The hurting middle class

Who is your neighbor? For most of us, it’s probably someone in the middle class – employed, maybe with a couple of kids and a dog, and increasingly likely to be uninsured or to struggle with paying out-of-pocket health care costs.

The middle class arguably has been squeezed the most by the rising cost of health care, says Jay Kieft.

Kieft, who is the director of Kandiyohi County Family Services, recounts the story of a local family who couldn’t afford employer-sponsored health insurance so they bought cheaper, high-deductible coverage instead. Then one of their children was severely hurt. Swamped by the resulting medical bills, this family ended up losing their home.

If you canvassed your neighborhood, you could probably find similar stories of ordinary people struggling to keep up with their health care expenses, Kieft told an audience today at Bethel Lutheran Church. It was the second in a month-long series of guest speakers on health care reform, organized by Bethel’s social ministries group to invite local conversation on how to fix health care.

There was so much food for thought in Kieft’s presentation that it would be impossible to cover it all. So instead I’ll share some of the highlights:

- There’s a safety net for the poorest of the poor, but the middle class – those earning a gross annual income of $44,000 to $88,000 – can generally expect little if any help paying for their health care coverage or health care expenses. Virtually none of them are eligible for assistance if they turn down employer-sponsored coverage because they can’t afford the premium.

For more context, consider this: Two-thirds of all jobs in Kandiyohi County pay less than $15 an hour. Health care premiums are rising at a faster rate than wages.

- The middle class is becoming uninsured at an accelerated rate. This report by the Kaiser Family Foundation found that nearly 25 percent of the non-elderly uninsured in the U.S. are from middle-class households. "To me that’s kind of an appalling number," Kieft said. "Where are their supports? How are they making up for the loss of health insurance?"

- As employers opt for higher deductibles and co-payments to rein in the cost of providing health coverage for their workers, how much of this burden can middle-class employees be expected to assume? Many working-age households are spending a growing proportion of their income on health care needs, especially if they are chronically ill.

- A growing number of people are skipping or postponing needed care because of the cost, Kieft said. When he asked for a show of hands on how many people in the Bethel audience had ever done this or knew of someone else who had, some hands were raised. "This is the United States of America. This is hard for me to accept," Kieft commented.

- Can we accomplish health care reform by tinkering at the margins rather than seeking wholesale change? Kieft’s opinion: Probably not. "It needs to be reform. It can’t be just a tweak here and a tweak there. We can’t complacently accept the status quo," he said.

- American attitudes about the health care system also need to change. People need to take some responsibility for the decisions they make, and not expect to pick and choose "like they’re in Wal-Mart," Kieft said. "We’ve got to examine that attitude if we want health care reform to work."

The next event in the Bethel series is at noon Wednesday, Aug. 19. It will feature Chris Conry of Health Care for America Now, with an overview of the health care reform bills under consideration by Congress. The last speaker on Aug. 26 will be Gary McDowell, administrator of Family Practice Medical Center in Willmar, on what this local clinic is doing to meet the challenges of the current health care environment.

Health care journalism: An endangered species?

A critique of the health care coverage on the morning shows at the major networks has generated considerable buzz this past week.

Gary Schwitzer, a professor at the University of Minnesota School of Journalism and Mass Communication and publisher of HealthNewsReview, gave ABC, CBS and NBC a failing grade and concluded the morning health news "may be harmful to your health":

One picture is quite clear. The morning health news segments on ABC, CBS and NBC do the following regularly:

- Unquestioningly promote new drugs and new technologies.

- Feed the "worried well" by raising unrealistic expectations of unproven technologies that may do more harm than good.

- Fail to ask tough questions.

- Make any discussion of health care reform that much more difficult.

Professor Schwitzer provides more than a dozen examples of specific stories, ranging from weight loss to heart disease, that are one-sided, short on data and hype the "gee-whiz" factor at the expense of solid information.

I’d agree the media needs to take a good share of the responsibility for unrealistic consumer demands, false hopes and a high use of tests, technology and prescription drugs that drive up costs and might not be medically justified.

