How To Cope With Pain brings us a truly amazing video.  It’s a reminder to be thankful for all that we have, and for the things in life (like this video) that inspire us.  It’s well worth the five minutes it takes to watch it.

Amy Tenderich of Diabetes Mine shares a “would you rather…?” moment from her 9-year old daughter.  It’s a poignant reminder, seen through the eyes of a child, that all of the parts of our lives – even the bad parts – combine to make us who we are.

Kerri Sparling, of Six Until Me, has a very moving story about her pregnancy and how the online diabetes community has helped her along the way.  Kerri has put an immense amount of effort into getting her body ready for a baby, and it’s wonderful to know that things are going well for her and her husband as they expand their family.

The Hippocratic Oaf gives us some glimpses of life as a medical student, detailing interactions with patients and highlighting incidents that remind him to be grateful for his own life and health.

The rest of the articles cover a wide range of subjects, from the perspectives of patients, doctors, nurses, and policy makers.  Read on…

Dr. Val Jones, writing at Get Better Health, has written a very insightful article about how medical malpractice insurance premiums make it nearly impossible for primary care doctors to practice part time.  The premiums aren’t affordable unless the doctor is a specialist, or a full-time PCP.  She points out that our PCP shortage could be remedied by adding more part-time docs.  But in order to do that, malpractice premiums have to become more reasonable.  And in order for that to happen, we need tort reform.  Hopefully the lawmakers are listening.  Maybe if they’re trying to find a PCP in Washington DC they’ll notice the problem Dr. Val describes.

Health Business Blog’s David Williams brings us an interview he did with Dr. Henry Anaya of the VA, a research scientist working with HIV.  Dr. Anaya describes new rules at the VA that require less paperwork in order to give consent for an HIV test, and the benefits of a rapid result HIV test that is done with a swab instead of a needle, with results in 20 minutes.

Dr Rich, writing at The Covert Rationing Blog, gives us a very colorful depiction of the migration of cardiologists to other specialties.  It conjures up images of marauding Huns and defeated Roman Empires.  But in addition to the Western Civilization lesson, it brings up several good points about the territorial nature of specialists, the Medicare reimbursement cuts for certain cardiology procedures, and the options that are available for doctors seeking to replace lost income once the Medicare cuts take effect.

Lauren, from Novel Patient, describes her recent visit to a Sjogren’s specialist.  Instead of getting the answers she was looking for, she is now on a quest for a new diagnosis, as the specialist thinks there is an underlying condition.  While she’s in the midst of such a frustrating situation, Lauren manages to keep a positive outlook.  We wish you well Lauren, and hopefully the visit to Johns Hopkins will provide some answers.

Barb Olson, of Florence Dot Com, writes a very interesting article about a survey of 1000 non-profit hospital board chairs regarding the quality of care that their hospitals delivered.  Only 1% rated the quality of care at their hospitals as worse or much worse than a typical hospital.  But as Nurse Olson points out, it’s typical for people to overestimate their own positive attributes when self-evaluating (the Lake Wobegon Effect).  And in addition, the hospital board chairs generally weren’t well trained on quality measures, so it’s hard to expect them to have a clear understanding of what constitutes quality of care.  Good food for thought for people who are responsible for improving quality of care standards at our nation’s hospitals.

Clinical Cases and Images Blog has an article about a study showing that for married couples, having children has a positive impact on life satisfaction – and that the level of satisfaction increases with the number of children.  I know that our son has added a great deal of happiness to our lives, but I don’t think I’ll test this theory by having a dozen children!

Laika Spoetnik of Laika’s MedLibLog is making it easy for people to combine social networking with an interest in science and medicine.  She’s created Twitter lists pertaining to biomedical journals, medical journals, and scientific journals – making it easy for a person interested in one or all of those subjects to find up-to-the minute articles and commentary.

Dr. Jolie Bookspan, the Fitness Fixer, brings us a detailed post about how to look upward without placing strain on our necks.  I like the part about how our necks are not Pez dispensers – good visual image.  The article is a good reminder that we need to use proper form in all of our daily activities, not just while we’re at the gym.

Nancy Brown, PhD, of Teen Health 411, brings us some insight into what teens want when it comes to their relationships with their parents.  If we think back to our own teen years, I imagine we can all relate.

InsideSurgery has written about Dr. Nidal Hasan, the Fort Hood shooter.  The article delves into the responsibility that doctors have for their patients, and the moral obligation they have to seek help for themselves if they feel that they are being overwhelmed by their responsibilities.  In addition, the article address the fact that physicians who get their training paid for by the military have to expect that during their required years of service to the military, there may be a war, and they may be deployed.  Especially during times of peace, this is food for thought for anyone who would consider having the military pay for their training in return for military service.

