A June article in the New Yorker by Atul Gawande, which is reportedly required reading at the White House, examines the costs of health care by looking at the most and least expensive health-care markets in the US. In particular he studies McAllen, Texas, which has one of the highest costs of medical care per person in the country, and Rochester, Minnesota (home of the Mayo Clinic), which has among the lowest. Rochester also provides some of the best quality health care in the nation. Gawande’s findings led him to conclude that the Mayo Clinic system, which pays doctors an annual salary to keep them from treating their practices like “profit centers”, and emphasizes a peer-review process to improve quality of care, are the best hope for improving American health care. This requires breaking the “untenably fragmented, quantity-driven” systems that are becoming the norm in US medical care.

Gawande notes at the end of his piece that the decisions that need to be made about America’s health care system are greater than the public versus private insurance debate; rather, they involve a total reorganization of the health system. Enacting the principles already in place in the lowest-cost, highest-quality medical institutions in the country – removing any financial incentive for doctors to order unnecessary procedures and taking collective responsibility for patients – require a significant reordering of our priorities.

Others are also looking outside of the political discussions that focus on either “raising taxes or cutting care,” instead seeing a better way: “redesign.” Medical professionals from ten communities across the country with below average health spending and above average health outcomes recently traveled to Washington DC to discuss how changes they have implemented have lowered cost without reducing quality. Gawande, one of the meeting’s organizers, explained that change in these communities occurred quickly, as “[h]alf of these communities used to be high cost and transitioned to low cost over the last decade,” suggesting that national reform is also possible.

The meeting, organized by the Institute for Healthcare Improvement, allowed professionals from low-cost, high-quality hospital groups to exchange ideas about cutting costs and preventing unnecessary care. For example, physician groups in Everett, Washington were combined and two hospitals were merged while health coaches counseled healthcare workers to smooth admission and discharge practices. A health group in La Crosse, Wisconsin, has focused on working with elderly patients to create advanced directives, a crucial component of end-of-life care that can also help lower healthcare costs significantly. These methods, along with a shift to electronic medical records, improvement in health care data collection and better coordination among providers, were among the most common steps cited by medical groups seeking to restrain expenses.

Similarly, health care practitioners in Birmingham, Alabama studied a health program in Zambia to create their own AIDS clinic based on the Zambian model. At this clinic, called “Project Connect,” patients receive appointments in five days or less after calling, and social workers interview all patients to address issues that might make it difficult for a patient to return for follow up appointments. Another example is the Prevention and Access to Care and Treatment Program, a community-based project that uses community health workers to assist HIV/AIDS patients in staying adherent to treatment. The program, modeled on work begun in Haiti under Partners in Health, has been adopted for use in inner-city Boston and is expanding to include New York City and Miami.

Mark Dybul, the former US Global AIDS Coordinator, explains why methods of care in poorer nations are now receiving greater attention: “We learned from Africa that in a very resource-limited setting, you can do very effective chronic care delivery that doesn’t have to be overmedicalized.” With much of the debate on health care reform focusing on lowering expense, it appears that these cost-effective programs from the developing world will become more popular to US health care providers.

More information on health in America:

Getting good value in health care

Whistleblower tells of America’s hidden nightmare for its sick poor

Concerns on plan show clashing goals

Forget who pays medical bills, it’s who sets the costs

How are the current proposals for health insurance reform treating an industry that siphons off roughly $10 billion in annual profits? We now have two health reform bills reported out of congressional committees (“America’s Affordable Health Choices Act” in the House and the “Affordable Health Choices Act” in the Senate – using terminology pushed by Democratic pollsters, no doubt). Neither of them meets key human rights standards, and both cast private insurance corporations in the role of gatekeepers that control people’s access to care. At the same time, opposition is mounting against all and any reform measures.

Yet there continues to be great hope among many long-time health policy advocates that will we see meaningful health reform later this year. Advocates count on this reform to solve or at least alleviate the current health care crisis, which results in an estimated 22,000 preventable deaths due to lack of insurance each year, as well as skyrocketing costs that bankrupt families and public budgets alike. Pundits optimistically point to the many new measures the reform bills introduce: reining in the “free” insurance market through tougher regulation, including through a so-called Exchange mechanism; setting up a public insurance plan; expanding Medicaid; requiring employers to contribute to costs; and mandating everyone to buy insurance. All Americans (though not all immigrants – documented or not) will get health insurance – or so the hopeful want to believe.