From my perspective, however, there’s an even bigger issue the HealthNewsReview critique more or less glosses over: The dwindling newsroom resources for covering health care, period. It’s no secret the news industry is under a tremendous amount of strain right now. When a newspaper like the Boston Globe – home of Harvard Medical School, Massachusetts General Hospital and Beth Israel Deaconess Medical Center – axes its weekly health and science section, you know the situation is serious.

I’d argue it’s even worse at the small community newspapers that are the backbone of the American news industry. Newsrooms at these papers have always been relatively small. Few of their reporters have ever had the luxury of devoting themselves full time to covering health care; they’re busy covering other things as well.

Health care reporting is more challenging than most. It’s about science. It’s about technology. It’s about statistics. It’s about institutions. It’s about people. It’s about community dynamics and relationships. Covering it is like climbing a series of mountains with no end in sight.

I’ve been fortunate enough to work in a community where there’s always a lot happening in health care. Folks in health care here have been incredibly generous with their time (they even return phone calls) and their willingness to share what they know. But the learning curve is steep, and I feel humbled and stupid on almost a daily basis.

It shouldn’t be surprising, then, that health care journalism is ailing so badly. Many newsrooms simply don’t have the time or the staff to invest in covering health care at the level it deserves. I don’t see this changing dramatically any time soon.

We here in rural Minnesota ought to be especially concerned. There are compelling stories about rural and local health care that need to be told. Rural health care is not the same as health care in cities and suburbs. The market is different; the community and institutional dynamics are different. We can’t rely on the state’s largest newspapers to provide the coverage. For one thing, they have their own news to cover; for another, they’re not vested in rural health in the same way that rural readers and rural communities are.

Who’s going to tell the health care stories in rural communities? It’s a question that leaves me deeply worried.

Death, politics and denial

Somewhere near the middle of the 1,018-page health care reform bill is a provision that would entitle seniors to Medicare coverage for an end-of-life consultation every five years – or more often if their health condition changes.

This relatively obscure and minor portion of the bill has ignited a firestorm of debate about government intrusion and the slippery slope toward euthanasia. In the past couple of weeks the public discussion has practically exploded over this one issue.

Here’s Catholic Online:

Will this National “Health Care” Plan encourage our elderly to take their own lives rather than somehow become a “drain” on the rest of us? Will it withhold medical care from them based upon a bureaucrat’s decision regarding so called “quality of life” issues? Will it encourage the rationing of medical services? Will it counsel the withdrawal of nutrition and hydration in order to expedite their death? In short, is Euthanasia included in this National “Health Care” Reform? The more I have looked at the proposals, the more it seems not only possible but probable.

Chain e-mails are making the rounds, warning that seniors will be browbeaten into suicide for the sake of saving Medicare dollars. Watchblog calls it a mandate that “would make George Washington throw up in his grave.”

But here’s the thing: None of it is true.

FactCheck.org did the research and concluded that “the claim that the House health care bill pushes suicide is nonsense.” Snopes.com, one of the leading debunkers of urban myths, came to the same conclusion. AARP leaders were so concerned about the disinformation that’s being spread that they felt compelled to issue a news release, calling for an end to the scare tactics.

What’s apparently going on is a whole lot of political maneuvering. I’ll leave it to others to explain in more detail and move on to the real issue here: Since when have we as a society become so averse to death that we can’t even discuss it without having it turn into a moral showdown?

Most of us, if we really thought about it, would like to have at least some control over how we die. Most of us don’t want a death that’s prolonged or agonizing. We’d like to be able to die at home, if possible, surrounded by family and loved ones.

But there seems to be a huge barrier to actually talking about it. Although laws recognizing the validity of health care directives have been on the books for almost 20 years, the majority of Americans don’t have a health care directive. According to this source, fewer than 30 percent of us have completed a health care directive or living will. Conversations about when to bring in the hospice team are still difficult to have, and all too often these conversations don’t take place soon enough.