Healthline’s Dr. Paul Auerback writes about how physicians who receive training in high-tech environments and then go on to work in settings with less technology often feel uncomfortable about their ability to provide quality care to their patients.  Most teaching hospitals are more technologically advanced then the average small town hospital or clinic where the doctor might end up working, so it might be advisable for the teaching hospitals to incorporate some low-tech training for their students, in order to better prepare them for situations where they might need to improvise in order to help a patient.

InsureBlog’s Hank Stern brings us a very interesting article about a British hospital that will no longer admit expectant mothers with a BMI of more than 34 (210 pounds for a 5′6″ woman).  The hospital’s labor and delivery unit is run by midwives, and not high-tech.  Because they have patients who want to delivery in a low-tech setting (which I can very much understand), they have no plans to make the facility more capable of handling complicated births.  In addition, one has to assume that there would be significant expense involved in making the hospital equipped to handle birth complications.  The ban on very obese mothers (the lower edge of obesity is defined as a BMI of 30) has to do with the higher risk of delivery complications associated with obesity.  I can understand the hospital’s position, but it seems that it would make more sense to go on a case-by-case basis, evaluating the mother’s health during her pregnancy to see if complications arise (for thin mothers, as well as obese ones).  If they do, it makes sense to have them deliver at a hospital that is better equipped to handle complicated deliveries.  It seems that this might serve their purpose better than a blanket ban on all mothers with a BMI over 34.

Dr. Catherine Busch of Child Psych explains the impacts of the mental health parity law that was passed last year.  The law takes effect on January 1, 2010, and will apply to group health insurance policies covering more than 50 employees.  Individual and small group plans are not required to comply with the law, and the law does not require policies – even for large groups – to offer mental health services.  If they do offer mental health services, the benefits have to be equal to the coverage offered for any other medical condition, but we might start to see policies discontinuing their mental health benefits all together under the new law.  Time will tell.

Eve Harris, writing at A Healthy Piece Of My Mind, gives us a clip of comedians Larry David and George Lopez discussing the results of an ancestry DNA test.  It’s lighthearted, but does make one wonder about the accuracy of direct-to-consumer DNA testing that claims to be able to scientifically determine our ancestry.

HealthBlawg’s David Harlow gives us an intro to what he calls Son of HIPAA – the new federal regulations that went into effect in September regarding protected health information and how data breaches are to be handled and reported.  As medical data is increasingly stored and transmitted electronically, these rules are both necessary and cumbersome, depending on your perspective.  David’s article is a good primer for providers and patients alike.

Allergy Notes explains that IL-33 is a newly-discovered marker of severe asthma.  In a study of people with mild, moderate, and severe asthma, along with non-asthmatic control subjects, those with asthma showed higher levels of IL-33 than those without, and the difference was especially pronounced in cases of severe asthma.

Elyse Nielsen, writing at AntiClue, details the information technology component of opening a new hospital.  One of the aspects that stood out for me was that we should work to eliminate multiple systems that serve the same purpose.  IT is the way of the future in medicine, and much has been said about the ability of technologically advanced systems to save health care dollars.  But this will be especially true if we make sure that our IT systems are as efficient as possible, with no redundancy.

Ryan DuBosar, writing at ACP Hospitalist, tells us about the results of a study that indicates that men with sleep apnea who are treated with nasal positive airway pressure (NPAP) improve their golf handicaps compared with control subjects.  Not surprising, since a better night’s sleep is probably linked to improved performance in nearly every activity.  But promises of a better golf game might make people more likely to be compliant with their treatment.

Laurie Edwards, writing at A Chronic Dose, reminds us all that unsolicited advice is rarely appreciated.  The H1N1 vaccine (along with the seasonal flu shot and pretty much any other vaccine you can think of) is a controversial topic, and it gets people fired up.  But each of us need to make our own decisions, for ourselves and our children, regarding whether to get the shot.  Our health care providers can be expected to weigh in with advice – that’s their job.  But no matter how strongly any of us feel one way or another about the vaccine, it’s not right to give unsolicited advice to other people, especially when we know nothing about their medical history.

Dr. Charles, of The Examining Room, has a very thorough article about Desiree Jennings, the Redskins cheerleader who was supposedly stricken with dystonia following a seasonal flu vaccine in August.  I remember seeing the clip on the news of Desiree, but hadn’t followed the story since then.  Dr. Charles’ article uncovers quite a few details that are worth reading.

