Veterans and Zombies
The Hype Behind the Health Care Scandal
by Paul Krugman
You’ve surely heard about the scandal at the Department of Veterans Affairs. A number of veterans found themselves waiting a long time for care, some of them died before they were seen, and some of the agency’s employees falsified records to cover up the extent of the problem. It’s a real scandal; some heads have already rolled, but there’s surely more to clean up.
But the goings-on at Veterans Affairs shouldn’t cause us to lose sight of a much bigger scandal: the almost surreal inefficiency and injustice of the American health care system as a whole. And it’s important to understand that the Veterans Affairs scandal, while real, is being hyped out of proportion by people whose real goal is to block reform of the larger system.
The essential, undeniable fact about American health care is how incredibly expensive it is — twice as costly per capita as the French system, two-and-a-half times as expensive as the British system. You might expect all that money to buy results, but the United States actually ranks low on basic measures of performance; we have low life expectancy and high infant mortality, and despite all that spending many people can’t get health care when they need it. What’s more, Americans seem to realize that they’re getting a bad deal: Surveys show a much smaller percentage of the population satisfied with the health system in America than in other countries.
And, in America, medical costs often cause financial distress to an extent that doesn’t happen in any other advanced nation.
How and why does health care in the United States manage to perform so badly? There have been many studies of the issue, identifying factors that range from high administrative costs, to high drug prices, to excessive testing. The details are fairly complicated, but if you had to identify a common theme behind America’s poor performance, it would be that we suffer from an excess of money-driven medicine. Vast amounts of costly paperwork are generated by for-profit insurers always looking for ways to deny payment; high spending on procedures of dubious medical efficacy is driven by the efforts of for-profit hospitals and providers to generate more revenue; high drug costs are driven by pharmaceutical companies who spend more on advertising and marketing than they do on research.
Other advanced countries don’t suffer from comparable problems because private gain is less of an issue. Outside the U.S., the government generally provides health insurance directly, or ensures that it’s available from tightly regulated nonprofit insurers; often, many hospitals are publicly owned, and many doctors are public employees.
As you might guess, conservatives don’t like the observation that American health care performs worse than other countries’ systems because it relies too much on the private sector and the profit motive. So whenever someone points out the obvious, there is a chorus of denial, of attempts to claim that America does, too, offer better care. It turns out, however, that such claims invariably end up relying on zombie arguments — that is, arguments that have been proved wrong, should be dead, but keep shambling along because they serve a political purpose
Arnold Relman, medicine's longtime conscience, dies at 91
By Robert Lowes
Medscape Medical News, June 19, 2014
PNHP note: See links to additional obituaries of Dr. Relman at end of this article.
Arnold "Bud" Relman, MD, a pace-setting former editor of the New England Journal of Medicine (NEJM), died June 17 of cancer at the age of 91, just weeks after another journal published his latest call for physicians to press for healthcare reform in the name of patient-centered care and professionalism.
If that kind of reform did not occur, "we will end up either with a system controlled by blind market forces or with a system entangled in complicated and intrusive government regulations," Dr. Relman wrote in an article published online June 2 in JAMA Internal Medicine.
Dr. Relman had advocated along those lines since he first warned of the corrupting influence of a "medical-industrial complex" in a landmark NEJM editorial in 1980, but "Bud was never one to let up on a subject," said Jerome Kassirer, MD, who succeeded him as editor-in-chief at the journal.
"If there was no response, he just said it again, and again, and again," Dr. Kassirer told Medscape Medical News. "He got people to listen. Even when people shrugged him off, they knew what he was saying was right."
Dr. Relman was editor-in-chief of the NEJM from 1977 to 1991. In addition to making the journal a forum for healthcare policy debate, he helped enlarged its influence. Its circulation, Dr. Kassirer reported in 1991, increased from 167,000 in 1976 to 233,000 in 1990, while the number of unsolicited manuscript rose 47%.
