Archive for the 'US Health Care' Category
Add a comment September 24th, 2008 by bronxdoc
Cara Muhlhahn, Certified Nurse Midwife (left) with Mayra and David Radzinski. Photo Credit: Paulo Netto
Social Medicine Rounds on 9/23/08 was devoted to a showing of the film The Business of Being Born, produced by Ricki Lane and directed by Abby Epstein.
The film, which traces several pregnancies and births, offers an extended contrast between the highly medicalized world of US obstetrics and the world of homebirths and midwifery. It argues that American medicine has so lost touch with the basic needs of women in labor that most obstetricians have never seen a home birth and only rarely witness a ‘normal’ birth.
In 1900, 95% of birth in the US occurred in homes. Fifty-five years later less than 1% did. During this time, physicians asserted control over pregnancy and birth, progressively marginalizing midwifery. With the introduction of fetal monitors in 1970, Cesarean Section rates in the US climbed from 4% of births to 23% in the space of a decade. This dramatic change in medical practice occurred without evidence to support the benefit of fetal monitoring. The film argues that hospitals and physicians, anxious to keep the assembly line of the obstetrics floor moving smoothly, simply don’t have time for normal labor. Women are started on epidurals for pain, their labors slow, they are given pitocin to augment contractions, they get more pain, more pain medicine, more pitocin, and so on in a cycle of ever increasing medical intervention. “Her labor is taking longer than it should,” is the comment of the obstetrician. Finally when the monitor shows fetal distress, the doctor intervenes “for the sake of the baby.” The woman ends up with a Cesarean, the safest solution, we are told, for the doctor concerned about malpractice.
Woven into this story is the counter tale of how home birth was revived by the hippies during the 1960’s. Ina Mae Gaskin, the “mother of authentic midwifery” is interviewed and we see scenes of her working at the Farm Birthing Center. She proudly recounts that they did not do their first Cesarean until after over 180 births. The film also follows a contemporary certified nurse midwife (seen in the photo above) as she rounds in New York City. We witness several home births - including that of Ricki Lane. These are clearly the most striking moments of the movie. The women labor in a variety of positions - squatting down, lying in a tub, squatting in a tub, lying propped on a couch. In an amusing moment a Brazilian doctor describes how the lithotomy position (lying flat on your back with your feet up) is the worst possible one for a woman delivering a baby. Finally, after the intense pain of labor, there is a moment of silent release and the baby is born. “Reach down and take your baby,” the midwife says to the new mother. As a physician who has experienced only hospital births these scenes were revelatory.
Running throughout the film is a concern over the safety of homebirth and the competence of midwives. And not all of the home births shown are successful. But if one can question homebirths and midwifery, is it not also legitimate to question hospital births and the competence of physicians? Clearly, 1/3 of all births don’t have to be done by Cesarean Section. The question really is how to design a health care system that can find the right place for each type of practice. But academic medicine seems largely unable to even pose that question.
Our thanks to the filmmakers for posing it so movingly. And for allowing us to share in the births of their children.
The film’s website has links to a variety of resources on midwifery and a short trailer.
Posted by Matt Anderson, MD
Add a comment September 15th, 2008 by bronxdoc
Dr. Jean Silver-Isenstadt
On Tuesday, September 11, Dr. Jean-Silver Isenstadt, the founding Executive Director of the National Physicians Alliance spoke at Social Medicine Rounds about the work of the NPA since its formation in 2005.
She began her presentation with Broken Covenant, a short film which captures the issues and events surrounding the birth of the NPA; it is available on the NPA website. The Alliance developed from a core group of AMSA (American Medical Student Association) ex-presidents who wanted to create an “AMSA beyond AMSA,” i.e. a physician’s organization that could better express the values animating AMSA. These core values, as identified by NPA’s founders, were: service, integrity and advocacy.
Core Issues
The core issues identified by the new organization were:
Integrity & Trust in Medicine
Equitable, Affordable Health Care for All, Without Health Disparities
Prevention and Wellness
NPA Campaigns
These core issues have translated into three major NPA campaigns:
1. The Unbranded Doctor (which will be the subject of our next posting).
2. Rx: Vote, a voter registration campaign (see our posting of June 20, 2008)
3. Secure Health Care for All
The Secure Health Care for All campaign has chosen not to endorse a specific plan, but rather endorses the Institute of Medicine’s general principles for health care reform:
1. Health care coverage should be universal.
2. Health care coverage should be continuous.
3. Health care coverage should be affordable to individuals and families.
4. The health insurance strategy should be affordable and sustainable for society.
5. Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.