Their hope is born out of desperation. Most advocates are painfully aware that health care is treated as a market commodity in the United States, and that market rules are stacked against those with little purchasing power. And these are usually the very people who need health care the most: poor people and people with serious health issues. In a blatant affront to the basic human rights principle of equity, minority groups and poorer communities in rural and inner city areas suffer disproportionally from market barriers to health care.

Reminders of the insurance industry’s power are everywhere: people who lack insurance, people whose claims are denied, whose coverage is rescinded, or who pay exorbitant premiums that may – or may not – preempt catastrophic bills but do not cover actual visits to the doctor. The business model of insurance companies only works if as many healthy people as possible buy policies and pay premiums that are as high as possible, and if those same people then forgo actually using the health care covered by that policy. None of this is news to mainstream health reformers, yet hardly anyone points to the emperor without clothes: because insurance corporations can profit only by restricting access to care, they act as hostile gatekeepers rather than as vendors of a value-adding service. In one of our news media’s rare instances of bluntness, a Paul Krugman blog in the New York Times explains that “private insurance basically spends a lot of money on socially destructive activities.”

Yet both Obama and congressional leaders remain worryingly silent on the role of the insurance industry, despite their rhetorical shift from health care to health insurance reform. Hence they struggle to devise a sustainable cost trajectory for their proposed reforms, which are weighted down by the immense costs of keeping private insurance corporations in business. These costs include profits and corporate salaries, plus the even greater amounts wasted on underwriting and marketing to exclude people who might actually need care, and on claims administration to deny care to those who have already paid for it. To help meet those costs, reformers have proposed a requirement on all individuals to purchase an insurance policy, which amounts to a massive bailout for an industry that has continued to make record profits and is accountable only to its shareholders. Such public subsidies to the industry, via policyholders, constitute the greatest cost factor in any of the bills under discussion, yet they fail to guarantee access to health care for all. Even under the best proposal, people would still have to pay up to 11% of their income in premiums for a skimpy policy, on top of co-pays and deductibles. These provisions illustrate that the economic costs of sustaining the private insurance industry can only be paid through the social costs of restricting access to care to those able to pay.

Always on public relations alert, all key industry players – hospitals, pharmaceuticals and insurers – claim to have made concessions that would curb the excesses of the market and sustain the policy consensus for commodified health care. Yet smoke and mirrors cannot hide that market-based health care is inherently unable to contain costs at the same time as ensuring access to quality care for all. Even the President accepts that universal coverage is not possible without a publicly funded and administered system, such as single payer, that automatically includes everyone. Such a system would treat health care as a public good rather than a market commodity, and enable access on the basis of need, not payment. Guided by the principle that basic human needs give rise to government human rights obligations, such a public health care system would be financed collectively in order to meet people’s health needs with equitably shared resources. Instead of providing profits and benefits to a few, a rights-based system would enrich everyone living in a healthier society.

A hearing by the House Subcommittee on Oversight and Investigations on June 16 brought up criticism of the policy, reporting that in the past five years, over 200,000 people have had their coverage cancelled by three of the largest US health insurers, WellPoint Inc., UnitedHealth Group, and Assurance Inc. The hearing also found evidence that employees of these insurers had been encouraged and rewarded for terminating policies of people who had serious medical expenses, saving the companies over $300 million (see the performance reviews of these employees here and here, and the complete findings of the hearing here).

The subcommittee also heard testimony from patients and families of patients who had lost insurance coverage after developing serious health problems. Robin Breaton, a nurse from Texas, lost coverage three days before she was meant to undergo a double mastectomy to remove invasive breast cancer. Her insurer, Blue Cross, cancelled her policy after launching an investigation into her medical records and finding a note from her dermatologist that mistakenly noted she could have had a pre-cancerous skin condition. At the hearing, Breaton explained, “The sad thing is, Blue Cross gladly took my high premiums, and the first time I filed a claim and was suspected of having cancer, they searched high and low for a reason to cancel me.”

Losing health insurance, especially while struggling with poor health, can be financially devastating. A new study has found that medical problems contributed at least in part to almost two-thirds (62%) of bankruptcy filings in 2007. Even those with health insurance were not immune to financial losses – over 75% of those in the study had coverage, and 60% had private insurance. Researchers found that illness frequently led to job loss, which in turn led to a loss of insurance coverage. The lead author of the study, Dr. David Himmelstein of Harvard University, explained: “For middle-class Americans, health insurance offers little protection…. Private health insurance is a defective product, akin to an umbrella that melts in the rain.”