At the same time, Dr. Relman instilled an editorial purity at the NEJM in the 1980s that eventually became the standard for medical journal publishing. He was part of a seminal group at that time called the International Committee of Medical Journal Editors that sought to strengthen the scientific integrity of published research.
"He pointed out to all of us that we needed to think about the motivation of authors and funding sources," said George Lundberg, MD, then editor of the Journal of the American Medical Association.
Under Dr. Relman's direction, the NEJM became the first medical journal to require that study authors disclose any financial conflicts of interest. "This was revolutionary," said Dr. Lundberg, now an editor at Medscape Medical News. Other journals followed suit, but not before some foot-dragging. Disclosure statements "were seen as an invasion of privacy," he said. "Many editors and authors didn't think it was anybody's business what they owned or didn't own."
Naysayers notwithstanding, Dr. Relman won accolades for his tenure at NEJM. The late Saul Farber, MD, once dean of the New York University School of Medicine in New York City, said in 1988 that a collection of Dr. Relman's NEJM editorials would comprise "a universal, modern code of ethics for medicine."
'We are not vendors'
Dr. Relman brought street credibility to his role of publishing scientific research. In 1949, 3 years after he earned his medical degree at Columbia University in New York City at age 22, his own studies began to show up in peer-reviewed journals. Dr. Relman went on to become an authority on acid-base and electrolyte metabolism, nephrology, and renal physiology.
His career as an educator included long stretches at Boston University School of Medicine in Massachusetts, the University of Pennsylvania School of Medicine in Philadelphia, and finally Harvard Medical School in Boston, where he was an emeritus professor at the time of his death.
Before he arrived at the NEJM in 1977, Dr. Relman had already had made a name for himself in medical-journal circles. In the 1960s, he was editor of the Journal of Clinical Investigation, which Dr. Lundberg described as the premiere showcase for clinical research at the time.
At the NEJM, Dr. Relman began hammering away at the profit motive in healthcare, which he considered outsized and harmful. His disfavor fell on for-profit hospitals, for-profit nursing homes, and health insurers, among other market players. More than anything, Dr. Relman worried about the effect of the medical-industrial complex on his profession.
http://www.pnhp.org/print/news/2014/june/arnold-relman-medicines-longtime-conscience-dies-at-91
Obamacare: What About the Working Class and the Middle Class?
By Robert Lowes
Medscape Medical News, June 19, 2014
PNHP note: See links to additional obituaries of Dr. Relman at end of this article.
Arnold "Bud" Relman, MD, a pace-setting former editor of the New England Journal of Medicine (NEJM), died June 17 of cancer at the age of 91, just weeks after another journal published his latest call for physicians to press for healthcare reform in the name of patient-centered care and professionalism.
If that kind of reform did not occur, "we will end up either with a system controlled by blind market forces or with a system entangled in complicated and intrusive government regulations," Dr. Relman wrote in an article published online June 2 in JAMA Internal Medicine.
Dr. Relman had advocated along those lines since he first warned of the corrupting influence of a "medical-industrial complex" in a landmark NEJM editorial in 1980, but "Bud was never one to let up on a subject," said Jerome Kassirer, MD, who succeeded him as editor-in-chief at the journal.
"If there was no response, he just said it again, and again, and again," Dr. Kassirer told Medscape Medical News. "He got people to listen. Even when people shrugged him off, they knew what he was saying was right."
Dr. Relman was editor-in-chief of the NEJM from 1977 to 1991. In addition to making the journal a forum for healthcare policy debate, he helped enlarged its influence. Its circulation, Dr. Kassirer reported in 1991, increased from 167,000 in 1976 to 233,000 in 1990, while the number of unsolicited manuscript rose 47%.
At the same time, Dr. Relman instilled an editorial purity at the NEJM in the 1980s that eventually became the standard for medical journal publishing. He was part of a seminal group at that time called the International Committee of Medical Journal Editors that sought to strengthen the scientific integrity of published research.
"He pointed out to all of us that we needed to think about the motivation of authors and funding sources," said George Lundberg, MD, then editor of the Journal of the American Medical Association.