ACP Internist’s Ryan DuBosar explains how easy it was for him to get the H1N1 vaccine.   He was able to get it at the county clinic without even standing in line – even though his baby’s pediatrician and his family doctor didn’t have the vaccine available at all.  It does seem to be pretty random in terms of where the vaccine is available and to whom.  In our own family, we have childless adults who have been able to walk right into their doctor’s office and get the shot, along with families with small children who were told they had to continue waiting.

Thanks to everyone who submitted articles for this edition of Grand Rounds.  They were a pleasure to read, and we’re honored to be your hosts this week.  Grand Rounds next week will be hosted by How to Cope with Pain.

Flickr Photo Credits:

• Thanksgiving dinner – CarbonNYC
  
• Leaf – ZedZap
  
• Thanksgiving drive – katmere
  
• Tree – OakleyOriginals
  
• Thanksgiving Turkey- xybermatthew

First, we have an overview of the bill.  Then there’s an article devoted to the public option and insurance exchange.  Next, you can read about how the reforms will impact delivery systems.  And to round things out, there’s an article that details the last minute changes to the bill (like the Stupak amendment).  A big thanks to Professor Jost for making the reform bill so easy to understand.

Now that we all understand what the House of Representatives has been up to lately, I’d like to highlight a few other posts that I particularly enjoyed this week:

Dr. Glenn Laffel, writing at EHR Bloggers, has a very insightful article about how the public option “compromise” that would allow states to opt out is likely to only muddy the waters and create a fragmented “public option” available to people depending on where they live.

Dr. Roy Poses shares a fascinating account of alleged transplant fraud involving liver transplants, Japanese organized crime bosses, and the UCLA medical center.  Transplant lists are the norm for people awaiting new organs in the US, but apparently – for a price – one can jump to the front of the line.  Well worth reading.

Dr. Brad Flansbaum, writing at the Hospitalist Leader, gives us a gem of an article about how health care reform is portrayed in the media, what people – including lawmakers – really understand about the various reform proposals, and the impact of buzz words on popular perception.  I particularly liked his take on comparative effectiveness research, which some have said would put a “government bureaucrat between you and your doctor.”  Dr. Flansbaum’s response is that the “government bureaucrat” is “likely a health services researcher, and someone [he] would look to for guidance even for [his] own family’s health.”

Jaan Sidorov of the Disease Management Care Blog examines a published medical article that reviews the merits of “decrementally cost effective treatments.”  These are treatment options that involve a tradeoff between significant cost savings and a relatively smaller loss of effectiveness.  When it comes to medical treatment, we (especially here in the US) tend to focus on newer and better all the time.  But our medical innovations are often much more expensive than the treatment they are designed to replace.  And sometimes we can have treatment that is nearly as good, for a fraction of the cost.  Jaan says that our failure to bend the cost curve (terminology that Dr. Flansbaum specifically allows to be included in a worthwhile article) means that we’ll need to examine this closely in the not too distant future.

I decided to include two articles from Brad Wright, the voice behind Wright On Health Care.  They were both too good to pass up, and both good enough to land themselves in my editor’s choice section.   First, he gives us a visual breakdown of who the uninsured are, where they live, how healthy they are… demographics in general.  And he comes to the conclusion that the people voicing the strongest opposition to health care reform are part of the same demographic that makes up the largest uninsured sector of the population.  This isn’t a new idea, but the way Brad goes about detailing the evidence is highly compelling.

Brad also brings us his take on the Stupak amendment, which would prohibit health insurance from paying for abortions unless the mother’s life is in danger, or in cases of rape or incest.  He points out that the vast majority of abortions are currently not paid for by health insurance.  I agree with him that this amendment was designed as a wedge to divide people over a hot button issue, rather than as something of substance.

Rounding out the rest of the Health Wonk Review are a variety of good articles organized roughly by topic:

HEALTH INSURANCE:

Anthony Wright gives us an article about the weak employer mandate in the health reform bill, which would only impact large companies, and would only penalize employers by a fraction of the actual cost of providing health insurance if they choose to ignore the mandate.  Anthony points out that throughout the entire health care reform debate, lawmakers have repeatedly said that people can keep their current health insurance if they like it.  More Americans get their health insurance from their employers than any other single source, but that percentage has been declining in recent years as the cost of health insurance continues to climb.  Anthony notes that if employers keep discontinuing health insurance benefits, people might not actually have a choice of keeping their current plan, regardless of whether they like it or not.

