Monday, January 11, 2010

Turning health into a zero sum game in Britain

Health is an area where the gains of one would not normally come at the detriment of others. If one person is cured, it does not usually involve another person becoming ill. As society becomes wealthier and better educated, most of its members ought to have access to better health and greater longevity, without impeding the ability of others to do likewise.

Alas, the NHS has changed that. Given its universal provision and its necessarily finite resources, decisions have to be made about which treatments and procedures can be afforded and which cannot. In a recent case a leukemia sufferer was denied access to a possibly life-prolonging drug because the NHS regarded the £30,000 a year cost as an ineffective use of resources, given likely clinical outcomes.

The point is that within a closed system of finite resources, each treatment has to be assessed to see if it is worth denying funding to other treatments in order to supply it. Television reporters interview someone demanding extraordinary (and very costly) treatments for their brain-damaged premature baby, without ever alluding to the brutal fact that others must die if it is to be kept alive. In the NHS people have to ask if that extended life is worth more than the ten kidney patients who might otherwise have been saved. They have to ask if a drug which might offer a few extra years to one patient is worth the suffering to dozens of elderly patients who will not receive their hip replacements if the money is spent elsewhere.

The NHS has turned health into a zero sum game, in which the survival of some takes place at the expense of the death or suffering of others. The QALY, or quality-adjusted life year, was devised to facilitate these complex, and some would say repugnant, calculations. Many people also blanch at the way the NHS can withdraw all treatment if people obtain privately the drugs the NHS has refused to allocate to them. Gods might behave like this, but men and women shouldn't.

There has to be a better way, and it might involve encouraging charities and communities to rally round people who lose out on NHS allocations, and raise extra funds to support them. That breaks out of the fixed pie of the zero sum game, and brings in additional resources instead of taking them at the expense of others.


New breast cancer error disclosed in Britain

The number of women wrongly given the all clear for breast cancer at a hospital in Lancashire has risen. Accrington Victoria Community Hospital, which gave the all-clear to 18 women with breast cancer after screening errors, has now admitted another case was missed. In September it was revealed the women had been misdiagnosed by a radiologist at the hospital. But the BBC has now learnt that another woman, Susan Gilmore, was also called back and later had a mastectomy.

East Lancashire Hospitals NHS Trust has admitted she is the 19th woman who was misdiagnosed and has apologised, the BBC said.

Mrs Gilmore, from Earby in Barnoldswick, Lancashire, was given the all-clear by the same radiologist at the hospital in 2002 and 2005, outside of the period under review. She found out that she had the disease after being recalled for a third time in December 2008 to a different consultant. "It was only after I read about it, because I wasn't one of the 18 who were [originally] recalled," she told the BBC's Inside Out North West programme, to be screened in the North West region on Monday. "Once I'd read those reports I started to mull things over in my mind and thought, it's going to be this man, it's going to be this same consultant who sent me home twice."

The original blunder came to light through internal monitoring in the screening service which sparked an independent investigation, revealed in September 2009. Of the 355 cases reviewed in the study, 85 women were retested and 14 were diagnosed with invasive breast cancer. A further four had a non-invasive cancer which had not progressed. The radiologist involved last screened patients in December 2008 and has been suspended since April 2009.

Dr Richard Dobrashian, director of the East Lancashire breast screening programme, said: "We have now included Mrs Gilmore in the reviewed ladies so the 18 has become 19 in the misdiagnosis by this particular radiologist."

Seven of the women who were wrongly given the all-clear have instructed solicitors to fight for compensation.


GOP seeks converts on health care

Slim margins spark strategy

Democratic Sen. Ben Nelson thought he'd struck a deal that would please Nebraskans and give him cover for helping push his party's health care overhaul over its biggest hurdle to date. But his state's voters still don't like the bill and are embarrassed by the $100 million in special Medicaid payments he secured for Nebraska, leaving the embattled senator with a bigger bull's-eye on his back as Republicans and groups that oppose the overhaul search for converts.

Senate Democrats need to keep all 60 members of their caucus on board to pass a bill. House Democrats had a slim three-vote margin for their health care bill, turning every lawmaker into a potential make-or-break vote and spotlighting a list of potential defectors.

California Gov. Arnold Schwarzenegger, a Republican, upped the pressure last week in his state of the state address. He told California's congressional delegation to secure "the same sweetheart deal" on Medicaid as Mr. Nelson got for Nebraska, or else vote against the bill. "Health care reform, which started as noble and needed legislation, has become a trough of bribes, deals and loopholes," the governor said. "You've heard of the bridge to nowhere. Well, this is health care to nowhere."

In the House, which will resume work Tuesday, Republicans have listed 37 Democrats who they think are vulnerable to political pressure on the issues of Medicare funding, abortion and the federal budget. The list includes several Democrats in moderate districts who could face difficult re-election fights.