Under Dr. Relman's direction, the NEJM became the first medical journal to require that study authors disclose any financial conflicts of interest. "This was revolutionary," said Dr. Lundberg, now an editor at Medscape Medical News. Other journals followed suit, but not before some foot-dragging. Disclosure statements "were seen as an invasion of privacy," he said. "Many editors and authors didn't think it was anybody's business what they owned or didn't own."
Naysayers notwithstanding, Dr. Relman won accolades for his tenure at NEJM. The late Saul Farber, MD, once dean of the New York University School of Medicine in New York City, said in 1988 that a collection of Dr. Relman's NEJM editorials would comprise "a universal, modern code of ethics for medicine."
'We are not vendors'
Dr. Relman brought street credibility to his role of publishing scientific research. In 1949, 3 years after he earned his medical degree at Columbia University in New York City at age 22, his own studies began to show up in peer-reviewed journals. Dr. Relman went on to become an authority on acid-base and electrolyte metabolism, nephrology, and renal physiology.
His career as an educator included long stretches at Boston University School of Medicine in Massachusetts, the University of Pennsylvania School of Medicine in Philadelphia, and finally Harvard Medical School in Boston, where he was an emeritus professor at the time of his death.
Before he arrived at the NEJM in 1977, Dr. Relman had already had made a name for himself in medical-journal circles. In the 1960s, he was editor of the Journal of Clinical Investigation, which Dr. Lundberg described as the premiere showcase for clinical research at the time.
At the NEJM, Dr. Relman began hammering away at the profit motive in healthcare, which he considered outsized and harmful. His disfavor fell on for-profit hospitals, for-profit nursing homes, and health insurers, among other market players. More than anything, Dr. Relman worried about the effect of the medical-industrial complex on his profession.
http://www.pnhp.org/print/news/2014/june/arnold-relman-medicines-longtime-conscience-dies-at-91
Medscape Medical News, June 19, 2014
PNHP note: See links to additional obituaries of Dr. Relman at end of this article.
Arnold "Bud" Relman, MD, a pace-setting former editor of the New England Journal of Medicine (NEJM), died June 17 of cancer at the age of 91, just weeks after another journal published his latest call for physicians to press for healthcare reform in the name of patient-centered care and professionalism.
If that kind of reform did not occur, "we will end up either with a system controlled by blind market forces or with a system entangled in complicated and intrusive government regulations," Dr. Relman wrote in an article published online June 2 in JAMA Internal Medicine.
Dr. Relman had advocated along those lines since he first warned of the corrupting influence of a "medical-industrial complex" in a landmark NEJM editorial in 1980, but "Bud was never one to let up on a subject," said Jerome Kassirer, MD, who succeeded him as editor-in-chief at the journal.
"If there was no response, he just said it again, and again, and again," Dr. Kassirer told Medscape Medical News. "He got people to listen. Even when people shrugged him off, they knew what he was saying was right."
Dr. Relman was editor-in-chief of the NEJM from 1977 to 1991. In addition to making the journal a forum for healthcare policy debate, he helped enlarged its influence. Its circulation, Dr. Kassirer reported in 1991, increased from 167,000 in 1976 to 233,000 in 1990, while the number of unsolicited manuscript rose 47%.
At the same time, Dr. Relman instilled an editorial purity at the NEJM in the 1980s that eventually became the standard for medical journal publishing. He was part of a seminal group at that time called the International Committee of Medical Journal Editors that sought to strengthen the scientific integrity of published research.
"He pointed out to all of us that we needed to think about the motivation of authors and funding sources," said George Lundberg, MD, then editor of the Journal of the American Medical Association.
Under Dr. Relman's direction, the NEJM became the first medical journal to require that study authors disclose any financial conflicts of interest. "This was revolutionary," said Dr. Lundberg, now an editor at Medscape Medical News. Other journals followed suit, but not before some foot-dragging. Disclosure statements "were seen as an invasion of privacy," he said. "Many editors and authors didn't think it was anybody's business what they owned or didn't own."