Health Access Blog’s Beth Capell brings us a sobering discussion about the ramifications of being an uninsured child.  While it’s relatively rare for a child to die, Beth looked at a study that found that half of the children who died following a hospitalization between 1988 and 2005 were uninsured.  This is far higher than the proportion of uninsured population in the general population, and speaks volumes about the perils of being uninsured.  Beth points out that the Children’s Health Insurance Program (SCHIP) was in effect for the second half of the study, and yet there are still seven million uninsured children in the US (nearly 170,000 of them are here in Colorado).

POLITICS AND HEALTH CARE REFORM:

InsureBlog’s Hank Stern wrote about a recent blogger teleconference with Rep. Joe Wilson, for a glimpse at a right wing Representative’s take on all things health care.

Mad Kane has written a limerick for Fox News and a limerick for Joe Lieberman. I don’t think she’s particularly fond of either of them.

My Wealth Builder has an article about why the government isn’t fit to run our health care system.  I think most of us agree that the income tax system is way too complicated, and that some government programs could be run more efficiently.  But indeed there are plenty of people who believe that Medicare is a good example of a well-run health care system that could be a model for providing care for the rest of the population.

Chris Langston, writing at the John A Hartford Blog, has drafted a “Declaration of Innovation” (modeled on the Declaration of Independence) pertaining to health care.  He’s primarily focused on geriatric care and health care for an aging population, but his words are appropriate for health care in general.

Tinker Ready, of Boston Health News, writes about the relationship between medical academics/doctors and the medical industry (think: “consulting” fees for docs, vacations to exotic destinations sponsored by drug companies, speaking fees for medical professors, etc.).  Part of the health care reform bill includes long-overdue “sunshine provisions” intended to increase transparency when it comes to the relationship between doctors and industry.

INFORMATION TECHNOLOGY:

Healthcare Technology News brings us an article about provisions in the House health care reform bill that would eliminated a lot of the complexity and frustrations that go along with our current (non-electronic) health care reimbursement system.  Real time determination of a patient’s financial responsibility for a service, either before the procedure is scheduled, or at the time of service, would be a huge improvement over our current system of waiting for the bills to arrive with only a sketchy idea of how much they will be.  In general, the adoption of an electronic and standardized health care administration system is a definite positive in the House bill.

David Kibbe, writing at the Health Care Blog, details the importance of a Continuity of Care Record for every patient, ideally in an electronic, easily accessible format.  Allowing doctors and nurses to see at a glance a patient’s health history, allergies, medications, and basic vitals would eliminated the need for redundant testing (a cost-saving plus), and would enhance decision making when it comes to current care.  David points out that while most of our health data is currently being entered into a computer somewhere, it tends to be in disparate systems that aren’t easily compiled into one continuous record for each patient.

Elyse at AntiClue has written an article about the various technologies available to help reduce the incidence of adverse drug effects.

EVERYTHING ELSE:

Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon NH, puts a personal face on advance directives in an article that should encourage all of us to add an advance directive to our to-do lists.  As he says, “you don’t have to be dying for these discussions to matter.  You just have to be mortal.”

Workers’ Comp Insider’s Julie Ferguson brings us an article about the largest fine ever levied by OSHA – $87 million in penalties – directed at BP for a refinery explosion four years ago that killed 15 people and injured 170.  Incidentally, the second-largest fine they ever levied was also against BP, related to the same explosion.  BP is contesting the fine, saying that it is an example of big government intruding on private business.  Without knowing anything more about the situation than what I just read in Julie’s article, my bet would be that BP is probably more concerned about profits than they are about the health and safety of their workers.

Susan DeVore, CEO of the Premier Healthcare Alliance, writes about the collaborative efforts of 157 hospitals working together to improve patient outcomes and control costs through a program called QUEST (Quality, Efficiency, Safety, and Transparency).  The hospitals shared data and information with each other, and after a year the hospitals had 14% fewer deaths than expected, and had saved $577 million.  Systems like QUEST, implemented throughout the country, encouraging collaboration and transparency among all hospitals could result in even more impressive results.

But while hospital collaboration can produce better outcomes and save money, we don’t want to take a good thing too far, as hospital mergers are a factor in driving up health care costs.  Ken Terry, writing at BNET explains how costs have grown much faster than usual over the past decade, following a period of unprecedented hospital mergers that resulted in much less competition between hospitals in most metro areas.

Amer at Healthcare Hacks tells us about the FDA’s Emergency Use Authorization for Peramivir, a drug that can be used to treat H1N1 – without the normal extensive trials that drugs must go through in order to be approved.  He also throws in a reminder about hand washing, since prevention is always the best strategy.

