# Chronic Illness

Obama must deliver on health care

I don’t expect to get everything I want from Democratic politicians in power. Probably liberals like me will have plenty of disappointments in the coming years. But if Barack Obama and the Democratic Congress only follow through on one big campaign promise, I hope it’s health care.

The many injustices of our current health care system have been thoroughly documented by nyceve, among others, but I want to add my two cents.

The 46 million Americans lacking health insurance represent one very large part of problem. Some can’t afford insurance, and others can’t find a private insurer who will sell them a policy for any price. You could spend all day listing the ways uninsured Americans get a raw deal on health care. They can’t afford preventive care and routine diagnostics, so they are more likely to be diagnosed with late-stage, incurable cancer. They are less likely to receive care for any number of chronic illnesses. They live with terrible, crippling pain. Few Americans without health insurance coverage are able to receive organ transplants, though many become organ donors after dying prematurely.

We need to get these people covered and get away from our broken employer-based health care system. Every day Americans who thought they had good benefits are joining the ranks of the uninsured–like my friend whose husband got laid off in October, right before his employer (a small manufacturer) went under. It turned out the boss had secretly stopped paying the health insurance premiums some time before. Or the retirees who worked at Maytag or at John Deere for many years and are now losing some of the health benefits they were promised.

Employer-based health care is also a huge drag on large corporations and our national economy, as clammyc pointed out in this recent diary.

In an ideal world, I’m for a Canadian-style single-payer system (also known as HR 676 or “Medicare for all”), but as a political compromise I would settle for something like what John Edwards and Hillary Clinton proposed during the primaries: mandatory health insurance, which would be portable with no exclusions for pre-existing conditions, and the option for any American to buy into a public insurance plan. Momentum is building in Congress for this kind of reform.

But getting Americans health insurance will solve only part of the problem. It’s shocking how many Americans with “good” insurance go without needed medical care. Only occasionally does a case makes national news, as when the teenager Nataline Sarkisyan was unable to get a liver transplant last year. A recent study found many Americans with chronic illnesses forgo medical care for cost reasons, even if they have insurance.

Then there are the “lucky” people who get the care they need for a medical emergency, but later face financieal ruin when their insurance company denies coverage. Medical bills are implicated in about half of all personal bankruptcies in the U.S.

When I had a medical emergency last winter, I got to the doctor relatively early, I received good care in the hospital, no lasting damage was done to my body, and my insurance company covered almost all of the costs (once we had exhausted our deductible). I remember our relief when the biggest bill arrived in the mail, for about $18,000, and our required payment was only $600. (I recognize that $600 would be a hardship for many families, but we are fortunate to be able to pay that without cutting back on any essentials.)

Yesterday I was reminded again of how things could have turned out very differently for my family. If you are a regular at Daily Kos, you may recognize the handle AdmiralNaismith. Among other things, he wrote a series of diaries about the political scene in all 50 states between April and October. The links to all of those pieces are here, and he wrote an interesting post-election wrap-up diary here.

AdmiralNaismith doesn’t write many personal diaries, but he recently discussed his own family’s “medical horror story”: Drowning in medical bills, despite insurance (another link is here).

He describes the sequence of events, including his wife’s life-threatening embolism, which left his family owing thousands of dollars for medical care–more unpaid bills than AdmiralNaismith earns in three months. He asked fellow bloggers to help pay down the three largest bills, which will otherwise be sent to collection agencies within 30 days. (He’s not asking anyone to send him money directly but provides contact details for the insurer, with name and account number.) A few hundred people paying $10 or $20 each would help enormously.

I will be calling to make a payment on Monday, and I encourage anyone who’s ever benefited from reading AdmiralNaismith’s informative diaries to do the same.

But equally important, I ask the community of Democratic activists, who did so much to elect Obama, to hold his feet to the fire next year on delivering the comprehensive health care reform he promised.

I haven’t been thrilled with Obama’s cabinet appointments so far. My number one hope for the new government is that Ezra Klein is right about what Tom Daschle as secretary of Health and Human Services means:

This is huge news, and the clearest evidence yet that Obama means to pursue comprehensive health reform. You don’t tap the former Senate Majority Leader to run your health care bureaucracy. That’s not his skill set. You tap him to get your health care plan through Congress. You tap him because he understands the parliamentary tricks and has a deep knowledge of the ideologies and incentives of the relevant players. You tap him because you understand that health care reform runs through the Senate. And he accepts because he has been assured that you mean to attempt health care reform.

Please share your thoughts or health care horror stories in the comments.

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Why do we tolerate our immoral and ineffective health care system?

Via nyceve at Daily Kos I learned about a new study called “Class and Race Inequalities in Health and Health Care.” The three authors found that very few Americans lacking health insurance receive organ transplants, although the uninsured often become organ donors.

