The Ironic Cherry Reads... An American Sickness

An American Sickness:

How Healthcare Became Big Business

and

How You Can Take it Back

by

Elisabeth Rosenthal

It takes a lot of hands to mess up healthcare as badly as we have done in this country.  And Elisabeth Rosenthal has described pretty nearly all of those interested parties and how they have affected us and our health care in this book.  She has done it in a way that makes each aspect of the healthcare disaster personal to each of us.

Rosenthal is a writer and non-practicing physician who now writes for Kaiser Health News.  Not only is the book well-researched, but she does have her finger on the pulse of American healthcare.  In the book, she documents chapter by chapter the different pieces of the healthcare puzzle, with personal stories about wrestling with the massive and systemic incompetence and corruption.  These personal stories come from people not in the field, but also other physicians, and Rosenthal herself.  Importantly, the people whose experiences she describes are not anonymous.  They have all come forward to tell their story in order to help change this awful system.  And then she details practical ways we can effect both political change and fight personal battles over things like drugs and hospital bills.

I would like to run down all the most important details, but it seems that I would have to basically transcribe the entire book.  There is critical information on every page.  And it is information that could affect any of us.  Rosenthal has broken the book down into chapters about each aspect, from insurance, hospitals and doctors, to pharmaceuticals, medical appliances and research.

Each of those facets of health care, since the sixties, has contributed to changing the goal from improving health to increasing profit.

Blue Cross Blue Shield was once a true non-profit which goal was to make health care affordable, but when for-profit companies like Cigna stepped in, the competition forced Blue Cross to make profit a goal in order to survive.  Money was increasingly spent more on advertising and executive salaries than on health care, to the point that the Affordable Care Act now requires that the industry spend at least 80% of premiums on health care.

The initial function of hospitals was charitable.  These days many of those hospitals have become an important way to bring in money to the Catholic Church.  Again, executive pay and advertising run up the bill.  Hospitals compete by offering the services that will increase profit rather than those that are most needed.  Part of their business model is that they must continually get larger, swallowing up smaller hospitals or forcing them to close.  Hospital administrators now tend to have business backgrounds rather than medical experience.  And those administrators work hard for their big paychecks, by figuring out ways to increase profit.  Unnecessary tests and extended hospital stays, $10 aspirin, contracting out rather than having in-house doctors -- just a drop in the bucket of creative ways to jack up hospital profit, with little to no accountability.

Likewise, physicians were increasingly likely to run their practices with an eye to profit rather than the needs of their patients or community.  The doctor that stops by your bed to see how you are doing is billing you for it.  "Physician extenders" can step in and do the work of the specialist without the qualifications; double billing; coding for a more costly procedure; out-of-network physicians who are contracted by a hospital without your knowledge, leaving you with a huge out-of-pocket bill.  And you may never see the doctor who quickly scans your treatment from an office miles away, yet bills you as though he has actually provided treatment.

If you are wondering why our drugs cost so incredibly much more than those sold in any other country, the culprit is a for-profit system with a pharaceutical industry that pays lobbyists a fortune to keep government regulations at bay.  The tricks they play to keep the prices sky-high are mind boggling.  There are actual legally accepted methods that can keep a generic off the market for years after the patent should have expired.  Competitors actually make deals with companies that have big-name drugs, agreeing to keep their drug off the market for a price.

Remember Martin Shkreli, the cocky, immoral narcissist who bought the rights to a cheap generic and raised the price from $13.50 to $750 a pill?  The thing about Shkreli is not so much what he did, but that he did it so publicly and shamelessly.  In fact, that kind of abuse goes on all the time, at every available opportunity.  The government is unwilling to step in and regulate.  The drug companies make billions from our suffering.  Marketing new, expensive drugs that are less effective than older generics, extending a patent by adding a new coating to a pill, fishy FDA rules that allow drug approval with inadequate testing... again, I could go on and on.