While we’re on the topic of H1N1 treatment, Eric Turkewitz has an interesting article about drug wholesalers trying to peddle flu vaccine for eight times the normal price, while also refusing to say where the vaccine originated.

Thanks to everyone who submitted articles; it was a pleasure reading them.

Colorado barely squeaked into the green state designation, with 15.2% of adults eating at least two servings of fruit and three servings of vegetables each day.  That means that 84.8% of our population isn’t eating that much produce.  Our health care costs are soaring; the incidence of obesity and illnesses like diabetes and heart disease continues to climb.  Yes, we need to address the issue of health insurance – everyone needs it, and we must find a way to provide it.  But even with health insurance, the likelihood of achieving life-long good health without consuming fruits and vegetables is slim.

Eating habits become ingrained in childhood, which makes school lunch programs vital to the cause of eating more fruits and vegetables.  In northern Colorado, there are local farmers tackling this issue through farm to school programs, but such programs are still relatively rare.  Among high school students, nine out of ten aren’t meeting the recommendations for fruit and vegetable intake.

The government is actively involved in shaping the diets of the American people through farm subsidies.  In terms of dollar amounts, feed grains are by far the most heavily subsidized crop (this is effectively a subsidy on the price of meat and dairy products, since the grains are used to feed the animals).  This is followed by subsidies on cotton, wheat, and rice, with those four crops receiving more than 80% of all of the agriculture subsidy dollars in the United States.  You won’t find crops like carrots and tomatoes and blueberries on the list.

There are people who advocate personal responsibility as the crux of health care reform, and to some extent I agree with them.  No matter how good our doctors are, and no matter how comprehensive or affordable our health insurance is, we won’t be healthy without a good deal of personal commitment.  But it’s unrealistic to expect people to purchase fruits and vegetables over less expensive grain products.  And as long as we continue to subsidize the grain products, they will continue to be less expensive and more widely available.

Now, an insurance company called GuideOne Mutual actually had a question about “religious denomination.” And it seems that Atheists and Agnostics were charged more.

The Department of Justice sued GuideOne in federal court in Kentucky after receiving complaints about the insurer’s “FaithGuard” policy that offered homebuyers, owners and renters in 19 states special benefits and discounts if they were churchgoers.

I wrote about HB 1224 last month, and have been watching its progress over the last several weeks.  Unlike some of the other health care bills in Colorado right now, I doubt that HB 1224 will have much of an effect on the number of people in Colorado who are uninsured.  It’s true that premiums for younger women would decrease if gender could no longer be considered in setting rates.  And this would likely result in an increase in the number of insured women in Colorado.  But on the other side of the equation, young men would pay higher premiums than they currently do, which would likely mean that fewer of them would purchase health insurance.  For myself and Jay, and all of the other families that include a husband and wife, the net effect will probably be negligable – my premiums will go down, Jay’s will go up, and the total amount we pay each month will remain virtually unchanged.

I can see the point of this legislation – equality and fairness should be sought after whenever possible.  But there’s a stereotype about men and women and health care.  We’ve all heard it: that a man has to be bleeding to death before he’ll go to the doctor, whereas women will go in at the first sign of a sore throat.  Obviously this is an exaggeration of the truth, but there is a grain of truth in it.  As with any stereotype, it doesn’t apply to all members of either group (I’m a woman, but other than preventive care, I have been to the doctor three times in my life – maybe I should petition to get male rates?)  All joking aside, women do tend to seek medical care more often than men.  While I can see the point of the legislation in terms of fairness, it doesn’t seem fair to penalize men by making them pay more for their health insurance even when as a group they seek medical care less often.

I would prefer to see more focus on addressing ways to lower our overall utilization of health care, especially among women.  I’m seeing more news articles lately about health insurance companies looking into reimbursing doctors for email and phone consultations with patients (which I assume would be less expensive than an office visit), and I think this is a good start.  Patient education in terms of which illnesses are self-remitting and which need medical attention would be helpful too.  The ad campaign to convince people that antibiotics don’t work on viral infections like colds and flus is another good start.  Overall, I think that the focus needs to be on reducing health care costs (which requires addressing all aspects of the health care system, from patients and doctors, to pharmaceutical companies and health insurance carriers) rather than redistributing the costs among men and women.

