cancer patient die in a messy, chaotic hospital room in a flurry of strangers while his loved ones waited outside.
we need to create a culture that doesn’t judge people one way or the other for the decisions they make– and we need a culture that encoruages them to make decisions.

President Obama Win!

Entire text here, but just for us nurses:

“So I know how important nurses are, and the nation does too. Nurses aren’t in health care to get rich. Last I checked, they’re in it to care for all of us, from the time they bring a new life into this world to the moment they ease the pain of those who pass from it. If it weren’t for nurses, many Americans in underserved and rural areas would have no access to health care at all.

And that’s why it’s safe to say that few understand why we have to pass reform as intimately as our nation’s nurses. They see firsthand the heartbreaking costs of our health care crisis. They hear the same stories that I’ve heard across this country — of treatment deferred or coverage denied by insurance companies; of insurance premiums and prescriptions that are so expensive they consume a family’s entire budget; of Americans forced to use the emergency room for something as simple as a sore throat just because they can’t afford to see a doctor.”

There’s a slew of healthcare stuff here, but I just had to point out the nurse-love! GoBama!

The new plans involve a “health insurance exchange,” allowing consumers to comparison shop, and a public healthcare option available to everyone (like a broader medicare), which would hopefully increase competition and improve private insurance as well. Of course there are kinks and details, but we’re rolling. . .

Ping-Pong Post: Sotomayor Nomination

President Obama’s nomination of Sonia Sotomayor for the Supreme Court raises several nurse-and-lawyer issues:

1. Abortion.

Lawyer: We don’t know what she thinks. We have a little bit of evidence (upholding the Bush administration’s right to restrict federal funds to overseas agencies that perform or promote abortion, granting asylum to Chinese women (and their husbands) who would either be forced to abort or charged with a crime for allowing a pregnant woman to escape forced abortion) but neither of these rulings gives us much of a glimmer about a Roe challenge, which hinges on an implicit right to privacy as part of substantive due process.   As the Times says, objecting to forced abortion is hardly a radical stance — and it doesn’t really come down on either side of the choice debate as we know it in this country.

Nurse: Abortion is clearly a health issue, and a major one– and frequently kind of a litmus test (but we’ll get into that later). I think if a judge had NOT objected to forced abortion, it would be a huge, major red flag– whether or not we were looking Roe v. Wade in the future. I think that in the abortion issue, having another woman on the court– liberal or conservative– is a good thing. It’s hard to have a conversation about somethig which is so clearly a women’s issue without any women.

Lawyer: That’s a really good point, and one that I think is underplayed in the discussion. Gotta love the idea of a room full of men deciding things about women’s bodies. But that’s how it’s been.
2. Gun control.
Lawyer: SCOTUS ruled last year  that the FEDERAL government cannot make a law prohibiting guns to be kept in the home for self defense, and that played out in DC, which exists under federal laws — Judge Sotomayor sat on a panel that decided that a state CAN make such a law, and that’s  headed for the supreme court this summer (Maloney v. Cuomo.) She would almost surely recuse herself from this case, having already ruled on it, but there are others coming along on which she could rule.
Nurse: Violence is also a health issue– and some people don’t think so, but as a health care professional, I do. It’s good practice to ask about guns in the home when doing a health interview. I feel that law that regulate where guns can be have the potential to be really good– but like any laws, they need to be done well
Lawyer: I also think this issue is an interesting test of a judge’s judicial philosophy, as the Second Amendment, more than much of the rest of the constitution, seems a little anachronistic.  It was written to address a specific type of situation that no longer occurs, but other related situations do occur. So looking at how a judge interprets a question like this can give us a good sense of how much she wants to be living in the eighteenth century and how much she is willing to view the Constitution as a living document, a question that becomes more and more important as our society changes ever faster.
3. Gay marriage:
Lawyer: It’s already in the works. She has a history of siding with victims of discrimination — but that’s no sure bet.
Nurse: Again, in terms of health, we talked about gay marriage and the right to make healthcare decisions– this IS discrimination, no question. The law should protect people from discrimination.
Lawyer: I’m curious about where civil unions come into this discussion. Theoretically, a couple who was civilly united would have all those same visitation rights — right? I’m not condoning it — but in a way, that option being available makes the marriage fight harder to fight, because the discrrimination isn’t as blatant as it seems like it might be.
General thoughts:
Lawyer: The bigger question, from where I sit: to what degee is it right to look for a sure bet? We’re choosing a judge, not a congressman —  the President and Senate are not supposed to choose based on a stated platform. But at the same time, the President and the Senate need to make sure they choose someone who will protect our fundamental rights under the Constitution (though we differ on what those may be). It’s a fine line to walk.
Nurse: No, I don’t think we should look for a “sure bet.” We shouldn’t be picking judges on their positions on laws and issues, but rather on their process and their views on the law and the constitution, no? Healthcare is an area that needs law, and it needs it badly, so these are good questions to ask– but we need to remember in what context we’re asking them.
Lawyer: Either way, barring some revelation of a major ethical transgression, she’s almost certain to be confirmed. And I feel good about that.
Nurse: Me too.  :)