Dr. Drew Rosielle, who co-blogs at the Pallimed hospice and palliative care blog, ponders what the current political tempest is telling us about our collective beliefs about death and dying:

… these people make these claims in part because they believe they will have traction with some of the public and should give us pause as a community to acknowledge that this speaks to some portion of the public, and thus our patients. And as better end-of-life care and palliative care are being put out there as potential solutions (in part) to the U.S. health care crisis, this is likely to escalate. Anytime it’s pointed out that “palliative care” (or discussing end-of-life options) saves money, that is going to be sufficient for some to conclude that this is a government conspiracy to euthanize people with disabilities and deny Grandma dialysis because she’s 80.

We need to talk about it anyway, Rosielle says, urging hospice and palliative care providers to “Be Out, Be Proud, Superb End-of-Life Care for All, No Apologies!” He writes:

What we do helps people, tremendously, and it’s what most want (when it’s time), and the fact that it probably saves Medicare a few bucks should be seen as good news by everyone.

Good news too if the political debate causes a few more Americans to stop and examine why we are often so intent on denying the death that inevitably comes to all of us.

No health care reform for you!

Sooner or later, I suppose, it was bound to enter the conversation. And here it is, what physician/writer/blogger Dr. Edwin Leap calls "the elephant in the room": Some people don’t deserve health care reform.

His take:

The "elephant in the room" is that some patients (rich and poor alike) do nothing to care for themselves, take no responsibility for their well-being, are never accountable for their actions and will happily bleed any system dry, public or private.

These folks don’t listen, won’t listen and are proud of it.

Dr. Leap’s conclusion is that we need to "address the morality of giving more of our tax dollars, with no personal expectations, to those who already cost us so very much."

If you read physician blogs on any regular basis, you’ll know there’s often tremendous frustration – anger, even – over patients who can’t or won’t be a partner in their own health. It seems to be especially strong among emergency-room physicians, who deal with the poor, the unfortunate, the unlucky and the unwise on a daily basis.

I could argue that this perception is skewed by the fact that doctors tend to see patients at their worst or at their most vulnerable. I could argue with the absolutes expressed by Dr. Leap – doing "nothing" to care for themselves, "never" being accountable, taking "no responsibility." There’s really no such thing as never, and blanket statements like these should sound the alarm on our collective exaggerationometer. I could even argue that these sentiments go completely against the ethos of the medical profession and its oath to care for patients.

I’m not going to argue, though, because for once I really don’t know what to say. The idea of imposing some kind of merit system on who’s worthy to receive health care and who isn’t pretty much renders me speechless.

How would you even decide this? We all have moments when we maybe don’t deserve health care, but that doesn’t make us need it any less. Do we shut people out of the system and tell them, "No soup for you!" because they can’t or won’t measure up to the right expectations? What’s going to happen to these people? What kind of health care system would this look like?

I’ll say it again: I don’t know what to say.

Class of 2013

First-year students entering the University of Minnesota Medical School will undergo a rite of passage Friday at the annual white coat ceremony. It’ll be held at Northrop Auditorium on the university campus, followed by a reception for the students, their families and friends.

What’s the significance of the white coat? Until the late 1800s, physicians wore black, which was considered formal dress suitable for the seriousness of the doctor-patient encounter. But as science invaded medicine and the role of germs in transmitting disease became more clearly understood, white came to symbolize cleanliness and medical authority. (As it turns out, white coats aren’t so clean after all, and some medical organizations have decided to ban them – but that’s another story altogether.)

There’s an interesting account here that explains the meaning of the white coat ceremony:

… Students beginning their studies in medical school see their education and role as future physicians as aspiring to be worthy of the long white coat. Medical school must give students the scientific and clinical tools to become doctors. Just as importantly, the white coat symbolizes the other critical part of students’ medical education, a standard of professionalism and caring and emblem of the trust they must earn from patients.

A few tidbits about the U of M’s medical class of 2013: There are 170 students. Seventy-two percent of them are from Minnesota. There are six international students, one each from Canada, Mauritius, Nigeria, Vietnam and Zimbabwe.