Don’t get me wrong – I thought that Daschle had some good ideas.  But I understand how his job as a special public policy advisor to a private law firm, where he earned millions of dollars over the last few years and was apparently provided with a car and a driver, could be regarded as a conflict of interest.  And of course there’s the issue with the IRS.  I imagine that Daschle does not burn the midnight oil each spring crunching numbers on his own tax returns.  And I believe him when he says that it was a mistake and an oversight that caused the error.  I’m sorry that this issue has led to Daschle’s withdrawl, but I agree with him that anyone who holds the position of HHS Secretary has to have the full trust and faith of the American people and the lawmaking bodies.  And even if this issue had been worked out during a confirmation hearing, it would likely have compromised that faith.

Today I’ve been seeing lots of online chatter about how Daschle’s withdrawl is a blow to the Obama administration’s efforts to bring about swift and meaningful health care reform.  But I doubt that will be the case.  I think that the new administration is going to face challenges with any swift and meaningful changes they attempt, pertaining to healthcare of otherwise.  The ongoing fight over the preident’s proposed economic stimulus package is an indicator that things are not going to fall into place as easily as perhaps the Democrats had hoped.  Health care reform will face the same challenges, and will need bipartisan support in order to pass, regardless of who is at the helm of the reform efforts.  I think that anyone who ends up in the position of HHS secretary will be focused on dealing with the health care challenges facing our nation.  The millions of Americans who lack any type of health insurance and the ever-increasing cost of health care are issues that must be addressed.  And unfortunately they’re going to have to be addressed during a time when money is squeaky tight.  I imagine partisan politics and lack of money will be a far bigger hurdle for health care reform than Daschle’s withdrawl.

Dr. Rich’s article delves into the sticky subject of how to get around a ban on patients being able to pay directly for their own medical care in the event (highly likely, as he sees it) that the US adopts universal healthcare and bans private purchase of healthcare outside of the government-run system.

I’ve written about the NHS and bans on private purchase of expensive pharmaceuticals that are not covered by the UK’s government health care system.  I can see the logic behind such government bans, but if a person chooses to forego a new car and spend her money instead on healthcare benefits that are not covered by her healthplan, I believe she should be able to do so without becoming an outlaw.

Here’s the way I see it: currently, we have 47 million people in this country who have no health insurance at all, and thus no realistic access to healthcare.  The implementation of some sort of basic health insurance to allow everyone access to care is the first step.  And I truly believe that everyone should have access to at least basic care before the wealthy have access to extraordinary care.

I agree with Dr. Rich that prohibition doesn’t work.  It doesn’t work with drugs or guns or prostitution, and it won’t work with healthcare.  Before abortion was legal in this country, women still had abortions.  Poor women had backalley abortions and often suffered horrendous trauma or death as a result.  Wealthy women went to countries where safe abortions were readily available.  This is a perfect example of what happens when the government tries to ban something that a portion of the population want or need – healthcare is no exception (and given the importance of healthcare and the fact that a life or death situation might be at stake, I can’t think of a scenario where people would try harder to get something outside of the official system if they deemed it necessary).  Dr. Rich’s prediction that medical tourism would boom in the event of a ban on private pay healthcare is exactly correct.

Perhaps I’m just an eternal optimist, but I believe that if some sort of universal healthcare system is put in place in the US, it will cover all necessary and proven treatments.  So hopefully the only treatments that people would be seeking outside of the government system would be experimental ones.  That’s not to say that experimental treatments shouldn’t be administered, just that the problem of not being able to access care through a government health system would hopefully be the exception rather than the rule.

Medicare is an example of a universal healthcare system (for the over 65 population and those who are deemed disabled).  It also has private sector involvement in terms of Part D and Medigap plans.  People with money can choose very comprehensive supplemental coverage for Medicare.  Those without money can choose just basic Medicare (although they could end up in financial trouble if they need expensive treatment).  What if a similar system were to be enacted for the whole population?  Expand Medicare to cover everyone with very basic health insurance.  Then allow people to purchase private supplemental plans if they wish, with a wide range of options available to fit various budgets (similar to what we have now in the private health insurance market, but with the understanding that the plans are in addition to a basic policy provided by tax dollars).  Wealthy individuals would be able to buy the best supplemental coverage, giving them access to the best care.  Is that fair?  Maybe, maybe not (the answer might depend on how big ones brokerage account is)  But at least everyone would have basic coverage.

