Reminder – Application due July 30th for Northern Uganda Social Medicine Course

Dear all,

We’re writing to remind you that applications are due in just over two weeks (July 30, 2010) for this exciting social medicine and global health course held in Northern Uganda. Please see the course invitation below and feel free to let us know if you have any questions:

Course Invitation 2011
We invite you to apply for the second annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 10, 2011 through February 4, 2011. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can also be arranged. It is estimated that total student costs for the course will be $2650. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).

For more information, we invite you to read the attached prospectus and view the short video about this year’s course, available at:

If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.

Sincerely,

Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
Michael Westerhaus, MD, MA
Brigham and Women’s Hospital
Division of Global Health Equity
Boston, MA 02115

Discussion in 2010 Course

In health care as elsewhere, cheaper is not always better.

So the dirty little secret has come to light. As it appears, in health care, cheaper is not always better. The “pioneering” research produced by the Dartmouth group, propagating the belief that many areas of the country spend more in health care than others, while providing no better, and sometimes worse, care (the study used comparisons within Medicare) because in these regions doctors are simply “wasteful”, may have been based on faulty research after all.

At least this much was admitted in a recent article in the New York Times, even as the very New York Times editorial board, and key reporters such as David Leonhardt, have been all along major supporter of the science and philosophy underlying Dartmouth and of the many “cost-saving and quality improving” measures that will be implemented under the new law, the “Patient Protection and Affordable Care Act”. One key measure is to reduce “superfluous” services to Medicare patients, and thus “rein on waste, fraud and abuse“.  Somehow, this will not undermine, but rather improve, the quality of care provided to them, or so says the law.

Indeed, for New York Times editors one key problem in our health care system has been all along the “profligate” behavior of doctors. If we can tame this behavior, our collective savings will be extraordinary, the Times and its health reporters have asserted repeatedly, and will enable us to eventually provide health care to all Americans at lower costs. Promoting this view, The Cost Conundrum, by Atul Gawande, a Harvard-affiliate doctor and author, became “required reading” in the White House, and turned its author into a Washington star virtually overnight.

But as it turns out, the research may have been faulty.

Just so as not to clog cyberspace with redundancies, here an excellent analysis of what the Dartmouth study really showed (you guessed it: correlation is not causation), and what may have been the motivations of researchers who  promoted the study (you guessed it: money!).

Single payer anyone?

Social Medicine Course in Northern Uganda

We invite medical students to apply for the second annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 10, 2011 through February 4, 2011. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can also be arranged. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).

For more information, we invite you to view the short video about this year’s course, available at:

If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.

Sincerely,
Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
(course instructors)

Healthy People 2010: Not quite there yet

Two articles in the Perspectives section of a recent issue of the New England Journal of Medicine (May 6, 2010) provide an interesting view into the state of the U. S. public health system.  In the first, Dr. Howard Koh provides an evaluation and reaffirmation of the Healthy People initiative, started in 1979 by the Department of Health and Human Services as a way of systematically setting health goals, collecting relevant data, and monitoring outcomes for health-improvement activities in the U.S.(1)  He points out that while small but measurable improvements in quality of life have been acheived in the last decade, the goal of eliminating disparities in health outcomes has been largely unmet.  In the second, Dr. David Hemenway, laments the state of funding for public health in the U.S. and attempts to explain the underfunding of public health measures.(2) Taken together, they highlight a trend that is widely understood by advocates in social medicine: underfunding of public health initiatives directly impacts the level of disparity in health outcomes.

Healthy People 2010 focused on two main goals: increasing quality (and quantity) of life for Americans and eliminating health disparities.  Dr. Koh demonstrates that the results have been mixed. For 28 focus areas, ranging from access to quality health services to oral health to vision and hearing, just over half have seen improvement and nearly 20% have seen their target met.  By some measures, we have either remained discouragingly far from stated goals or actually worsened.  Cigarette smoking, for example, which is the leading cause of preventable death worldwide, decreased from a baseline of 24% in 1998 to 21% in 2008, far from the stated goal of 12%.  We are significantly more obese as a nation than we were ten years ago.  Approximately 1/3 of all adults over 20 years of age are obese, up from under ¼ two decades ago.  Unfortunately, the gains and losses in the health of Americans are not equally shared.  The goal of eliminating disparities remains, according to Koh, “unmet.”  Increased rates of obesity, for example, are greater in Blacks and Mexican Americans than they are in Whites.  Dr. Koh cites a review by Sondik et al (3), who demonstrate numerous examples of increased disparities in indicators of quality of life and overall health. They conclude that “overall, in the area of disparity reduction, there is not much good news.”

