Uninsured in America

Several provisions of the new healthcare law also called the Affordable Care Act went into effect yesterday. Yesterday also was the day when the GOP unveiled its Pledge for America. The document included proposals to cut spending and taxes, a staple. In addition it also included a proposal to repeal the Affordable Care Act. In case you haven't noticed, we are in an election cycle and each side will spend the next few weeks touting or assailing the new healthcare law.

But politics aside, the reality is that number of uninsured has been on a steady rise for the last decade. For the first time last year it crossed the 50 million mark. Now there can be debate about whether all the 50 million are legal residents or not. But that's besides the point. The number of uninsured has risen in almost every age group (except the under 18), as the graph below shows, and the recession has made it worse.

Data Source: US Census Bureau

Healthcare Spending and Quality of Care

When it comes to healthcare spending, the United States leads the developed countries in terms of amount of money spent on Healthcare. If we look at Healthcare spending as a % of GDP among the developed countries, the United States is the highest with Health Care spending accounting for 15% of GDP.

For all the spending associated with Healthcare, the US ranks 37th in the most recent WHO rankings. Though the rankings methodology might have its shortcomings, given the complexity of ranking a national healthcare system, the US has been slipping in ranking in other indicators or public health including male and female life expectancy and infant mortality. 

Data Source: CATO Institute 

Random Musings of The Week

Its time again for a post on some interesting articles that I read this past week.

First, lets starts with the most important topic of discussion: Healthcare. Every body keeps talking about the rising healthcare costs. The debate in Washington to overhaul the healthcare system has been centered on two issues: Making sure that everybody who is eligible can buy health insurance and how do you control the out of control healthcare costs. When it comes to cost, one of the drivers that is often overlooked is the rate of hospital acquired infection. They add significant cost to the overall care of the patients. Yet preventing them does not take rocket science. Its as simple as providers washing their hands before a procedure, or touching a patient etc. Read an interesting conversation with one of the Physicians leaders who is spearheading efforts to reduce rates of hospital acquired infections.

The second article is also about reducing cost of healthcare. Its an idea (though I admit its far more radical just washing your hands) that is being considered by one of the lawmakers in the state of Vermont. If this lawmaker has his way and can muster enough support in the legislature, then hospitals would be banned from advertising their services to consumers.

This third article is about the role of the media, in an age where information can travel as fast as the thought process itself. And when information travels so fast, how does an individual know if the information has been filtered for its accuracy and whether it can be trusted. This conversation between Fareed Zakaria and Eric Schmidt, the CEO of Google, reminded me of the infamous death panels. Eric Schmidt hits the nail on the head when he says:

We're in a situation where we're going from a model where everything you saw was true and was highly metered -- that is, highly controlled -- to an explosion of information where not everything you see is true. And it's very difficult for humans to sort out what's true and what's false.
This will be the bane of politicians. It will be the bane of people like yourself, people everywhere. How do I know that this is true?
And the problem gets worse with real-time information and the fact that people are willing to say things that aren't true, and so forth and so on.

Check out my other Random Musing posts 1,2,3, 4

Want to See a Doctor - How Much Will it Cost?

If you want to buy something in the market place, you look for the product and you know exactly how much it is going to set you back. Various factors go into how the price is set. The chief among them is competition among various sellers.

But when it comes to healthcare, nobody knows what it is going to cost for a doctors visit, an X-Ray, MRI etc. Neither is there any information available on what the various doctors will charge for the same test/procedure. Why is it that the price of a gallon of milk can be found by the click of a button, it is so difficult to find the true cost of seeing a doctor for your illness?

Well, there is a bill in the US Congress called "Transparency in All Health Care Pricing Act of 2010", which plans to take the first step in developing a transparent pricing for healthcare costs.

Read more about the bill at Transparency in All Health Care Pricing Act of 2010

Also read a similar post Could Price Tags Save American Health Care

Just on a side note: If you are in France and need to see a doctor, you will know exactly how much the doctor will charge you for a particular test. If you want to find out more about the French, Germany, Japanese, UK or the Canadian health care system and how they are run, check out the excellent book The Healing of America

Why do we need Health Care Reform in the US?