Hopefully the Obama Health Team reads Dr. Rich’s blog.  I believe that any form of outlawing private pay healthcare in a universal healthcare system would be doomed (as is the idea of any prohibition, really).  Taking a helicopter ride out to a Liberian-registered nuclear aircraft carrier that has been retrofitted as a swanky hospital (would there be a spa service, I wonder?) would add a whole new level of excitement to healthcare.  But I think that most of us would rather continue to be able to seek healthcare options a bit closer to home.  A little government intervention in terms of providing affordable basic healthcare access to all Americans through a tax-funded program is a good idea.  But too much government intervention, in the form of a moratorium on private pay healthcare, is a bad idea.

The Colorado Health Insurance Insider article about attracting more docs to primary care was included in this edition of Grand Rounds.  Thanks for hosting, Dr. Leap!

The city of Pueblo banned smoking back in 2003, long before the rest of the state.  And now the results are in from a study that tracked the number of heart attack hospitalizations in Pueblo for three years following the smoking ban, and compared the numbers with data gathered before the ban went into effect.  The results were significant: Before the ban, the heart attack hospitalization rate was 257 per 100,000 and in the years following the smoking ban, that number dropped to 152 in 100,000.  The study also tracked data from surrounding Colorado communities that did not institute a smoking ban, and found no significant changes in the number of people hospitalized with heart attacks.

It’s not surprising that a ban on smoking in public places is beneficial to public health – everybody knows that secondhand smoke is a killer.  But I think that a lot of people are surprised by the degree of impact that the ban had, and how quickly the number of heart attacks dropped.

Not only are people in Colorado no longer smoking in public places, but it appears that they aren’t buying as many packs of cancer sticks here in the state, and that is spelling trouble for state health agencies like Medicaid and SCHIP that rely on tax revenue from the sale of cigarettes.  If it’s because people are smoking less, that’s a good thing.  In that case, I would be in favor of raising the tobacco tax rate in order to make up lost income.  But it looks like part of the problem is that people are buying cigarettes across state lines, over the internet, and on the black market – all of which reduce the tax dollars that Colorado has available to provide health insurance coverage to low income residents.

This is an example of a time when I think that states need to work together.  If every state had the same tax rate on tobacco, there wouldn’t be any incentive for people to buy cigarettes across state lines.  The black market will always exist for products that are regulated and/or heavily taxed.  But at least by having a consistent nationwide tobacco tax, each state could get its rightful tax revenue.

I’m thrilled that the smoking ban in Pueblo has yielded such positive effects on the health of the population, and I’m glad that the rest of the state followed suit a few years later.  Now let’s hope that the state can figure out the funding for programs like Medicaid and SCHIP – both of which provide health insurance to Colorado populations that desperately need it – despite dwindling tobacco sales.

There are lots of factors involved: less education, higher rates of tobacco use and obesity, and less access to transportation (which makes it harder to get to screenings and medical appointments).  Then of course there’s the health insurance issue.  People with Medicaid are more likely to be diagnosed with cancer when it’s in an advanced stage, and people without health insurance are also more likely to die from cancer than their insured neighbors.  And those living in poverty or near it (in Colorado and just about everywhere else) have a pretty good chance of either being covered by Medicaid or uninsured.  For a Medicaid recipient who doesn’t have a car and lives 40 miles from the nearest doctor who accepts Medicaid, realistic access to health care is pretty limited.  The same is true for someone who doesn’t have health insurance at all.  There may be plenty of doctors nearby who screen for cancer, but if money is tight, putting food on the table is likely to come before a colonoscopy in the family’s priorities.

It’s true that there are aspects of choice in all of this, but there’s a lot that is beyond the control of the individuals affected.  Medicaid was enacted to try to provide health care for Americans who live in poverty, but it’s not a perfect system.  And when people don’t have any money at all, just getting to the doctor can be a challenge – even if Medicaid will pick up the tab.  Perhaps our focus should be on eradicating poverty instead of trying to provide state-funded health insurance to those who struggle to pay for basics like food and heat.  When people have to worry about coming up with money to pay for the basic necessities, it’s easy to see how cancer screenings could get pushed to the back burner.

There are lots of ways to improve on the cancer statistics for impoverished Colorado residents.  Expanded low-income health insurance coverage, more free screenings, state-provided transportation to hospitals, child care for parents battling cancer, etc.  But some overall changes in our tax and employment systems to “spread the wealth” might be a better place to start.  This idea was roundly mocked by Joe the Plumber and his buddies during the election, but reducing the number of Americans living in poverty benefits all of us.  We all pay for Medicaid in our taxes, and when hospitals treat impoverished patients who don’t have health insurance, we all pay in the form of increased health care prices (the hospitals have to cover the costs somehow).  Eradicating poverty doesn’t just benefit those who currently live in its grips.