Dr. Hemenway points out that “it is generally acknowledged that public health is systematically underfunded and that shifting resources at the margin from cures to prevention could reduce the population’s morbidity and mortality.”  He cites four reasons for the underfunding of public health:  first, the benefits of public health measures are not immediate and therefore require a delay of gratification.  The costs are immediate but the results are both distant and unpredictable.  Second, “the beneficiaries of public health measures are generally unknown.”  Money flows more readily towards identifiable victims than hypothetical victims of future events.  Third, the benefactors of public health intitiatives are unknown by the beneficiaries: “when people benefit from public health measures, they often don’t recognize that they have been helped.”  The current TEA party movement provides a wonderful, if tragic, example of this, blind as it is to the concrete benefits of taxes and government.  Fourth, public health efforts often suffer from disinterest or, worse, outright opposition.  Hemenway cites “status quo bias” and “tradition-bound resistance” as examples of human characteristics that impede progress in public health initiatives.

It is reasonable to hypothesize that the systematic underfunding of public health initiatives contributes directly to disparities in health care.  And it is likely that the Healthy People Initiative will never realize the goal of eliminating disparities until public health funding can be consistently and meaningfully funded.  After all, it is the poor, the under- and un-insured, who tend to benefit most from public health initiatives like vaccinations, clean water supply, and clean air, and who suffer disproportionately in their absence.  Michael Harrington, in his landmark book, The Other America (1962), wrote about an America that was “hungry, and sometimes fat with hunger, for that is what cheap foods do. They are without adequate housing and education and medical care.”  Nearly five decades later, these problems have not gone away.  As Healthy People 2010 comes to an end, in some cases they are worse.

It might be tempting to use Healthy People 2010 as an example of the ineffectiveness of public health initiatives.  Or one could argue that the Healthy People initiative sets unrealistic goals.  I would argue that the US government has a chance to prove otherwise with Healthy People 2020.  As the DHHS plans for the next decade, healthcare professionals must push our legislators to assure adequate funding for the public health initiatives that improve all of our lives in unseen but measurable ways.  We must urge them to block out the loud voices of those who would stop paying taxes without knowing what taxes pay for.  Finally, and most importantly, we must ask for more coordination between those that initiate public health interventions and those that measure the results.  Those who implement public health programs must work directly with those who establish goals for their efficacy. Measuring our own failure can only be of value if we have the means to turn it around.

1.  Koh H. A 2020 Vision for Health People. NEJM 2010;362:1653-6.

2.  Hemenway D. Why We Don’t Spend Enough on Public Health. NEJM 2010;362:1657-8.

3.  Sondik EJ, Huang DT, Klein RJ, Satcher D. Progress toward the Healthy People 2010 goals and objectives. Annu Rev Public Health 2010;31:271-81.

U.S. health system causes headaches in more than one way, and the “Patient Protection and Affordable Care Act” will do little to change this

(From PNHP.org)

Migraines, often characterized by excruciating headache and nausea, are much worse for the uninsured, a new Harvard Medical School study shows.

Researchers say migraine sufferers who lack private health insurance get poor care for their condition. They are about twice as likely to get inadequate treatment for their headaches as their privately insured counterparts. People with Medicaid also get substandard care.

Because migraine is common in the United States, affecting about 18 percent of women and 6 percent of men, and because so many Americans lack health insurance, a startling 5.5 million people are at risk of getting substandard care for their often painful and disabling headaches, the researchers say.

The study, titled “The impact of insurance status on migraine care in the United States: a population based study,” was published on Tuesday, April 13 in Neurology, the world’s leading clinical neurology journal.

Study senior author Dr. Rachel Nardin, assistant professor of neurology at Harvard and chief of neurology at the Cambridge Health Alliance in Massachusetts, said: “The tragedy is that we know how to treat this disabling condition. But because they are uninsured or inadequately insured, millions of Americans suffer needlessly.

“Unfortunately,” she said, “the new health law doesn’t fully address this problem. At least 23 million people will remain uninsured nine years out.