When we think of healthcare reform in the US, things that come to mind are the rising cost of healthcare, how the US spends 15% of its GDP on healthcare: the highest in the world, the growing number of uninsured, or how the doctors are burdened with unnecessary paperwork etc.

Everybody from politicians to laymen agree that something needs to be done about it. Everybody has a reason to make changes to the system be it political, economic or medical. And this last year has been spent talking about how to reform a broken system. But lost in all of this din is one essential question. Is there a moral responsibility on the part of any government to provide good and affordable healthcare to its citizens?

TR Reid, in his book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, asks that question. He writes

Those Americans who die or go broke because they happened to get sick represent a fundamental moral decision our country has made. Despite all the rights and privileges and entitlements that Americans enjoy today, we have never decided to provide medical care for everybody who need it. In the world's richest nation, we tolerate a healthcare system that leads to a large number of avoidable deaths and bankruptcies among our fellow citizens. Efforts to change the system tend to be derailed by arguments about "big government" or "free enterprise" or "socialism" .... and the essential moral question gets lost in the shouting.

Whats on the Net

Some interesting articles that I have read over the last couple of days

1. Breaking American addiction of Fast Food in one of the most un-healthiest regions in American by cooking food British Style
2. If you followed the nomination of Sonia Sotomayor to the US Supreme Court, you will remember the controversy surrounding the "Wise Latina" comment. Ever wondered how this obscure comment made by the now Supreme Court justice become the focal point in her confirmation hearings. Mark Bowden in an excellent article for The Atlantic magazine explains.
3. I have heard alcohol addiction, drug addiction, even gambling addiction. But Internet Addiction, this is news to me.

With that thought, I will end my post as I don't want to be addicted to the internet.

Why Health Care Reform is Needed Now

According to a recent report released by the Kaiser Family Foundation, insurance costs have increased 131 percent since 1999, when a year of family coverage cost about $5,791. Compare that to 38 percent increase in wages and 28 percent growth of inflation over the same period

This just underscores why health-care reform which can provide affordable healthcare to everybody and at the same time control health care costs is needed urgently.

Yearly Health Care Premiums:

Image source Kaiser Family Foundation 2009 survey of Employer Health Benefits

Yearly Inflation Rate:

Inflation rate data obtained from Inflationdata.com

Health Care Reform - Why Bipartisanship Does not Exist

When it comes to Health care reform trying to find a common ground between Democrats and Republicans is like hunting for a needle in a haystack. It still exists but there is no hope of finding it.

Christoper Beam in a recent article for Slate Magazine summarizes why there is very little hope, if at all, to find bipartisan support:

The first problem is that Republicans and Democrats can't even agree there's a problem. McCain and McConnell say we're No. 1 in health care, while Democrats agree with the World Health Organization that we're more like No. 37. Democrats say there are 47 million uninsured Americans. McCain and McConnell, meanwhile, are skeptical. "I don't question that number in summary," McCain said, "but I think when you break it down it gets more interesting." For example, he said, 5 million are college students, 9 million are people making $75,000 a year or more, 10 million are non citizens, 11 million are eligible for Medicaid or S-CHIP but haven't enrolled. "So really, we're talking about 12 to 15 million who are uninsured today."

The True Cost of Healthcare

All over the country, it seems that the one topic on everybody's mind is healthcare. Be it the various town hall meetings from Altantic to the Pacific, or the irrefutable center of the health care debate, Washington DC, everybody seems to be talking about health care and ways to reform it. Few of the ideas for reform being thrown out include providing coverage for every individual in the country, promoting electronic medical records, reducing costs by providing the right incentives for physicians and other providers etc. But nobody seems to be talking about the cost of the current system and the toll that it is having on the economy as a whole.