This campaign has been undertaken in alliance with a number of groups including HCAN, Health Care for America Now. HCAN calls for a plan which guarantees affordable coverage and allows people to: “keep your current private insurance plan, pick a new private insurance plan, or join a public health insurance plan.” It appears this plan has been controversial within the NPA, some seeing it as too left, others as not left enough. (For a recent critique of HCAN from Physicians for a Naitonal Health Plan, see the PNHP blog). The campaign also offers NPA’s report card on the health plans of the current presidential candidates.
In addition to these three large campaigns, the NPA website has information on campaigns to address malpractice, safety, and the global health worker shortage.
The NPA lays great importance on the role of physicians as advocates. Dr. Silver-Isenstadt stated: “Patient advocacy is a responsibility of the profession.” And their website offers many opportunities for physicians to work as advocates. In addition, NPA has a blog and a facebook page.
From the NPA website: “Jean Silver-Isenstadt holds a doctorate in the history and sociology of medicine from the University of Pennsylvania, a medical degree from the University of Maryland, and a master’s degree in nonfiction and science writing from the Johns Hopkins University. Her doctoral work focused on 19th-century American health reform. She is the author of Shameless: The Visionary Life of Mary Gove Nichols (Baltimore: Johns Hopkins University Press, 2002), a biography of the infamous and influential health advocate and social reformer best known for her leadership of the water-cure movement and for her scandalous public lectures to women on anatomy and physiology.”
After her talk, Dr. Silver-Isenstadt reminded me that the Social Medicine Portal was one of the first sites to give publicity to the NPA in 2005.
Posted by Matt Anderson
1 Comment July 8th, 2008 by bronxdoc
One of the advantages of belonging to Physicians for a National Health Program is their excellent newsletter. It offers reprints of articles related to the advocacy of a single payer plan in the US.
Perhaps the most interesting reprint in the last PNHP report was the letter published April 1, 2008 (not a joke we hope) in the Annals of Internal Medicine by Aaron E. Carroll and Ronald T. Ackerman. The text of this letter can be downloaded from the PNHP website. In 2007 Carroll and Ackerman surveyed 5000 randomly selected members of the AMA, 51% of whom replied. They asked only two questions:
1) In principle do you support or oppose government legislation to establish a national health insurance?
The answer to this question was: Strongly support - 28%; Generally support -31%; Neutral - 9%; Generally opposed - 15%; Strongly opposed - 17%. In short 59% of US physicians support a government sponsored national health insurance.
2) Do you support achieving universal coverage through more incremental reform?
The answer to this question was: Strongly support - 14%; Generally support-41%; Neutral -21%; Generally opposed - 10%; Strongly opposed - 14%.
The authors compared these numbers to a similar study they had done in 2002 when 49% of physicians supported a national health insurance. Support had increased in every specialty of medicine except pediatric subspecialists (who had high levels of support in both surveys).
The Carroll and Ackerman study has been criticized for failing to demonstrate that their sample accurately reflected the views of US physicians. It’s hard to know how biased the sample was. What does seem to be clear is that in 5 years, using the same methodology, Carroll and Ackerman found that support for a National Health Insurance had increased from 49% to 59%. This change is probably spurred by the growing difficulties physicians are having with getting reimbursed by the insurance companies.
The fact that the American College of Physicians, the 124,000 member association for internists came out in December 2007 in favor of a univeral health insurance is also strong evidence of physician support for a national solution. The ACP position paper is entitled “Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries” and covers many of the key issues in this debate.
It would be nice if some pharmaceutical company, or perhaps a large HMO, would do a big-scale survey of physicians asking if they supported a National Health Program. But since single-payer has been declared out of the question by the political class, we aren’t holding our breath for such a survey.
Of course, a government-sponsored National Health Insurance has many advantages other than physician reimbursement. To quote from PNHP: “The U.S. spends twice as much as other industrialized nations on health care, $7,129 per capita. Yet our system performs poorly in comparison and still leaves 47 million without health coverage and millions more inadequately covered.”