“Optimizing migraine care requires improvement in our health care systems as well as educating physicians to prescribe the best available drug and behavioral treatments.”

The researchers analyzed data from two federal surveys, the National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey, which together provide a nationally representative sample of all U.S. visits to doctors’ offices, hospital clinics and emergency rooms. They analyzed the 6,814 visits for migraine between 1997 and 2007, representing 68.6 million visits nationwide.

Neurologists recommend two types of drugs when a moderate-to-severe migraine strikes: “triptans” (such as sumatriptan) or dihydroergotamine (DHE). For the majority of migraine sufferers whose headaches are frequent or severe, neurologists also recommend a daily dose of one of several preventive medications.

The researchers used these recommendations from the American Academy of Neurology to define standard migraine treatment and found that the uninsured were nearly twice as likely as the privately insured to receive substandard treatment.

Medicaid enrollees were 50 percent more likely to receive substandard treatment, suggesting that “access to some forms of insurance is not the same as access to adequate care,” the researchers wrote.

Care in doctors’ offices was substantially better than in emergency departments. The fact that the uninsured are less likely to get care in doctors’ offices explained some, though not all, of their substandard care.

Most people with migraine are impaired by their headaches and the accompanying nausea, and lose an average of four to six days of work annually.

Dr. Steffie Woolhandler, professor of medicine at Harvard and study co-author, said: “Lack of insurance clearly takes a heavy toll on our patients and the economy. Regrettably, the health bill just signed into law will leave tens of millions of Americans uninsured or poorly insured and thus unable to get the care they need.”

What Frontline missed, and health care justice advocates should know

Oh yeah! The progressive, single payer community did look forward to the screening of the Public Broadcasting Service (PBS) Frontline production “Obama’s deal”, frustrated as we were by our voice having been buried in a misleading, media-backed “debate” that portrayed all opponents of the “Patient Protection and Affordable Care Act” as right-wing lunatics “against reform” – yes, the usual trick “you’re with us or with the terrorists”.

And to their credit, Frontline did a terrific job of documenting the countless back-room deals struck by the White House and Congress with Big Pharma and Big Insurance. As the production illustrated, these deals chipped away whatever progressive features the Act may have initially had, and turned it into a weapon of mass destruction of the pockets of ordinary folks who already barely make ends meet, and into an extraordinary sweet deal that will substantially increase the political and economic power of for-profit insurers for years to come. Unsurprisingly of course, given that the Act was almost literally dictated by WellPoint Inc., as the Frontline production pointed out.

Disappointingly, however, Frontline did not live up to its promise. While it did reveal some of the “realities of American politics, the power of special interest groups and the role of money in policy making”, it omitted showing viewers just what “Obama’s deal” had sacrificed, and what single payer advocates were being dragged to jail for, as they entered the meetings of the Senate Finance Committee chaired by health care czar Max Baucus. Rather, it merely portrayed them as yet another disaffected group within “President Obama’s liberal base”, which had to be appeased so that our president could move on with the serious stuff — “reforming” healthcare.

But it is precisely what the deal sacrificed that matters. Because single payer advocates, including many doctors such as Margaret Flowers, risked arrest, and were arrested, for standing up for a right to health care, through a publicly-financed and publicly delivered single payer system, that was being sacrificed at the altar of special interests, even as President Obama asserted, with a straight face, that “all options (for health care reform) are on the table”.

Now, could the reason for sacrificing a right to health care be that our charismatic president received at least ten times the money that his designated health care czar, Max Baucus, received from the very industries they were supposed to rein in? We don’t know, but the hypothesis is not implausible, and Frontline producers would have done their viewers a service had they explored this or any other plausible and alternative to the mainstream hypothesis further. In so doing they would have spoken truth to power, the least we can expect from progressive mass media.

Americans have by now gotten used to having the best Congress (and Presidency) “that money can buy”. Let us not be forced to put the progressive media into an equivalent category — “it’s the best media money can buy”.

Rebuilding the US Health Left

The most recent edition of Social Medicine, our on-line academic journal has just been published.  We will post a short description of the articles later this week, but wanted to share the lead editorial entitled: Rebuilding the US Health Left. We would be most interested in comments from readers of the Portal.

Rebuilding the US Health Left

Matthew R. Anderson, MD, MS, Lanny Smith, MD, MPH, and Victor W.  Sidel, MD

With this issue Social Medicine begins a series of invited papers on the topic: “Rebuilding the US Health Left.”  In this editorial, we will outline our vision for this series.