In a recent article How Healthcare Killed by Father, David Goodhill discusses the true cost of the healthcare hidden or otherwise and the return on investment that we are getting by paying into a system that is broken. The paragraph below highlights, how much we are losing in terms of other growth opportunities by not reforming a bad and broken system:

Yet spending on health care, by families and by the government, is crowding out spending on almost everything else. As a nation, we now spend almost 18 percent of our GDP on health care. In 1966, Medicare and Medicaid made up 1 percent of total government spending; now that figure is 20 percent, and quickly rising. Already, the federal government spends eight times as much on health care as it does on education, 12 times what it spends on food aid to children and families, 30 times what it spends on law enforcement, 78 times what it spends on land management and conservation, 87 times the spending on water supply, and 830 times the spending on energy conservation. Education, public safety, environment, infrastructure—all other public priorities are being slowly devoured by the health-care beast.

Is There a Debate on Health Care Reform Anymore?

Recent reports of town hall meetings organized by US Congressman and Senators have witnessed unruly crowds shouting against the reform bill that is being discussed in the US Congress. The crowds have been so boisterous and unruly that the room for debate has been pretty much shut out.

Well some people may have legitimate concerns about the health care bill, a lot of people are just showing up with misinformation or no information at all that can add value to the debate at hand. The best example of the misinformation or no information out there was a man who recently showed up at Rep. Robert Inglis (R-S.C.) town hall meeting and told him:

“keep your government hands off my Medicare.”

Charles Blow in his most recent column for the NY Times puts it best:"Belligerence is the currency of the intellectually bankrupt."

So is there some sort of debate left in the health care reform anymore, or has it been hijacked by fear mongers, the misinformed, and the ideologues?

The Health-Care Debate

The topic for the last few week across the country has been whether we can get a significant health care reform bill passed. Since there are so many stakeholders involved including physician groups, insurance companies, pharmaceuticals and medical device companies, patients, politicians and of course lobbyists, any significant reform which will address the needs of all these stakeholders will be a tall order.

Every stakeholder has an interest to protect, and nobody is willing to coincide, as coinciding would mean significant loss in revenues and profits for them. In addition health care reform has to address a whole host of issues including, providing some sort of coverage for the 47 million uninsured, improving efficiency of care and slowing the growth of health care costs. All of this without adding to the burgeoning federal deficit.

So will there be any significant reform this year, only time will tell. But in the meanwhile, these two websites provide a basic understanding of what is at stake.

The first website is the Mayo Clinic Health Policy Center, and the second website is Health Beat a blog dedicated specifically to health care.

Whats in the Stimulus Package to Kick Start the US Economy

The American Recovery and Reinvestment
Act of 2009,aka economic stimulus package, was signed into law this week by President Barack Obama. Total size of the package is $787 Billions and includes a mixture of spending and tax cuts. Now the question is, are there enough provisions in the bill which will help jump-start the ailing US economy. Read the summary of the bill to find out.

SPENDING

AID TO POOR AND UNEMPLOYED

_ $40 billion to provide extended unemployment benefits through Dec. 31, and increase them by $25 a week; $20 billion to increase food stamp benefits by 14 percent; $4 billion for job training; $3 billion in temporary welfare payments.

DIRECT CASH PAYMENTS

_ $14.2 billion to give one-time $250 payments to Social Security recipients, poor people on Supplemental Security Income, and veterans receiving disability and pensions.

INFRASTRUCTURE

_ $48 billion for transportation projects, including $27.5 billion for highway and bridge construction and repair; $8.4 billion for mass transit; $8 billion for construction of high-speed railways and $1.3 billion for Amtrak; $4.6 billion for the Army Corps of Engineers; $4 billion for public housing improvements; $6 billion for clean and drinking water projects; $7.2 billion to bring broadband Internet service to underserved areas; $4.2 billion to repair and modernize Defense Department facilities.

HEALTH CARE

_ $24.7 billion to provide a 65 percent subsidy of health care insurance premiums for the unemployed under the COBRA program; $86.6 billion to help states with Medicaid; $19 billion to modernize health information technology systems; $10 billion for health research and construction of National Institutes of Health facilities; $1 billion for prevention and wellness programs.