Medical devices are another area of creative price gouging, one that is buried in other bills.  The device manufacturers' lobby has been so successful that as some members of the Senate are attempting to work together on fixing the ACA, thus far the only item that has been altered is eliminating the 2.3% medical device tax, which is actually closer to 1.5% after deductions.  20,000 jobs were not lost as a result of the tax.  The tax is not on consumer devices, like eye glasses, but only on "non-retail medical devices," like MRI's and pacemakers.  And like the $4,000 screws used in some back operations.  The prices from hospital to hospital vary like crazy; there is no rhyme or reason to the pricing.

One of my favorite boondoggle stories is a personal one.  A few years ago, while I was working at a branch of the Charleston County Public Library, each branch had installed a defibrillator.  It was a great source of wonder and comic relief for the staff.  As a library assistant, high school degree required, the assumption was that one of us would be required, with no training, to operate the defibrillator on a patron suffering a heart attack.  One of us thought that it should only be used if the patron was unconscious.  We hadn't even been given an emergency phone number.  In a very cynical way, it cracked me up.  But wasn't it a damn clever idea to sell those things to zillions of local governments across the country? With little proof of effectiveness of defibs in public places, no funds for training, and a pretty good-sized price tag for governments that, in the 2000's were bearing the weight of huge budget cuts.  Hate the government?  Blame the corporations that prey on them.

Medical tests are overpriced and overused; in-house testing creates greater profit for doctors and hospitals and sometimes ridiculously higher bills for patients.  Ambulances are now in many areas contracted out, and the costs non-negotiable, and often, not covered by insurance.  Physical therapy used to be an affordable service but is now big business.

Medical coding, rather than being a language that makes it easier for professionals to know a patient's medical status, is now an opportunity for obfuscation and profit.  Consultants are hired to find a way to pad the bill by entering a more highly reimbursed procedure code.

And then there is research.  Research is the excuse given by pharmaceuticals and device manufacturers for their exorbitant prices and insistence on longer patent times.  But "new" items too often these days merely replicate old, tried and true -- and less expensive --  drugs or devices, research is oftentimes not as rigorous as seems to be required.  And results and follow-ups, well, they just aren't cost effective when it comes to the bottom line, so when the regulators aren't paying attention, they too often are minimized or don't happen.

Medicare and the Affordable Care Act have both attempted to improve medical outcomes and curb costs, but those who stand to profit work tirelessly to get around those efforts to provide affordable quality care.  And lobbyists ensure that our lawmakers don't do much to get in the way of the industry.  Al Franken, Amy Klobuchar and -- my god -- Elizabeth Warren, all worked across the aisle to support REPEAL of the medical device tax, which had been intended to finance Obamacare.  Why?  Because Minnesota and Massachusetts are home base for three of the largest device manufacturers.

On that sobering note, the author goes on to itemize by category our $3 trillion health care bill.  And then, in a short but important section, she gives practical instructions for combating the health care behemoth in our own lives, as, for example, when you get an unexplained charge on a hospital bill.

It would be in your own interest to read this book.  But we don't all have the time.  But I urge you to check it out of the library, glimpse through it, and pick a chapter that calls out to you.  Fifteen minutes of your time (if you can put the book down) will give you an idea of why it has taken so long to get to Obamacare and why there has been so much energy, and so many dollars, put into dismantling it.  And why it is so important to take down this massive waste of money and lives.

Tim Scott's Tireless Battle Against Cost-Effectiveness

When I get my weekly email from Senator Tim Scott, I groan and debate whether I have the stomach to open it.  The power went out for several hours last night, and I got a bad night's sleep, so let's attribute my weakness to that.

If you can't find "Obama" in one of Scott's weekly emails, it means you haven't opened it.  One of his handlers told him that bringing forth the President's name has the same effect as Mark Sanford's successful run against Nancy Pelosi in 2013.  And Tim Scott does listen to his handlers.