Slightly more than half the class, 54.1 percent, are male; 45.9 percent are female. Their average undergraduate GPA is 3.74.

They have four long, hard years ahead of them. Let’s wish them well.

Health care reform: Local perspectives I

How do we fix health care? This question is being asked by a lot of people right now, with no clear answers.

An equally critical question, however, is why we would need health care reform. It’s an issue that is being increasingly obscured by politicking, arguing and ideology, but it was brought back into focus during the opening session today in a series of talks on health care reform, hosted by Bethel Lutheran Church.

(That’s guest speaker Ann Stehn, director of Kandiyohi County Public Health, at the far left in the photo, visiting with some of the attendees.)

Andrea Carruthers, of the social ministries committee at Bethel, said the speaker series is an opportunity for the public to "read, listen and discuss" about one of the most pressing issues in the U.S. right now. And, we’d add, a valuable chance to hear some facts and to get away from the heated rhetoric that’s dominating the blogosphere, the airwaves and just about everywhere else.

So, why do we need health care reform? For one thing, current costs are rising at a pace that’s unsustainable. From 1980 to 2004, per-capita spending on health care in the U.S. rose more steeply than in any other country. Despite all this spending, U.S. citizens aren’t any healthier nor does the American health system perform any better than those in other nations.

Minnesota generally ranks as one of the healthiest states, but health care spending is climbing sharply here as well, and is growing faster than income and inflation. The average family is now spending more than $13,000 a year on health insurance premiums. Meanwhile, the numbers of uninsured are growing and fewer Minnesotans are covered by group or employer-sponsored insurance.

Some more facts shared by Ann Stehn: The vast majority of health care dollars in the United States are spent on direct care such as hospital stays, prescription drugs and physician visits. Yet medical care accounts for only about 10 percent of our individual health status; 40 percent is influenced by lifestyle/behavior, 30 percent by genetics, and the balance by environmental and socioeconomic factors.

The message that resonated the most with me is that individuals and communities aren’t entirely powerless. Said Stehn: "We can make progress on these things… It requires us as individuals to make different choices and change our behavior."

About 50 people attended the noon-hour discussion – a good sign of community interest in health care reform. There were also some thought-provoking questions and answers afterwards.

The series continues at noon each Wednesday for the rest of August. The next speaker, on Aug. 12, is Jay Kieft, director of Kandiyohi County Family Services, on "Do you know your neighbor? The middle class and health care." I’ll be blogging it, so check back here next week.

HealthBeat photo by Anne Polta

When the fat lady sings

Why are opera singers fat? Or, rather, why is there such an enduring stereotype of fat opera singers?

I was in the audience at Orchestra Hall Saturday night for the Sommerfest finale, a concert performance (minus the stagecraft) of Verdi’s “Aida.” Not all the singers were fat. In fact, they displayed more or less the same range of body types you’d find among the general population: tall, short, slender, average, overweight. None of them looked obese.

Like a lot of myths, the one about fat opera singers is grounded at least partially in reality. Early forms of opera were relatively small-scale productions. By the 1800s, however, composers and opera houses wanted their work to be grand, with singers capable of really belting it out. The larger the singer, or so the theory went, the greater the lung capacity and breath support to enable a show-stopping performance that could be heard all the way back to the last row, especially in an era before sound systems and acoustically designed concert halls.

Dr. Stephen Juan, an anthropologist and advice-meister from Australia, explains some of the thinking behind this belief:

There are several theories attempting to explain why opera singers are often pleasingly plump. One holds that a large amount of fatty tissue surrounding the voice box (larynx) increases its resonance capability and thus produces a more pleasing sound. The amount of this fatty tissue varies from singer to singer. It is almost impossible to have a great deal of fatty tissue around the voice box without carrying a great deal of fatty tissue elsewhere on the body.

A second theory holds that opera singers need a far more powerful diaphragm than normal to be able to project their voice above the sound of a large orchestra in a large opera house. A large chest cavity and good control of the lungs will provide a suitable mass to help drive the diaphragm to some extent. A large body mass and a large body frame to support it help even more, so there is a huge advantage in being huge.