STATE BLOCK GRANTS

_ $8.8 billion in aid to states to defray budget cuts.

ENERGY

_ About $50 billion for energy programs, focused chiefly on efficiency and renewable energy, including $5 billion to weatherize modest-income homes; $6.4 billion to clean up nuclear weapons production sites; $11 billion toward a so-called "smart electricity grid" to reduce waste; $6 billion to subsidize loans for renewable energy projects; $6.3 billion in state energy efficiency and clean energy grants; and $4.5 billion make federal buildings more energy efficient; $2 billion in grants for advanced batteries for electric vehicles.

EDUCATION

_ $44.5 billion in aid to local school districts to prevent layoffs and cutbacks, with flexibility to use the funds for school modernization and repair; $25.2 billion to school districts to fund special education and the No Child Left Behind law for students in K-12; $15.6 billion to boost the maximum Pell Grant by $500 to $5,350; $2 billion for Head Start.

HOUSING

_$4 billion to repair and make more energy efficient public housing projects; $2 billion for the redevelopment of foreclosed and abandoned homes; $1.5 billion for homeless shelters; $2 billion to pay off a looming shortfall in public housing accounts.

SCIENCE

_ $3 billion for the National Science Foundation for basic science and engineering research; $1 billion for NASA; $1.6 billion for research in areas such as climate science, biofuels, high-energy physics and nuclear physics.

HOMELAND SECURITY

_ $2.8 billion for homeland security programs, including $1 billion for airport screening equipment.

LAW ENFORCEMENT

_ $4 billion in grants to state and local law enforcement to hire officers and purchase equipment.

___

TAXES

NEW TAX CREDIT

_ About $116 billion for a $400 per-worker, $800 per-couple tax credits in 2009 and 2010. For the last half of 2009, workers could expect to see about $13 a week less withheld from their paychecks starting around June. Millions of Americans who don't make enough money to pay federal income taxes could file returns next year and receive checks. Individuals making more than $75,000 and couples making more than $150,000 would receive reduced amounts.

ALTERNATIVE MINIMUM TAX

_ About $70 billion to spare about 24 million taxpayers from being hit with the alternative minimum tax in 2009. The change would save a family of four an average of $2,300. The tax was designed to make sure wealthy taxpayers can't use credits and deductions to avoid paying any taxes. But it was never indexed to inflation, so families making as little as $45,000 could get significant increases without the change. Congress addresses it each year, usually in the fall.

EXPANDED COLLEGE CREDIT

_ About $14 billion to provide a $2,500 expanded tax credit for college tuition and related expenses for 2009 and 2010. The credit is phased out for couples making more than $160,000.

CHILD TAX CREDIT

_ About $15 billion to provide the $1,000 child tax credit to more families that don't make enough money to pay income taxes.

EARNED INCOME TAX CREDIT

_ $4.7 billion to expand the Earned Income Tax Credit for low-income families with three or more children.

HOMEBUYER CREDIT

_ $6.6 billion to repeal a requirement that a $8,000 first-time home buyer tax credit be paid back over time for homes purchased from Jan. 1 to Nov. 30, unless the home is sold within three years.

AUTO SALES

_ $1.7 billion to makes sales taxes on paid on new cars, light trucks, recreational vehicles and motorcycles tax deductible through the end of the year.

RENEWABLE ENERGY INCENTIVES

_ About 20 billion in tax incentives for renewable energy and energy efficiency over 10 years, including extending tax credits for energy produced from wind, geothermal, hydropower and landfill gas; grants to build renewable energy facilities; tax credits for purchases of energy-efficient furnaces, windows and doors, or insulation; tax credit for families that purchase plug-in hybrid vehicles.

BONUS DEPRECIATION

_ $5 billion to extend a provision allowing businesses buying equipment such as computers to speed up its depreciation through 2009.