California Insurance Commissioner Steve Poizner proposed new regulations that would require application forms to be written in clearer language and include “not sure” options to questions about medical conditions (see full text of the proposed regulations here). Many of the questions in insurance application forms are difficult to understand or intentionally confusing. Under the new regulations, insurers would not be allowed to drop policies if the patient was unaware of, or did not understand, the medical information requested in the application.

More links:

The Health Care Crisis Hits Home

Commentary: Health Care Outrage Goes Uncovered

Consumerist: Insurance Industry Still Wants to Cancel Sick People’s Coverage

Insured but Bankrupted by Health Crises

Airborne: A Journey into the Challenges and Solutions to Stopping MDR-TB and XDR-TB is a powerful new book written by John Donnelly that features interviews and images to put a human face on the TB epidemic across the world. In her foreword, WHO Director-General Margaret Chan wrote, “I urge you to read the personal stories collected in AIRBORNE. These are human tragedies that should never have happened. But these are also stories about the uplifting success possible when the right elements are in place.”

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Australian Abortion-Aid Ban Lifted

A thirteen-year ban in Australia on providing foreign aid for abortions has been lifted and Australia will provide  funding of up to $15 million for reproductive health activities to help reduce maternal deaths across the world.

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$50 Million US Contribution to UNFPA

President Obama has recently signed legislation to provide $50 million to the United Nations Population Fund (UNFPA) to improve the health of women and children and reduce poverty throughout the world.

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US Capital Blighted by HIV/AIDS

The U.S. Capital has an HIV/AIDS rate on par with or worse than some African nations the city’s health department reports.

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US Urged to Fix Iraqi Refugee ‘Mess’ It Created

As the Iraq war enters its 7th year, the United States is urged to provide aid to Iraqi refugees displaced by the fighting.

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In Reversal, US to Engage with Human Rights Council

President Obama’s decision to become actively involved in the U.N. Human Rights Council raises hope that the administration will take a multilateral, human rights approach to international diplomacy.

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Living in a Sea of Mud and Drowning in Dread

Hurricane season has left Haitians to navigate mud-covered towns; without clear evacuation and reconstruction plans, Haitians fear an even worse situation this year.

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Chad: Fighting Violence Against Women — But How?

Violence against women is endemic in Chad, where in December dozens of women took part in a protest march against the legal gaps and cultural norms that allow for rampant domestic violence, sexual abuse, and underage marriages.

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In Iraq, A Story of Rape, Shame and ‘Honor Killing’

Killing of a pregnant rape victim by her brother reveals the terrible frequency of ‘honor killings’ in Iraq.

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Mentally Ill and in Immigration Limbo

Xiu Ping Jiang, an illegal immigrant from China, faces the harrowing choice of deportation  or detention in a facility where she has, allegedly, received inadequate care for her mental condition.

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Women’s Health Insurance Fairness Act

U.S. Senator John Kerry has introduced a bill that would prohibit health insurance companies from charging women higher premiums and from discriminating against women based on whether they are pregnant.

Mother and Child in Bolivia

According to the World Health Organization (WHO), if you are a young Bolivian, you have a 6 percent chance of dying before your fifth birthday. Diarrhea and malnutrition, conditions rooted in poverty, are the leading causes of child mortality in the South American country. Against this background, a UNICEF-funded government health insurance plan will allow doctors to provide unrestricted care to children under the age of five as well as pregnant women. Bolivia’s health services still have much work to do to ameliorate the underlying causes of childhood diseases. UNICEF estimates that 2.5 million Bolivian children are living in poverty, leading to the compounded problem of chronic malnutrition.

While the UNICEF program, which covers the costs of the medical treatment of children, is an important step in making care readily available to Bolivians, the government still needs to reach out to the destitute rural and indigenous populations. Prohibitive distance and cost are not the only factors that separate these Bolivians from medical professionals. The systemic degradation of trust may stem from a communication barrier: Many doctors and nurses do not speak Quechua or Aymara (indigenous Bolivian languages). Cultural traditions, such as keeping a male child’s umbilical cord long to symbolize masculinity, or the association of white walls, such as those in hospitals, with the burial of babies, exacerbate the already dangerously poor health outcomes for these individuals. UNICEF’s health insurance program, while a critical first step in improving child life expectancy, will be unable to achieve lasting change in the most under-served populations until cultural dynamics, along with endemic poverty and rural inequality, are addressed.

More information on Bolivia below the fold.

WHO: Bolivia

UNICEF: Bolivia

Healthcare in Rural Bolivia