This week the intrepid senator is waging war against the "Part B Drug Payment Model."  In Scott's words,

 Medicare Part B Drug Payment Model

The Obama Administration’s “Part B Drug Payment Model” proposed rule disrupts care for vulnerable patients-such as those with cancer, rheumatoid arthritis, and other serious medical conditions. I, along with a number of my colleagues,have called for the withdrawal of the proposal because it will only hurt Medicare beneficiaries by increasing costs and decreasing the quality of care and patients’ choices.  The Centers for Medicare & Medicaid Services (CMS) did not consult with outside experts or those with real-world experience when coming up with this proposal and in my opinion that is a recipe for disaster. I was joined by my colleagues on the Finance Committee in writing CMS Acting Administrator Slavitt – you can read the letter here.

Are you scared?  Because the CMS (Centers for Medicare & Medicaid Services) has a different take on this proposal than do Scott and his evil republican colleagues.  The purpose of this proposed model is to test the ways in which out-patient administration of drugs by physicians are reimbursed, rewarding the use of the more effective drugs with more favorable rates:

  Today’s proposal is part of the Administration’s broader strategy to encourage better care, smarter spending, and healthier people by paying for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality.

In other words, the purpose of this test is to determine which treatments have more positive outcomes, and to provide financial incentives for physicians' use of those drugs.

Now if you distrust the government the way, say, Tim Scott distrusts the government, you will make the kind of hysterical assumptions that frankly, he is hoping you will make.  If you have a healthy distrust of government, you will wonder why Scott is so vehemently opposed to this proposal.  Here it is in two words:

Corporate Profit

It is the single most fevered purpose of Tea Partiers like Scott to push government out of the way of profit.  This is why we have a system in which the government is not allowed to negotiate better prices for Medicare.  The thought that the government might encourage more effective outcomes means that profit will be taking a back seat to patient care.  And it is this that Scott and fellow greedmongers in the House are fighting.

Scott lies when he claims that CMS did not consult with "outside experts or those with real-world experience."  Unless of course he is referring to the pharmaceutical industry, which does in fact have real-world experience -- in maximizing profit.  I can think of no better way than to study the effectiveness of treatment than to study outcome.  This is an honest-to-gods scientific method, and this is why our anti-science republican House is against it.

Living here in the bastion of anti-science and paranoia, you will no doubt hear someone at some point complain that the government is going to try to take away their Medicare drugs.  Please inform them that the reason Medicare costs are so high is that the pharmaceutical industry has been allowed to control drug costs, and the government has not been allowed to give incentives to doctors for more effective treatments.  You will hear people complain about drug costs out of control, but they will idiotically blame, not just the government, but the evil Obama.  You should explain that this is because republicans like Tim Scott have voted to prevent the government from having any input into drug prices, and so the pharmaceutical industry pushes drugs based on profit rather than outcome.

Scott would like all his frightened, angry, uninformed constituents to support him in his demand that this proposal be withdrawn.  Don't let him get away with it.  Let others know that this is the way to get better health care, by studying what works and encouraging its practice.

It is called quality control, something republicans have thwarted for as long as they have been the party of corporate power.

Why I Talk about Money

A few days ago, I wrote a blog post about my frustrating efforts to get information in anticipation of my upcoming switch to Medicare.  In that post I talked dollars and cents regarding the costs of Medicare Part B, and specifically the way our Congress has increased the cost to new recipients, while avoiding the shitstorm they might have had if people already enrolled could see how much the premium and deductible had gone up.

My purpose in writing the blog was not just to describe how difficult it is to maneuver the complexities of Medicare, or even to expose all the unconscionable costs that seniors are now expected to pay for health insurance.  I really wanted to leave readers with the awareness that this is very likely to be the future of Obamacare, which is currently affordable and comprehensive.

Since I wrote the blog, I have had a number of conversations with people where we have actually talked in dollars and cents.  It is amazing how many intelligent and aware people do not know or understand all the various components of their health insurance, who just pay what they are billed and are thankful that they are covered.  Which is just the way Congress and the health care industry want it.