REPEAL BANK CREDIT

_ Repeal a Treasury provision that allowed firms that buy money-losing banks to use more of the losses as tax credits to offset the profits of the merged banks for tax purposes. The change would increase taxes on the merged banks by $7 billion over 10 years

When he signed the bill , the President said that the bill will help save or create 3.5 million jobs going forward. A quick glance at the above summary and you should realize that the bill is top heavy with tax cuts and aid for low income Americans. The only provisions with any seeming potential of creating jobs are spending on Infrastructure, Health Care, Alternative Energy and Home Land Security. Now, whether these provisions will help in creating or saving 3.5 million jobs and kick start the economy is the Trillion Dollar question.

Alcohol, Smoking, Junk Food and Now Fairness Cream

If you are India's Health Minister, the challenges that you face are many. Just to name a few, malnourishment in kids, lack of access to basic health care, sorry state of public health system just to name a few.

But our current health minister, the esteemed Anbumani Ramadoss is more worried about the prevalence of pub culture and holding companies that make fairness cream accountable.

Musings about pub culture being against Indian ethos or fairness creams not making you white enough, would not in any way shape or form provide access to basic health care needs facing the millions of Indias.

For a country that prides itself in its rich history of medicine including the Ayurveda, and a country that wants to be the go to destination for health acre, this current lack of access to basic healthcare services to millions of Indians is totally unacceptable. I for one would like to hear Dr Ramadoss say "Lack of basic healthcare to every Indian is unacceptable and against Indian Ethos". That would be a good start

Why Smoking Ban in India Wont Work

Shekhar Gupta writes for the Washington Post that it would be very difficult for the recent ban in all public places in India to work.

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Nobody, however, objects to this law. There is no smoking lobby in the cities, nor is the ban being enforced in such a draconian way that smokers would be out in the streets protesting. But if the objective was to save the lungs of millions of Indians, this ban is not going to work because smokers will smoke as long as they can afford to buy cigarettes and find a corner on which to smoke them.
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Read the complete piece Indian Smoking Ban

Spread the Story - Stop XDR TB

If you do not anything about XDR TB or "Extremely Drug Resistant Tuberculosis", then this video should spur you to action.



Please spread the word about the disease. Learn more at XDRTB

Link obtained from Churmuri

John McCain's Health Care Plan

In all of the economic events of the recent days, a key topic for discussion has been put on a back-burner. Yes I am talking about health care. Both of the current presidential candidates want to reform the costly and highly inefficient American health care system. Of the two candidates, John McCain is proposing a completely radical approach to how individuals get health care coverage in this country.

Most Americans get their health insurance through their employer. Employees pay certain portion of the premium and the remaining tab is picked up by the employer which is substantial. According to a recent Kasier Foundation Study, employer contribution for the health insurance premium for a family is about $9300, while the employee contributes about $3300 towards the premium. See exhibit A for details on the breakdown.



Now coming to John McCain's radical proposal. According to John McCains health care plan, he wants the employer contribution (which is about $9300 for an average family) to be taxed as income. Remember this benefits are currently not taxed at all. In order to offset the stick of taxing the employer contribution, as a carrot, his plan offers a $5000 tax credit per family, which can be used to buy additional health insurance if needed.

Here is my question. If your employer contribution is taxed every month wouldn't your employer be withholding additional money from your paycheck to cover these taxes thus reducing your take home pay significantly depending on how much your employer contribution is. And if you are somebody who is living pay check to pay check every month, this reduction is monthly/weekly pay can make a significant difference. So wouldn't these individuals, even though knowing that they will get $5000 back at the end of the year, try to opt out of the employer based insurance all together to make ends meet?. Granted, these individuals can shop around for cheaper health insurance in the market. But what are the chances of of finding a cheaper option, as a individual compared to a group rate from your employer, which pays the same benefits. Pretty slim I would guess. Wouldn't this add to the number of uninsured?

All in all I think it is bad idea to tax the employer contribution of your health care premium.

Also read Bob Herbert's column on the same topic in the NY Times.