Naysayers notwithstanding, Dr. Relman won accolades for his tenure at NEJM. The late Saul Farber, MD, once dean of the New York University School of Medicine in New York City, said in 1988 that a collection of Dr. Relman's NEJM editorials would comprise "a universal, modern code of ethics for medicine."
'We are not vendors'
Dr. Relman brought street credibility to his role of publishing scientific research. In 1949, 3 years after he earned his medical degree at Columbia University in New York City at age 22, his own studies began to show up in peer-reviewed journals. Dr. Relman went on to become an authority on acid-base and electrolyte metabolism, nephrology, and renal physiology.
His career as an educator included long stretches at Boston University School of Medicine in Massachusetts, the University of Pennsylvania School of Medicine in Philadelphia, and finally Harvard Medical School in Boston, where he was an emeritus professor at the time of his death.
Before he arrived at the NEJM in 1977, Dr. Relman had already had made a name for himself in medical-journal circles. In the 1960s, he was editor of the Journal of Clinical Investigation, which Dr. Lundberg described as the premiere showcase for clinical research at the time.
At the NEJM, Dr. Relman began hammering away at the profit motive in healthcare, which he considered outsized and harmful. His disfavor fell on for-profit hospitals, for-profit nursing homes, and health insurers, among other market players. More than anything, Dr. Relman worried about the effect of the medical-industrial complex on his profession.
http://www.pnhp.org/print/news/2014/june/arnold-relman-medicines-longtime-conscience-dies-at-91
Obamacare: What About the Working Class and the Middle Class?
The administration issued a report yesterday that says individuals who selected plans in the federal health insurance exchanges have a post-credit premium that is on average 76% less than the full premium for the plans they selected. And, 69% are paying less than $100 after the subsidies––46% are paying $50 or less.
The administration also pointed out that 65% of individuals selecting the Silver Plan in the federal exchange chose the lowest or second-lowest cost Silver Plan.
As I have said before, only about one-in-three subsidy eligible people bought and paid for coverage during Obamacare's first open-enrollment.
It would appear from this data that it is the lowest income people who are most often signing up for coverage. They are the ones who get the biggest premium subsidies as well as the reductions in their deductibles and co-pays.
The Obama administration has been touting the report. The new HHS secretary said, "We're finding that the marketplace is working. Consumers have more choices, and they are paying less for their premiums. Nearly 7 in 10 consumers who signed up in the marketplace are paying $100 or less for that coverage."
That is one way to look at it.
Here is another. The lowest income people––who pay the lowest premiums and out-of-pocket costs––are the ones who are obviously signing up. That explains why the average consumer subsidy is so high and the average net cost is so low.
As I have said on this blog before, the biggest consumer problem Obamacare has is that the plans––with their still high premiums even after the subsidy, big deductibles, and narrow networks––are not attractive to working class and middleclass families and individuals who don't qualify for the biggest subsidies.
The administration also pointed out that 65% of individuals selecting the Silver Plan in the federal exchange chose the lowest or second-lowest cost Silver Plan.
As I have said before, only about one-in-three subsidy eligible people bought and paid for coverage during Obamacare's first open-enrollment.
It would appear from this data that it is the lowest income people who are most often signing up for coverage. They are the ones who get the biggest premium subsidies as well as the reductions in their deductibles and co-pays.
The Obama administration has been touting the report. The new HHS secretary said, "We're finding that the marketplace is working. Consumers have more choices, and they are paying less for their premiums. Nearly 7 in 10 consumers who signed up in the marketplace are paying $100 or less for that coverage."
That is one way to look at it.
Here is another. The lowest income people––who pay the lowest premiums and out-of-pocket costs––are the ones who are obviously signing up. That explains why the average consumer subsidy is so high and the average net cost is so low.
As I have said on this blog before, the biggest consumer problem Obamacare has is that the plans––with their still high premiums even after the subsidy, big deductibles, and narrow networks––are not attractive to working class and middleclass families and individuals who don't qualify for the biggest subsidies.
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