I have found, in my life, that we are more comfortable talking about our sex lives than about money.  I was told when I was in my twenties, by a far more sophisticated friend, that it is impolite to talk about money.  We don't want to brag and we sure don't want to beg.  We don't want sympathy, and we don't want scorn.

So we don't talk about our income.  If we were more comfortable sharing information about money, Lilly Ledbetter might not have been in the dark about being subject to wage discrimination.  We might all learn about bad financial deals and all those scams like car buying and loans.  We might exchange good information about tax breaks and government programs to which we are entitled.  We would be far more aware of how the republican right has worked with corporations and billionaires to manipulate our incomes and expenses.

Actually, not talking about money makes about as much sense to me as not talking about age.  It makes a big secret out of something that should be merely a sharing of information.  Really, who cares that I am 64?  It doesn't mean I'm going to die sooner, or look younger.  I believe people will judge me on far more than my age, and knowing how old I am is just a small piece of information that I provide.

Talking about costs is important to me, not because I need for people to know how much I personally live on, but because we all need to know more about how we all survive in this really bad plutocracy.  Absence of information makes us all vulnerable.  That is why corporations fight so hard to hide financial data; that is also why they are working so hard to collect data from all of us.

Here is another thing.  Since the Post and Courier published an article about serious problems with well water on Wadmalaw Island, a number of concerned people asked me how I was faring.  Fact is, I live in a relatively new development, the well is only about 25 years old, and there are people living with wells that were drilled in the 60's and 70's.  But, I add, there is a low income grant that qualifies me for a new well, so I am fortunate on that account as well.

Most people, I think, are uncomfortable learning that I qualify for a new well based on my income.  None of us really want to know that our friends are struggling financially, do we?  And then there are probably those who get their backs up just a bit over their tax dollars paying for my well.  If I end up with a new well and I am not obviously struggling, isn't that wrong?  After all, it wasn't long ago that the right-wingnuts in Congress were saying that you weren't poor if you had a refrigerator.

It's okay for tax dollars to pay for Boeing's success, and it's okay for corporate farms and pharmaceuticals to get huge subsidies from the government.  I recently heard a building contractor, when asked what he thought about Trump, reply, "If he becomes president, I'll be right there putting in a bid to build that wall."  There are acceptable ways to take government money and having a low income just isn't one of them.

I wrestled with agreeing to have that new well built.  I knew there were people far worse off than me.  But I was also told that if something happened to my current system, it would cost $6,000 to drill that new well.  So I agreed.

A businessman getting offered a good deal by the government would hardly turn it down.  But we individuals are made to feel like beggars and sponges if we accept a good deal.  Many, many people do not apply for financial assistance or food stamps because of the stigma, which our right-wing government is all too happy to magnify, by adding regulations from more frequent income checks to required proof of job-seeking to drug tests.

When the housing market collapsed not too long ago, hard working middle class people who believed in our capitalist system were thrown out on the street.  Congress fought over whether people who were unsuccessful looking for jobs should have their unemployment benefits extended.

There is an enormous myth that persists that if you work hard you will not need to turn to the government for help.  And yet those who are in government and trying to cut the benefits we deserve and depend upon are all to happy to take what the government gives them.  Our right-wing majority in Congress, and in too many of our statehouses, insist that people should work two jobs, mothers should work rather than stay home with children.  Meanwhile, members of the US House of Representatives, with full pay and benefits, are scheduled to work 111 days this year.

So let's not be polite about money.  We may think we don't know anyone who is struggling, or we may just think we don't know anyone who is struggling as much as we are.  Fact is, too many of us are in that same shaky boat, while the Koch brothers are in the yacht that is making all the waves. 