We undertake this project aware that our good friend and mentor, Dr. Walter Lear, one of the leading health activists of the 20^th century, lies critically ill.  Walter was the creator and custodian of the US Health Left Archives, a collection that is now with the University of Pennsylvania library.  The collection reminds us of the important role Left health care workers played in US history throughout the 20^th century. They advocated for a national health program (Committee on the Costs of Medical Care, Physicians Forum,  Medical Care Section/APHA, HealthPAC, Physicians for a National Health Program, National Physicians Alliance), provided international solidarity (American Soviet Medical Society, international brigades during the Spanish Civil War, Central American Solidarity Movement, Committee to Help Chilean Health Workers, Doctors for Global Health), traced the connections between disease and social class (Sigerist Circle, Spirit of 1848 Caucus/APHA), fought for workers’ health (Councils for Occupational Safety and Health; Occupational Health and Safety Section/APHA) participated in anti-war movements (Medical Committee for Human Rights, Physicians for Social Responsibility, International Physicians for the Prevention of Nuclear War, Peace Caucus/APHA), created new models of health care delivery (Health Cooperatives, Prepaid Health Maintenance Organizations, Community Health Centers, National Health Service Corps, Free Clinics), were central to the struggle for women’s rights (Planned Parenthood, Physicians for Repro-ductive Choice and Health), supported the civil rights movement both in medicine and in the broader society (National Medical Association, Medical Committee for Human Rights), played key roles in the movement for gay rights (ACT-UP, Gay & Lesbian Medical Association, Lesbian, Gay, Bisexual, and Transgender Caucus/APHA), challenged traditional models of medical education (Student Health Organizations, AMSA, Residency Program in Social Medicine), and worked in many, many other fields.

It is not by chance that “leftie” physicians were specifically targeted during the McCarthy era. Tragically, the repression of progressive ideas within the medical community had a chilling impact during the 1950’s when many progressive physicians were blacklisted and some saw their careers ruined. Organized medicine – through the AMA – made its peace with the nascent medical-industrial complex, becoming ever more conservative and eschewing the social values that had informed much of the medical community in the earlier parts of the century.  By 1961, the AMA’s Women’s Auxiliary (composed of doctor’s wives) participated in “Operation Coffeecup” during which they met to listen to Ronald Reagan discuss “the evils of socialized medicine”; their goal was to defeat an early version of Medicare.

– to read the rest, please click here.  And please leave us your comments.

posted by Matt Anderson

MASSACHUSETTS: Doing the same thing and expecting different results

There has been much talk about Massachusetts since the victory of Senate Republican Scott Brown. Many have suggested this victory was a referendum on the Democrat’s health care reform “overhaul” awaiting a unified bill to be signed by President Obama. The centerpiece of this plan is a mandate, i.e., a legal obligation to buy health insurance, with subsidies for eligible groups, or else face a fine.

But what is the reform law enacted as Chapter 58 of the Acts of 2006 that Mr. Brown has inherited anyways? Is it really the “universal coverage” it was promised to be?  The short answer is “no”.

The momentum for reform in Massachusetts in 2006 was spurred by the Bush Administration, who was insisting that the state reduce block funding of indigent care through the state’s free care pool or lose $385 million of Federal Medicaid funds. The state has an Uncompensated Care Pool that provides funds to hospitals and community health centers that deliver care to those without insurance coverage.  This pool is funded by assessments on hospitals, health insurance premium taxes, and federal matching funds. As the number of uninsured people rose significantly in 2006, the financing for the pool became fragile and the Bush Administration threatened their federal funds if Massachusetts failed to reduce the money spent on “free care”.

So, with 657,000 uninsured residents, or 10.4% of the population, the Massachusetts Health Care Reform Act was born.  At its center is The Connector, an independent state agency offering a “menu” of private insurance plans and assisting individuals obtain their insurance. For residents at or below 300% of the Federal Poverty Level (FPL), The Connector offers “Commonwealth Care”, where “customers” can choose a subsidized health plan based on a sliding scale.  So this should expand people’s health care choices, right? Wrong. Not if your employer offers insurance. If so, you are not eligible for these subsidized plans.  For all other residents above 300% PFL, and for small employers, The Connector offers “Commonwealth Choice”, a series of regulated, non-subsidized private plan options.  Truly American, “Commonwealth Choice” allows you to choose from the Gold, Silver, Bronze, or Young Adult plans, so-rated depending on how comprehensive they are. But the bottom line is: you get what you pay for.