Is Sarah Palin Ready to be President?

With the current set of challenges that the United States faces on the domestic and international front, the obvious question in the minds of the voters would be "Is the next president ready to tackle these challenges?".

With John McCain selecting Sarah Palin, the 20 month governor of Alaska and a former mayor of a town of 6000 people, as his running mate, the question becomes does she have the enough grasp of the domestic and international issues to be able to take over for John McCain if "God Forbid" something were to happen to him were he elected president.

Based on her first major interview with a nationally recognized journalist Charles Gibson it does not seem like she is ready.

The NY Times blasts John McCain in its most recent editorial by saying and I quote "If he seriously thought this first-term governor — with less than two years in office — was qualified to be president, if necessary, at such a dangerous time, it raises profound questions about his judgment. If the choice was, as we suspect, a tactical move, then it was shockingly irresponsible."

In an op-ed column for the NY times, columnist Bob Herbert also thinks She is Not Ready to be Commander in Chief of the United States

All Things Politics including Lipsticks, Pigs and Pork

Barack Obama's recent comments about "lipstick on a pig" during the presidential campaign have created another flash-point in the already heated race for the White House.

The Republican candidate John McCain has taken serious offense to these comments even though he had sued these same words against Hillary Clinton during the primary process.

Also this "lipstick on a pig" phrase has been used liberally both by Democrats and Republicans before today. So why express the outrage now? Why are the Republicans trying to create a mountain out of a mole-hill, when there are other important issues like health-care, immigration, economy and foreign policy etc to be discussed?

May be the Republicans have come to a realization that they cannot win the election by talking about these issues because of how badly the current administration has managed them and so they are trying to divert the discussion from these central topics.

Leroy Sievers - RIP

Leroy Sievers an award winning journalist for NPR passed away this past weekend of cancer.

Leroy made his battle with cancer public by documenting his experience living with the disease in his blog My Cancer. With his blog, Leroy provided a forum for a lot of people who suffer from cancer to share their stories and offer support.

Morning Edition today had a remembrance for Leroy Sievers, Leroy Sievers - A Farewell In His Own Words

Hospitals Killing ER Patients?

Slate had an article by two Emergency Room Physicians about how the Emergency Rooms across the country are having a problem with large waiting time for patients to be seen by the physicians and boarding of patients (patients wait in the ER's for an Inpatient bed due to the Inpatient beds been full) in the ER's. According to the authors, hospitals have a huge financial incentive to keep the patients boarded in the ER.

Having worked in a local ER in Columbus, OH for the last three years, trying to tackle this same issue, I had to chime in with my two cents on this topic. Below is my response to the article which is also posted on Slate.

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Though I agree that boarding of patients in the ER is a huge problem in all of the ER's across the country, I disagree with the authors point of view that patients are boarded in the ER because there is a financial incentive to do so.

Assuming the authors point that boarded patients are mostly uninsured or underinsured, which can be disputed as well, aren't the boarded patients occupying ER resources in terms of nursing and physician time for which the hospital is responsible for if the patient cannot pay for the same. Also they are occupying a valuable ER bed which can be used for treating the next patient coming in.

Ultimately 99% of these boarded patients will be transferred to the Inpatient floors where they will consume the same amount of resources, as they would have before, if they were not boarded. So I do not see the financial incentive of keeping these patients boarded in the ED. Infact I see the opposite or more of an incentive to get the patients out because they will be consuming more resources then is necessary.

Patients are boarded in the ER not because a hospital has a financial incentive to do so, but because there are so many inefficient and redundant processes both in the ER and on the inpatient floors. There are a lot of factors that contribute to these inefficiencies including when physicians round on the floor, mismatch between the peak discharge time and peak admission time, poor communication between the various individuals involved in moving the patients through the system including ER and Inpatient nursing, bed cleaning, transportation etc.

Attributing boarding to a financial incentive would be a wrong way to approach this problem. Infact the focus should be on ironing out the inefficiencies and improving the processes in the ER and Inpatient floors.
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