Get Out Your Pitchforks

I have been trying to be quiet through this latest episode of mass hysteria.  I really have.  But at the risk of raising the wrath of every single one of my friends, I am going to have to speak my mind.  Because that is what I do.

I usually enjoy Chris Hayes' liberal rants.  His young face gets all puffed up and he starts to stutter.  He is outraged, but he tends to wrap his outrage up in reason.  Except when it comes to vaccinations.  Then he becomes the 21st century yuppie parent, screeching about how my kid is going to infect his kid.  And since the latest "measles outbreak" it has been all-measles-all-the-time on All In with Chris Hayes.

It's not just Hayes, though.  For weeks we have been bombarded with the terror inspiring word of "100 cases" of measles, brought about by those bad parents who irresponsibly and selfishly chose not to have their kids vaccinated for measles AND THEN WENT TO DISNEYWORLD.  I have been listening, hard, to these news reports, waiting to hear of the 100 cases spreading into the thousands, or to hear how many of those hundred have died from the disease.  The answer, as far as I can tell, is none.

Then, two days ago, I heard that the worst fears had been realized:  five infants had been confirmed to have measles.  Before I began to write, I gave it one more try.  When I googled "measles," I learned that a "Baby Had Been Confirmed as First Victim in New Jersey."  Oh my god.  It finally happened.

But no.  The report goes on to say that the one-year-old has since recovered.  Everybody in the building, the town, the state and the country, however, has been alerted.  I can be fairly certain that if there had been a death it would be front page everywhere.  Not that it couldn't happen.  But in developed countries, where overall health and hygiene are good, measles is rarely fatal.

For those of you youngsters, like Mr. Hayes, even your parents are not likely to remember when measles was just a childhood disease.  A kid broke out, itched, ran a temperature, and stayed home from school for a week.  And then they got better.

Back in the 80's, when my daughter was born, there was a healthy debate about the value of vaccinations versus allowing natural immunities to develop.  That debate seems to have been hijacked by the debate over vaccines causing autism.  And over the past couple of weeks, even when anti-vaccine proponents have been interviewed, I have not heard a single word spoken about natural immunity.  So here it is.

An infant has a weak and developing immune system.  Nursing contributes to adding mother's immunities to the baby.  And just as a childhood disease like measles is likely to be worse in an adult, healthy babies tend to experience milder symptoms.  When my pre-school daughter got chickenpox at four years old, her six-month-old brother also contracted the disease.  While she itched and had a fever, her brother didn't even notice he was sick.  And they both now have lifetime immunity to chickenpox.

Which brings me to the point that I keep waiting to hear.  If you are vaccinated, you need to be re-vaccinated.  The immunity is temporary.  If you allow this childhood disease to run its course, however, you have immunity for life.  So that pregnant women who have had the measles as children need not fear contracting measles, which is truly dangerous to the development of a fetus.

Now, it also appears that drug companies are griping, and vaccine supporters are touting, the "fact" that drug companies are not making a fortune on vaccine.  A cursory search did not come up with any numbers, and it's true that we don't have to pay much for vaccines.  But drug companies have done an amazing job of hiding the cost -- and the profit -- of the most commonly used drugs.  Government subsidizes a lot of the cost of vaccines, which means drug companies still get paid.  It may be that they don't make the mint that they make on far too many much needed drugs.  But vaccines are the steady, guaranteed profit-maker.  Drug companies are more likely to balk at having to waste money researching more desperately needed vaccines for third world countries than to complain about reaping that steady US vaccine market.

Now, if MSNBC wanted to rant about what is endangering lives in America, they might want to take a look at overmedication.  There was a peep in the media a few years ago about the over prescription of antibiotics, and then it went away.  But in fact, prescribing antibiotics when an illness could just run its course, has led to the development of, oh, let's call it a master race of infections.  And you don't need to be the one taking the antibiotics to reap the rewards of being infected by these master bugs.  And the drug companies continue to make stronger antibiotics and the bugs that survive the drugs continue to get stronger and harder to eradicate.  Much like using Round-Up to kill weeds until you have master weeds that need ever stronger poisons to be killed.