By way of example, the cheapest plan available to a middle-income 56-year-old now costs $4,872 annually in premiums.  However, if the policy holder becomes sick, he or she must pay an additional $2,000 deductible before the insurance kicks in.  Thereafter, the policy holder pays 20% co-insurance, (20% of all medical bills) up to a maximum of $3,000 annually.  This totals to $9,972 dollars, if heaven forbid, the policy holder becomes ill. And we haven’t even begun to talk about “uncovered services”, that “affordable” policies Massachusetts-style are full of. For those, you are on your own, as you were before.

The plan also includes an “employer mandate”, that is, employers have some obligation to contribute to the cost of insurance, in 2008 an employer could opt out by paying $295 per employee and an individual could opt out by paying $912 yearly – as a fine. These surcharges were predicted to yield $45 million dollars annually, but totaled only $5 million in the first year of the program.   In addition, individuals can apply to be excluded from the program, for “hardship waivers”, if they can prove at a court of law that there is no affordable option available to them. In 2009, 79,000 residents applied and were “exempted” based on these grounds. Or, in plain English, 79,000 individuals remained uninsured.

The financing for this reform comes from the fines mentioned above and funds diverted from the state “free care pool”, that is, from appropriations originally invested on safety net facilities for those without insurance.

Since 2006, the outcome from the Massachusetts reform has been costly and still has yet to address the issue of access to health care. Because, it is important to remember, health insurance is not health care, but rather a means to it. And whether insurance will or will not improve access to medically necessary care depends of course on what type of coverage it offers. In Massachusetts, as explained above, coverage depends on how much you pay, from “Cadillac” plans (if you have the money) to bare-bones plans, if you belong to the so-called generation of “invincibles” (the young, often cash-strapped).

In 2008 the cost of the program for the state, to pay the subsidies and administrative costs to run the program, was 1.1 billion dollars, and rose again in 2009 reaching 1.3 billion. More expensive than expected, the Connector itself adds an addition 4.5% administrative cost to each policy it brokers. To reduce the price for the state, even if not for patients, insurers have increased premiums and co-pays.  As mentioned above, last year, as premiums rose 9.4% in 2009, 79,000 people who were not eligible for the subsidized Commonwealth plans were able to prove that they could not afford any other plan.

The Massachusetts reform does not change the cost of purchasing health insurance. In addition, the funding for these new insurance policies has replaced the “free care” system that included safety net clinics where low-income residents could receive care.  Now these residents are required to pay co-pays at the clinics due to the elimination of state funding, and they simply can’t afford to do so.  Therefore, this mandate to purchase a private product doesn’t achieve universal access to health care nor does it reduce the financial burden of disease on low- or middle-income families.

Steffie Woolhander, a professor of medicine at Hardvard, calls private insurance a defective product, one that leads people to bankruptcy and at the same time doesn’t provide the health care they need.  She explains, “Once failure to buy health insurance is a federal offense, what’s next? A Ford Pinto in every garage? Lead-painted toys for every child? Melamine-laced chow for every puppy?”  The idea here she’s exaggerating is that forcing residents to buy a flawed product they can’t afford, and that doesn’t provide what’s it’s supposed to, i.e. relief the “financial burden of disease”, is not a way to provide health care. Further, this mandate to buy a faulty product is no way to deliver “universal coverage” and Massachusetts should provide ample evidence for this.

But then, one does not need the over 2000 pages of legislation produced either by Congress or the Senate to realize why this is so. A much briefer paper of only 15 pages, written back in 2003, by four prestigious Princeton economists explains it very clearly. They studied why it is that the United States spends more than any other industrialized nation on health expenditures for the same amount of care, and concluded that “It’s the prices, stupid!” We may want to add to these extraordinary prices the close to 400 billion dollars in administrative waste generated by an extraordinary system built upon the idea of avoiding to pay for the costs of health care: private insurance policies.

Isn’t it time for U.S. policymakers to stop doing the same thing and expecting different results? Yet for for some odd reason, our President and many in Congress are “urging common ground” to go exactly in the same direction. Change we can believe in? Hardly.