There doesn’t appear to be any scientific evidence to support any of these theories. One intriguing study, published in 2001 in the Journal of Voice, suggests that professional opera singers tend to develop a larger-than-average rib cage and hence might look fatter than they actually are.

Busy touring and rehearsal schedules also can wreak havoc with performers’ efforts to maintain a schedule that allows them to exercise and eat well.

These days, though, opera has gone on a diet. Opera companies – and audiences, for that matter – want singers who are svelte. Some singers have even been turned down for a role because they’re deemed too heavy, most famously in the case of Deborah Voigt, who ended up having bariatric surgery to help keep her career on track.

Here’s a singer who blogs about the challenge of keeping her weight down:

Even though I’m producing four operas, running an opera company, working a day job, performing, auditioning, trying to manage my weight, about to have a birthday, and trying to survive day to day, I’ve also been dealing with other outside factors that involve people I love and trying to help them with their struggles. I think I’m pretty much at my breaking point.

In other words, opera singers are up against many of the same difficulties that everyone else faces. Maybe it’s time for the old stereotypes to make their final curtain call.

Image from the U.S. Library of Congress

Paying for sickness, penalizing for prevention

In case you missed it, the Minneapolis Star Tribune ran a thought-provoking commentary Sunday on how out of whack the Medicare payment system has become.

An excerpt:

Simply put, Medicare pays for putting patients in the hospital but not for keeping them out. So for every (congestive heart failure) patient in the program who avoids a hospital stay, Park Nicollet loses about $4,600.

Talk about rewarding success with punishment. What medical center grappling with this economy can afford to add a program further weakening its institutional bottom line?

Providers call this the "perverse incentive" issue. The goal should be to keep patients healthy. Yet providers are only rewarded when patients get sick enough to come into a clinic or need hospital admission.

The Willmar community received a painful lesson about perverse incentives last year when Rice Memorial Hospital eliminated two outpatient chronic disease management programs, one for diabetes education and the other for congestive heart failure. Both were long-standing programs; the diabetes program had been around since the 1980s. Willmar providers recognized a long time ago that if diabetes and congestive heart failure could be managed more intensively, patients would fare better and would be less likely to experience costly complications or an expensive hospital stay. By all accounts, these were excellent programs that provided a valuable service to patients. More importantly, they resulted in better outcomes.

But they also were money-losers for the hospital. The diabetes program alone lost more than $1 million last year before it was terminated in mid-September. And Medicare isn’t the only culprit here. Many of the private-sector health plans for the younger, working-age population are unwilling to pay for the level of clinical management and patient education it often takes for someone to live well with a chronic disease.

Rice Hospital’s image took a hit for making the tough decision to eliminate services. Patients and the public were upset and unhappy. As harsh as it sounds, however, the financial reality is that a 99-bed community hospital like Rice can’t indefinitely absorb this kind of loss without jeopardizing other services.

Luckily for local patients, Willmar medical providers stepped in to save both programs. The congestive heart failure program is now being offered by Family Practice Medical Center. The diabetes program, now known as the Willmar Diabetes Center, has been taken over by Willmar Medical Services, a joint venture between Affiliated Community Medical Centers and Rice Hospital.

Given how the payment system is misaligned, it frankly took a leap of faith, along with a strong dose of community-mindedness, for these organizations to accept the risk, knowing they might lose money by doing so.

It’s to be hoped that in a different setting, with economies of scale, the diabetes and congestive heart failure programs can keep going. The payment disincentives haven’t gone away, after all. They’ve just been transferred to other organizations who now have the challenge of trying to provide good care for patients – and save money for the health care system overall – without hurting their own bottom  line.

Does any of this make sense? It’s not fair that providers get financially punished for keeping their patients well, yet are rewarded for using costly services when people become sick. It’s not better for patients either, who are paying for this too in the form of higher insurance premiums and higher out-of-pocket expenses.

But until it gets fixed, this is the system we have, perverse incentives and all.