"If we can convince enough of these 37 members (along with the 39 Democrats who already voted no) to reconsider and switch their position on the bill, I know that we can defeat this government takeover of our health care before it becomes law," Minority Whip Rep. Eric Cantor of Virginia said in a memo to Republicans. He listed 18 Democrats who have a significant number of constituents enrolled in Medicare Advantage, whose funding would be cut under Democrats' plans. Mr. Cantor also pointed to 11 Democrats who he said might be forced to vote against the bill if a pro-life amendment that the House adopted is weakened in a final compromise.

If three Democrats switch their position, the bill will be defeated. The National Republican Congressional Committee has started targeting many of their districts with analyses showing how the bill would hurt their constituents.

House Democratic leaders are trying to hold together at least 218 votes, despite disagreement over how to pay for the bill. They largely oppose the Senate's method, backed by President Obama, that would tax high-valued insurance plans.

More here

Government health insurance option appears doomed

Senior House Democrats have largely abandoned hopes of including a government-run insurance option in the final compromise health care bill taking shape, according to several officials, and are pushing for other measures to rein in private insurers.

House Speaker Nancy Pelosi and other senior Democrats told President Barack Obama in recent meetings they want the legislation to strip the insurance industry of a long-standing exemption from federal antitrust laws, officials said. That provision is in the House-passed measure, but was omitted from the bill that the Senate passed on Christmas Eve.

They also want the final measure to include a House-passed proposal for a nationwide insurance exchange, to be regulated by the federal government, where consumers could shop for private coverage. The Senate bill calls for a state-based system of exchanges.

Additionally, House Democrats want to require insurers to spend a minimum amount of premium income on benefits, thereby limiting what is available for salaries, bonuses, advertising and other items. The House bill sets the floor at 85 percent; the Senate-passed measure lowers it to 80 percent for policies sold to small groups and individuals. The officials spoke on condition of anonymity because the negotiations are private.

The maneuvering comes as the White House and majority Democrats intensify efforts to agree on a final measure, possibly before Obama delivers his State of the Union address late this month or early in February.

Government intervention into the insurance market is one of the most contentious issues to be settled. Others include the fate of a Senate-passed tax on high-cost insurance plans, bitterly opposed by some labor unions; the extent to which abortions could be covered by insurance to be sold in the new exchanges; and the amount of money available to help lower-income families purchase coverage.

Liberals long have pressed to include a government-run insurance option in the legislation, arguing it would create competition for private companies and place a brake on costs. House Democrats included it in their legislation. In the Senate, it drew opposition from Democratic moderates whose votes are essential to the bill's fate. Even attempts to include an expansion of Medicare for uninsured individuals as young as age 55 _ widely viewed as a face-saving proposal for liberals _ had to be jettisoned.

Given the opposition in the Senate, Pelosi, D-Calif., signaled late last year she did not view a public option as a requirement for a final compromise. Asked in an interview Dec. 16 whether she could support legislation without it, she said, "It depends what else is in the bill." More recently, she listed her goals for a House-Senate compromise without mentioning the provision she long has backed.

"We are optimistic that there is much that we have in common in both of our bills and that we will resolve or reconcile this legislation in a way that is a triple A rating: affordability for the middle class, accountability for the insurance companies, and accessibility to many more people in our country to quality, affordable health care," she said.

While Obama favors a government option, he has said repeatedly it is only a small part of his overall effort to remake the health care system, and is not essential.

Pelosi and Senate Majority Leader Harry Reid, D-Nev., have expressed optimism about chances for a swift agreement, but there appears to be relatively little maneuvering room. That is particularly true in the Senate, where 60 votes will be needed to overcome a Republican filibuster, and any change carries the risk of alienating a Democrat whose vote is crucial.

The bill's future is further complicated by a scheduled Jan. 19 election in Massachusetts. Some polls show Democrat Martha Coakley in a closer-than-expected race against Republican Scott Brown and an independent contender. The winner will replace Sen. Paul Kirk, who became the 60th member of the Democratic caucus when he was named to his seat as successor to the late Sen. Edward M. Kennedy. A Republican upset would deprive Democrats of their 60th vote.

Some House Democrats say the proposed government insurance option remains alive, although they speak publicly of its possible demise as long as insurance companies aren't let off the hook. California Rep. Xavier Becerra, who's on the leadership team, said House members would only be willing to abandon the public plan if they were certain the final bill achieves the goals they want, as Pelosi described. "We're willing to give up what's good for America as long as we get something good back," he said.

Rep. Chris Van Hollen of Maryland, also a member of the leadership, agreed. "I think the House is very much of a view that before they'd consider dropping the public option" they have to be assured of a bill that achieves the goals they wanted the public option to meet.

But officials said little if any time has been spent in White House meetings on the issue, and there was scant discussion of it during a conference call for members of the Democratic rank and file earlier this week.


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