Eve’s diary includes a link to the full report in pdf format and summarizes one of its findings:

Strikingly, lack of insurance was a stronger predictor of organ donation than was any hospital characteristic or demographic factor other than age (older people’s organs are more often diseased and unsuitable for transplantation).

Why are the uninsured more likely to become organ donors? Could it be that more of them are dying prematurely?

The authors explain in the introduction why they embarked on this research project:

   “In September of 2005, one of us (Herring), then a third-year medical student, cared for a previously healthy 25-year-old uninsured day laborer who arrived at the emergency department with rapidly advancing idiopathic dilated cardiomyopathy.

   The patient was ultimately deemed unsuitable for cardiac transplantation. The decision on transplantation was driven, in part, by realistic concern about the patient’s inability to pay for long-term immunosuppressive therapy and to support himself during recovery. Absent such resources, the likelihood of a successful outcome is compromised. The clinicians caring for him faced a wrenching dilemma: deny the patient a transplant, or use a scarce organ for a patient with a reduced chance of success. He died of heart failure two weeks after his initial presentation. This tragedy inspired us to examine data on the participation of the uninsured in organ transplantation, both as recipients and as donors.”

Yes, you read that correctly. The patient was rejected for a heart transplant in part because, lacking health insurance, he was deemed unlikely to be able to buy the immunosuppressing drugs he would need to survive with a new heart.

Republicans scream about “socialism” and “rationing,” as if health care is not rationed every single day in this country. Maybe one of my Christian conservative readers can explain why it was ok to deny this young man a heart transplant. If his job had provided health insurance, he might have gotten that heart and be alive today.

Speaking of health care rationing, I learned from this MyDD diary that the academic journal Health Affairs recently published a study comparing care for chronically ill patients in eight countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States).

Click here to read the study, which found that “Chronically ill U.S. patients have the most negative access, coordination, and safety experiences.” I’ve excerpted some passages:

Asked about experiences, U.S. and German patients were significantly more likely than patients in the other countries to report wasted time because of poorly organized care. […]

The United States stands out in patient costs, with 41 percent reporting that they spent more than $1,000 out of pocket in the past year. […]

U.S. chronically ill adults were by far the most likely to report forgoing needed care because of costs. More than half (54 percent) reported at least one cost-related access problem, including not filling a prescription or skipping doses, not visiting a doctor when sick, or not getting recommended care (Exhibit 2). […]

U.S. patients were significantly more likely than those in other countries to report that medical records or test results were not available during a scheduled visit or that tests were duplicated unnecessarily. One-third of U.S. patients reported at least one of these experiences–a rate 30 percent higher than in any other country. […]

U.S. uninsured adults were significantly more likely than those insured all year to go without care because of costs and to wait when sick. Remembering that all in this study have chronic (often multiple) conditions, a disturbingly high 82 percent of the uninsured did not fill a prescription, get recommended care, or see a doctor when sick because of costs. Uninsured chronically ill adults were also more likely than those with insurance to report errors as a result of higher rates of delays in hearing about abnormal lab tests and wrong-dose/ wrong-medication errors. Not surprisingly, given these experiences, the uninsured were also more negative about the U.S. health system than insured adults were.

Still, the experience of fragmented and inefficient care in the United States cuts across insurance status. Insured and uninsured chronically ill U.S. adults reported similarly high rates of coordination concerns (duplication and records/tests not available) and perceptions of excess care or time wasted because of poorly organized care.

Although insured U.S. adults fared better than the uninsured, they were still more likely than their counterparts in other countries to forgo care because of cost and to encounter poor coordination. Their perceptions of waste, patient-reported errors, and negative system views also remained at the high end of the country range. […]

Repeating patterns observed in earlier surveys, the United States continues to stand out for more negative patient experiences, ranking last or low for access, care coordination/efficiency, and patient-reported safety concerns. The percentage of chronically ill U.S. adults who reported access problems, errors, delays, duplication, and other symptoms of poorly organized care was two to three times the level reported in the lowest-rate countries in the survey (a 20-30 percentage point spread). Along with Canadians, U.S. patients were also the most likely to indicate a primary care system under stress–lack of rapid access, difficulty getting care after hours, and high ER use.

Americans spend a higher percent of our gross domestic product on health care than any other industrial democracy, yet we don’t get good value for money. It’s worst for the uninsured, but as the above study found, even chronically ill patients with health insurance reported more problems with health care access than comparably ill patients in other countries.

I hope Congressional Democrats are serious about making big changes to our health care system, because the status quo is immoral and unacceptable.

UPDATE: More evidence that our current rationing of health care is immoral can be found in this diary by nyceve: “Many uninsured Americans endure terrible physical pain.”

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