Tag Archives: health reform

Highlights from President Obama’s First State of the Union Address

President Obama delivered his first State of the Union Address last night. The Presidential blog at www.whitehouse.gov/blog has an excellent summary of all the initiatives Obama announced and the entire 90 minute video. The full script is also available at http://www.whitehouse.gov/the-press-office/remarks-president-state-union-address.

I am going to highlight just a few initiatives that are particularly important to me:

  • 3-year federal budget freeze – Beginning in 2011, Obama has called for a 3-year federal budget freeze that applies to everything but defense, Medicare/Medicaid, and Social Security. He claimed that without true health reform, it would be impossible to freeze spending on health.
  • Financial reform package – use the Stimulus bank bailout money that banks are repaying to go towards funding small business loans; create a small business tax credit; eliminate all capital gains taxes on small businesses (the latter 2 received bipartisan clapping while imposing a fee on large banks to repay the stimulus bailout is not supported by republicans)
  • College Financing Reform – this one is big! “To increase college access and completion, the Administration will make student loans more affordable by limiting a borrower’s payments to 10 percent of his/her income and forgives remaining debt after 20 years – 10 years for public service works. We will also make permanent the American Opportunity Tax Credit. The President urges the Senate to pass the American Graduation Initiative, which invests more than $10 billion over the next decade in reforming our nation’s community colleges, promoting college completion, and moving toward the President’s goal of having the highest proportion of college graduates in the world by 2020. The President is also asking colleges and universities to do their share to make college affordable for all Americans cutting their own costs.”
  • Health IT – despite all the political action surrounding health IT right now (and a good amount of talk for and against it), this was not mentioned at all
  • Nuclear Power Plants – FINALLY the government is going to pave the way to open up some more power plants, after a 30-yr hiatus
  • Changing the way the government does business – The administration is going to continue with lobbying reform, increasing government transparency, and creating a public “earmarking” database so that the public can see what budget amounts have been earmarked for certain purposes. To see how serious this administration is about transparency, check out http://www.data.gov. For a very specific example, I have been able to call into every workgroup meeting and download the materials related to the Office of the national Coordinator’s work on meaningful use and the HITECH Act. Here’s the schedule: https://singularityblog.wordpress.com/2010/01/11/upcoming-hit-policy-standards-committees-workgroup-meetings/
Also, a few quotables:
  • And what the American people hope -– what they deserve -– is for all of us, Democrats and Republicans, to work through our differences; to overcome the numbing weight of our politics.  For while the people who sent us here have different backgrounds, different stories, different beliefs, the anxieties they face are the same.
  • It’s because of this spirit -– this great decency and great strength -– that I have never been more hopeful about America’s future than I am tonight. Despite our hardships, our union is strong.  We do not give up.  We do not quit.  We do not allow fear or division to break our spirit.  In this new decade, it’s time the American people get a government that matches their decency; that embodies their strength.
  • To recover the rest, I’ve proposed a fee on the biggest banks. Now, I know Wall Street isn’t keen on this idea.  But if these firms can afford to hand out big bonuses again, they can afford a modest fee to pay back the taxpayers who rescued them in their time of need.
  • Now, let’s clear a few things up. I didn’t choose to tackle this issue to get some legislative victory under my belt.  And by now it should be fairly obvious that I didn’t take on health care because it was good politics. I took on health care because of the stories I’ve heard from Americans with preexisting conditions whose lives depend on getting coverage; patients who’ve been denied coverage; families –- even those with insurance -– who are just one illness away from financial ruin. After nearly a century of trying — Democratic administrations, Republican administrations — we are closer than ever to bringing more security to the lives of so many Americans…Here’s what I ask Congress, though:  Don’t walk away from reform.  Not now.  Not when we are so close.  Let us find a way to come together and finish the job for the American people.  Let’s get it done.
  • for the first time in history –- my administration posts on our White House visitors online.  That’s why we’ve excluded lobbyists from policymaking jobs, or seats on federal boards and commissions.But we can’t stop there.  It’s time to require lobbyists to disclose each contact they make on behalf of a client with my administration or with Congress.  It’s time to put strict limits on the contributions that lobbyists give to candidates for federal office. With all due deference to separation of powers, last week the Supreme Court reversed a century of law that I believe will open the floodgates for special interests –- including foreign corporations –- to spend without limit in our elections. I don’t think American elections should be bankrolled by America’s most powerful interests, or worse, by foreign entities.  They should be decided by the American people.  And I’d urge Democrats and Republicans to pass a bill that helps to correct some of these problems.
  • In the end, it’s our ideals, our values that built America — values that allowed us to forge a nation made up of immigrants from every corner of the globe; values that drive our citizens still. Every day, Americans meet their responsibilities to their families and their employers. Time and again, they lend a hand to their neighbors and give back to their country. They take pride in their labor, and are generous in spirit. These aren’t Republican values or Democratic values that they’re living by; business values or labor values. They’re American values.