Attention Medical Students: CaPA Medical Student Fellowships Program is taking applications

The California Physicians Alliance (CaPA) would like to invite you to apply for the CaPA Medical Student Fellowship.  The fellowship is a phenomenal, one-year, full-time, PAID position to work on healthcare reform and advance the single-payer movement.  It is THE only fellowship of its kind in California and an incredible opportunity for those interested in health policy education, advocacy, and leadership.  For further details please see our ONLINE APPLICATION.

The DEADLINE for the application is March 15^th.

Please help us spread the word about this incredible opportunity by forwarding this email to:

1.     Friends and listservs.

2.     Deans and program directors.

3.     Local campus career services.

Please contact us at CaPA.Fellow@PNHP.org if you have any additional questions.

Thank you!

How many angels can dance on the tip of a pin? A comment on the New York Times’ Economix blogpost “Is Community Rating in Health Insurance Fair”?

With all the respect that Professor Reinhardt deserves, the question he poses in the New York Times’ Economix blogpost, “Is ‘Community Rating in Health Care Fair”?, is bogus – perfect economic nonsense, morality aside.

His own 2003 paper, “It’s the prices, stupid”, lay out why we have the highest health care costs in the world: it is, critically, because we pay the highest prices on the planet for services and goods that cost a fraction elsewhere. Additionally, as the professor surely knows, another big chunk is wasted by for-profit insurers’ pushing paper around to make sure that they can get away with paying as little for our medical needs as their campaign contributions will afford.

Not to mention the fact that because we are hopelessly divided as a nation into a gazillion pools and plans, we fail to cross-subsidize in publicly useful ways, namely, very broadly and randomly, so that the system can be financially sustainable. Even for-profit insurers cross-subsidize, but in their case they do so to make sure that they enroll the healthier (and cheaper) “customers”, so that they can bring increasingly handsome profits to shareholders. And they dump the sicker and poorer on increasingly strained public plans (and then blame Medicare or Medicaid for their “financial unsustainability”).

So if rather than insisting on “uniquely American solutions”, such as leaving to for-profit insurance the task of financing health care for the majority of Americans, we did what every industrialized nation in the world has done, namely, ban profit from the financing of medically necessary services (yes, even the Swiss, as of 1996, have concluded that “it’s the profit, stupid”), and move to a social insurance system, the scenario, indeed the prices, painted by professor Reinhardt would never occur, so the question would be moot: both group A and B members in his thought experiment would be very happy, I suspect, cross-subsidizing whoever happens to be sick at any given moment, at dirt prices (compared to what we Americans pay), and both groups would likely feel this is fairer than subsidizing health insurance shareholders and CEO’s fat paychecks. No less importantly, they would know that we (or our children) can follow the jobs of our dreams (or even start a business!), rather than limit ourselves to those that include “health benefits” (whose numbers are decreasing as we speak).

Put another way, everybody would benefit from substantially lower health care prices, none of us would see our health care money go to financing wasteful paper-pushing, and cross-subsidization would occur for the benefit of the overall public good, in the same way that it does for any number of other things, such as Fire Departments, public schools, or National Defense. And what is more, we would finally enjoy the freedom to choose what really matters: our doctors or medical establishments, rather than from within those euphemistic lists of “preferred providers”.

Everybody would benefit, that is, except from those who make a living either at the expense of Americans’ health or by sponsoring Orwellian health care debates tantamount to those in the Middle Ages attempting to establish the number of angels that can dance on the tip of a pin.

And do not believe those who tell you that it is your fault because of your unhealthy lifestyles: Britons spend a fraction of what we do — 95% of them never see a medical bill in their lives – yet there isn’t a shred of evidence that they go more often to the gym or eat more broccoli than we do (however recommendable broccoli and exercise might otherwise be).  And neither can “technology” or “aging population” be the whole story: if not, ask the Japanese, who use far more technology than we do, visit doctors substantially more often, and are substantially older than we are, yet pay 50% of what we pay.

Finally, don’t believe in those who tell you that social insurance is “politically unfeasible” either: when Otto von Bismarck started social insurance in Germany back in 1883, he did not do so because he was a socialist, but rather to defeat socialism, because he believed that “the social insecurity of the workers makes them a peril to the state”.

We can’t expect meaningful change from politicians or experts:

It’s really up to us.