Judging from the articles I saw online this morning, there seems to be immense confusion regarding revenue, profit, business expenses, and cost to buy a business.  Obama’s plan would increase business taxes by 3% (from 36% to 39%) on marginal profits over $250,000.  That means that only the profit over $250,000 would be taxed at the higher rate.  The revenue (total number of dollars generated) a business brings in has nothing to do with it, since most businesses shell out a considerable amount of their revenue in expenses.  And salaries are included in expenses.  So for a business to profit more than $250,000/year – after paying all expenses and salaries -it has to be taking in a huge sum of money in revenue.  Now that we have that cleared up, let’s look at the numbers.  Since I’m a health insurance agent, I’ll be focusing not only on the basic tax proposals, but also on the tax mechanisms that the candidates have proposed regarding small businesses and health insurance.

Wurzelbacher mentioned the business he’s looking at buying, Newell Plumbing and Heating, “that makes about 250, 270, 280 thousand dollars a year” and consists of himself and the owner of the company, Al Newell, as the only two employees.   I’m going to assume that the dollar figure he’s talking about is profit, after all company expenses (including salaries for himself and the owner) are paid, otherwise this whole discussion is a waste of time.  And to give him the benefit of the doubt, I’m going to go with his upper estimate, and say that the business has a profit of $280,000/year.   Since my focus is health insurance, I’m also going to assume that the business provides health insurance for Wurzelbacher and Newell and their families (which is likely, considering there are only two employees and the business appears to be thriving, to put it mildly). The Kaiser Family Foundation currently pegs average family health insurance premiums at $12,680/year.

So let’s look at how this business would fare under the various tax and health insurance platforms of the two presidential candidates.  With McCain’s plan, there would be no increase in tax rate on the profit the business makes.  But health insurance premiums, which are currently a tax-deductible business expense, would no longer be tax-deductible.  So if the business is paying premiums for two families, at roughly $12,680 each, that’s $25,360/year that the business is spending on health insurance premiums and deducting as a business expense.  So that money is currently not included in the $280,000 profit the business makes.  Losing that tax deduction would mean that the business would be paying 36% tax on the $25,360 that they currently pay for health insurance premiums.  That’s $9,129/year in additional taxes.  Now the business has two options – they can either continue to pay for health insurance for the employees and their families, or they can stop offering coverage and Newell and Wurzelbacher would have to go out on their own into the individual health insurance market and find their own policies.  Either way, that $25,360 that the business was spending on health insurance premiums is going to be taxable under McCain’s plan, since it would no longer qualify as a tax-deductible business expense.  Both employees would be eligible for the $5,000 tax credit McCain is proposing to help offset the cost of individual health insurance premiums.  But it’s likely that they would have to raise their deductibles and out of pocket exposure in order to get policies for $5,000/year, and if they or any of their family members have any pre-existing conditions, they will face difficulties in obtaining individual health insurance.

Whether people want to take the McCain health insurance tax credit and go out on their own and find individual health insurance probably depends a lot on how healthy they are, how old they are, and how much risk they’re willing to take.  As I’ve mentioned, the McCain tax credit for health insurance would be great for my family.  But for a lot of people – with pre-existing conditions, with large families, or without the means to save money to cover a higher deductible – the McCain health insurance reform would leave them with less access to affordable health care than they have now.  And in order for a health insurance reform measure to work, it has to work for everyone, not just those who design it.

Now let’s consider Obama’s plan.  True, he would raise taxes on small business profits (not revenue) that are over $250,000 (a threshold that the vast majority of small businesses don’t even come close to reaching).  In this case, that would be $30,000/year in profits being taxed at the higher rate.  The tax rate on that $30,000 would go from 36% to 39%.  The difference would be an additional $900/year in taxes for the business.  The business would still get  a tax deduction for the health insurance premiums they pay, so it would continue to make good business sense to offer group health insurance for the employees.

So Obama would increase taxes on the plumbing business by $900/year (if the business is making an annual profit of $280,000).  McCain would let the business keep that $900/year, but he would take away more than $9,000 in tax savings that the business gets by deducting health insurance premiums.

All of these numbers are chump change compared to the revenue the business would be pulling in to be showing a profit of $280,000/year.  A webpage showing information for Newell Plumbing and Heating shows that they aren’t incorporated and annual sales are actually $100,000.  So they currently have nowhere near the kind of profits that Joe is worried about making.  But if they had the business sense to incorporate, their business could get VERY wealthy and hire a LOT of employees with health insurance benefits before they needed to worry about the business showing a profit of more than $250,000 annually.