Public Health Experts Need to Reclaim the Phrase “Preventive Medicine”

“Preventive medicine” is a hot phrase in discussions of health reform. If we just get more people (why not everyone!) screened we can find disease early and save money by attacking these diseases before they become serious and expensive.

But this use of  ‘prevention’ is expensive. Or said another way: There’s a lot of money to be made in this kind of ‘prevention’.

True preventive medicine prevents disease: Reducing airborne particulate matter and pollution prevents incidence of asthma. Funding schools to provide healthy meals prevents childhood obesity. Eliminating the use of lead in paint prevents abnormal development in exposed children.

We must recognize that health screening technologies are not tools to prevent disease; rather, they are tools of early detection of disease. In a sense they define disease. Indeed as screening tools increase in specificity, the thresholds in defining disease status follow in their specificity. Certainly, early detection may give the upper hand to the patient and provider who can implement treatments that reduce the likelihood of that condition becoming life-threatening. But do all abnormalities warrant medical intervention?

Screening technologies such as MRIs are become increasingly sensitive to discovery. In his book How Doctors Think, Jerome Groopman, M.D., cites a physician: “The hateful part of MRIs – I mean they can be a wonderful technology – but they find abnormalities in everybody.” No doubt, part of the rise in the number of chronic conditions can be attributed to our increased ability to find abnormalities, even though not all abnormalities may warrant a medicinal response.

Screening tools do not and cannot prevent abnormalities. They can only find abnormalities.

The primary driver of health care costs is medical technology. Earlier detection coupled with expensive (yet often unproven) interventions have reduced mortality while increasing morbidity. Indeed, many diseases which even 15 years ago would have been a death sentence have now become manageable chronic conditions (HIV/AIDS is an obvious example). This is a testament to our ability to innovate and develop life saving technologies.

Simultaneously, technology has improved our ability to detect ‘disease’ while ensuring chronic care management through pharmaceuticals and/or invasive intervention through biopsies and more. Today, more than half of all Medicare beneficiaries have more than 5 chronic conditions. Soon it will not be uncommon for the bulk of Medicare beneficiaries to have eight or even ten chronic conditions.

One article published in the New England Journal of Medicine notes:

The demands of the public for definitive wellness are colliding with the public’s belief in a diagnostic system that can find only disease. A public in dogged pursuit of the unobtainable, combined with clinicians whose tools are powerful enough to find very small lesions, is a setup for diagnostic excess… Clinical medicine can only say, “With the methods we used, we found none of the diseases we looked for.” No one can measure the absence of all disease. (emphasis mine)

The unfortunate reality is that it is possible to over ‘prevent’ (to use the expensive version of the word). What is needed is not a halt on innovation nor a moratorium on technology. Rather what is needed is a conscious assessment as to when to screen and when treatment is necessary.

The decision as to when to do what should be made between physician and patient, but information is needed to build suggestive guidelines. Health IT, allowing for the aggregation of (anonymous) data, can help.