The PNHP is urging physicians to sign a letter to the Presidential Candidates urging them to consider a single payer plan. The link is at www.pnhp.org/letter. Their website is very well set up to put you in touch with your representatives in government.
Posted by Matt Anderson
Add a comment June 20th, 2008 by bronxdoc
The National Physicians Alliance has developed a campaign at www.RxVote.org to promote voter registration in health centers and clinics. This is being done in coordination with Rock the Vote.
The campaign’s website provides a fairly complete set of tools for organizing a voter registration drive. Among these are:
The information on felony voting rights comes from the Sentencing Project. According to the project “1.4 million African American men, or 13% of black men, are disenfranchised, a rate seven times the national average.” This is one of the many impacts of mass incarceration on our communities. And yet another reason for us to strengthen the ailing fabric of US democracy.
Add a comment April 17th, 2008 by bronxdoc
Per capita U.S. spending on health care is nearly twice that of any other country. Yet our health statistics are comparatively poor-life expectancy in the U.S. is 27th in the world and 45 million of our citizens go without health insurance (see US Health Care Spending In An International Context). The discrepancy between what we spend and what our health care system provides is clearly related to the fact that, alone among the advanced countries, we lack a national health care program. Our dependence on private, employer-based insurance is unique, and our system is failing-its costs rising by 10% or more each year, and its coverage declining, with less than 45% of private sector workers covered.
Physicians for a National Health Program, an organization of physicians, health care professionals, and concerned individuals, was founded in 1987 to work for a universal comprehensive national health insurance program. Current membership is over 10,000, with chapters throughout the country. The group has worked with Congressman John Conyers to develop H.R. 676, The United States National Health Insurance Act.
PNHP’s proposal for a national health care program was first outlined in a 1989 article in the New England Journal of Medicine. PNHP proposes what is called a “single payer” plan, a system of healthcare that is publicly funded but delivered largely by private entities. The latest version of their plan is the Proposal of the Physicians Working Group for Single Payer National Health Insurance, published in JAMA and endorsed by more than 12,000 physicians. PNHP argues that savings in administrative costs through adopting this efficient financing mechanism-very similar to what the U.S. has today in the Medicare program-would allow everyone to be covered, at no additional cost (see, for instance, “Paying for a Single Payer National Health Insurance Program: Where Will the Money Come From?”, a Forum Report from the NY Metro Chapter.
By international standards, single payer is not a very radical plan; many countries have similar plans, and poll after poll show that two-thirds of the American people would support it. But the continual refrain from the media that it isn’t “politically feasible” keeps it from gaining wider attention. For a lively description of single payer, see this animated presentation.
PNHP has been critical of the idea that marketplace solutions are the answer to the current healthcare problems in the U.S. In part, this criticism has been based on the failures of “actually existing” profit-driven medicine. “Mayhem in the Medical Marketplace” an article in Monthly Review by PNHP’s David U. Himmelstein and Steffie Woolhandler, gives a succinct overview of the current problems with market medicine in the U.S. We know that for-profit medicine is associated with poor quality care, vast amounts of fraud, radically higher administrative costs for paperwork, marketing, profits, and obscenely high CEO compensation, as well as a variety of practices meant to increase profits at the expense of clinical care. (Many of these issues have been discussed in a multiple articles by Drs. Himmelstein and Woolhander in the New England Journal of Medicine).
Other organizations are working for universal health care in the U.S. A principal one is UHCAN, the Universal Health Care Action Network, which brings together state and local health care activists around a range of health care reform issues.
PNHP members are active in writing, speaking and advocacy. Their national website (www.pnhp.org) offers a wealth of information and opportunities for taking action in support of a single-payer plan. In addition you can join their “quote of the day” listserv which provides critical analysis of health-related issues.
The New York Metro Chapter of PNHP is runs lively monthly forums, publishes Forum Reports and Issue Papers, and provides speaker training, grand rounds speakers, and other activities. Medical students and residents are active in the Chapter, with Chapter sub-groups on each of the medical school campuses in the New York area. See the Chapter’s web site, for ongoing programs, publications, and contact information.
- Leonard Rodberg and Matthew Anderson