It amazes me when smart people who tend to be rational go nuts.  I am thinking about the hysterics in the 80's over "catching AIDS" (and I hate to admit, I was one of those, although eventually I did succumb to reason).  Or how about last year's ebola scare, when healthy people where coming back from Africa, even parts that were nowhere near the reported outbreaks, and faced anger and outrage and even -- thank you Chris Christie -- quarantine.

The most idiotic argument, the one that is expressed every single time vaccination is "discussed" is that your unvaccinated kid is going to endanger my vaccinated kid.  Well, no.  If your kid is vaccinated, and the thing works the way you claim it works, your kid will be spared the scourge of the dreaded measles.  Or, if the kid comes down with the measles, it should be a mild version, and (if you're really lucky) it will be enough to immunize the child for life.  Wouldn't that be grand.

Anyway, I would like to conclude by saying:

JUST CALM DOWN.  If we were poor people who lived with poor health and poor hygiene, our children would be more vulnerable to extreme symptoms.  In that case, I would say, by all means get the vaccine.  And if you really believe that drugs trumps the body's ability to fight any disease, go for it.  But please stop trying to make it sound like children are dying in the streets from this disease.  Be smug in your superior parenting if you like, but stop trying to make it sound like people who disagree with you are arming themselves with deadly germs and coming after your kids.

Our Nanny State

My husband has cancer, and so far chemo isn't helping.  I only bring that up because he has been dealing with pain for nearly two years.  Increasing doses of Oxycontin do nothing to alleviate the pain, only increase his dependence on Oxycontin.

He has been left, at age 76, to skulk around trying to find connections to procure weed in order to ease his pain.  And this pisses me off.  Our legislators, drinks in hand, are quick to point out that marijuana is too dangerous to allow us simple folk access.  Meanwhile, they whine about having to clean up the air we breathe and the water we drink, claiming that the polluters would suffer if forced to clean up our living space.

In defiance of the facts, we are encouraged -- encouraged -- to bring guns into bars, schools, pretty much anyplace except the state and US capitols that these idiots inhabit.  And because facts would prove the need for gun control, they pass laws preventing the collection of data about gun control.

On the other hand, they are concerned enough for our bad behavior that they allow cameras on every street corner and permit police to invade our houses in search of illegal poker games and, of course, medicinal marijuana.

Just as much psychotic legislating goes on regarding our health care:  laws that grant the government the right to monitor our decisions about our bodies, while denying health care to pregnant women and infants.  Death panels?  Not from Obamacare, but from our own legislators, the ones whose stated goal is to protect us from the evils of providing health care to all.

Here we are, listening to bullshit about freedom from the people who are attempting to limit our choices, curb our freedom to live in pursuit of life, liberty and as much freedom from pain as possible.  These are the people who are all too quick to make laws that deny us our rights while granting them to corporations.  Regulate the people, not the banks, or the pharmaceutical industry, or Monsanto, or the Kochs.

So why do they get elected?  In the beginning, this time around, in the 70's, our good lives had some setbacks, and the fearmongers turned us against ourselves.  They had been waiting for their moment, and it came, and so they preached the evils of unions, and regulation, and ungodliness.  And they found a teflon coated actor to lie to us, and the American people bought it.  Morning in America.

And as corporate America became more powerful, even those of us who knew they were wrong began to believe we could not win.  We stopped voting, we stopped fighting.  Our unions compromised themselves out of existence.  Our politicians leaned ever more to the right in order to not fall off the sinking ship.

You don't have to look too closely to see the hypocrisy.  On the one hand, control the individual, with the Patriot Act, with electronic spying, with laws that make our lives more dangerous and on the other hand pass laws that prohibit us from making decisions that would keep us safe.

Meanwhile, my husband would just like to be able to buy some grass so he can get a little rest from the pain.