"We need to look at the German health care system!"
The latest scare that health care misers, i.e. conservatives, are circulating is that all of the current medical "entitlements" will soon become insolvent unless a radical change is made so "medical costs drop". And what is the best way to lower medical costs? Well, either by implementing a wider basis for HSAs (health savings accounts, e.g. Scott Atlas, WSJ, June 7 p. A15) or via HRAs or 'Health Reimbursement Accounts' (Laura Sanders, WSJ, Exchange, June 21-22).
In respect of the latter The Wall Street Journal editorial writers are absolutely giddy, writing ('Trump's Healthy Tax Break', July 2, p. A14 ):
"The miracle is that the GOP has managed to find a political winner that doesn't reignite the debate over pre-existing medical conditions. Republicans should spend time from here to 2020 telling voters that one party is thinking with ingenuity about how to expand choice - and another is eliminating every option except government run health care."
But it's hardly a case of "ingenuity" when only the richest or at least the upper 3 percent of income earners will be able to afford this miraculous alternative the WSJ and many others tout.
In regard to the former WSJ piece, for example, we're informed by Dr. Scott Atlas (of the Hoover Institution) that "disclosing prices isn't enough" because patients don't care so long as "it's all covered by insurance". In a sense this is correct, as I learned when I tried to make the case (in a prostate cancer support group) for halting further PSA tests for men in their mid- 70s or beyond. This was based on a UC Berkeley Health notice that found: "The National Comprehensive Cancer Network recommending routine PSA screening for all but very healthy men with a significant life expectancy, who are most likely to benefit from detection of aggressive tumors."
The issue being that given over $2 b is spent each year on the initial PSA testing and followup biopsies, other tests (e.g. MRIs), it's a significant chunk of change. Nearly all the respondents, however, accused me of being a shill for drug or insurance companies. Some of the blowback:
"What are you a politician running for office? An insurance company agent? I am sick of you guys coming in here and trying to tell us to try to control costs and not to get these tests!"
"I'm in no position to contradict medical science on this, but 70-75 seems a bit young. Yes, it leaves a "life expectancy" of 10 years (in 2018, living in the U.S., given today's technology), but healthy people with good genes and healthy lifestyles routinely live well into their 90 "
Of course, the latter guy's claim is wrong as it's now been learned that barely 7 % of longevity is accounted for by "good genes". Anyway, they were going to get their tests come hell or high water, even if it meant ultimately leading to draconian treatments. Usually ADT or androgen deprivation therapy- for which recent stats show more patients die from heart attacks (owing to complications from treatment, upsetting the hormone balance) than the cancer.
Where Atlas is right is that under the current systems - including Medicare - the insurance (i.e. supplemental plans) minimize the patient's share of costs. Hence, most advanced prostate cancer patients won't bother to comparison shop given what ever they need (Lupron, Casodex etc.) will be covered anyway. He has a point in respect of this issue.
Where he is wrong is in claiming that HSAs are the ticket to better medical care for everyone, lower insurance premiums, and better access for all. To make sure we grasp these entities, they are savings vehicles in which the person sets aside money tax-free for health expenses. Atlas' argument is that patients will be more careful in how they use health care if they have to use their own dollars. Else, if insurance companies are the providers, the "consequences are inflated prices, overuse of health care and unrestrained spending."
The problem with his argument is that even most middle class people in this country can't save enough to have viable HSAs. The proof? The Federal Reserve's recent economic survey and analysis which found that up to 40 percent of the putative middle class is unable to save even $400 for an emergency. Raise the amount to $1,000 and the proportion translates to a majority (65%) of citizens.
So let's say a guy gets prostate cancer and needs surgery or radiation therapy. We are looking at an amount in the range from $60,000 - $85,000 to be paid for treatments which means the HSA must have that kind of money to use it. Clearly most middle class folks newly diagnosed with this cancer will be out of luck. They simply won't have the money to cover the expenses of care unless they're in the upper 1-2 percent.
Now, related to the HSA is the HRA being touted by the WSJ in its editorial yesterday as the GOP miracle alternative to the ACA and any other Dem proposal. The HRA stands for the health reimbursement account. and in many ways is similar to the HSA. According to the WSJ Exchange piece cited earlier:
"Beginning Jan. 1, 2020, companies can provide employees with tax free dollars can purchase an individual policy rather than offer a group health plan."
Sounds like a bonanza. Is it? Nope. It's the Trump- GOP' cheapo alternative to the ACA or Obamacare. Or any single payer permutation, including the public option, the Dems might offer. The employer will give you tax free bucks (maybe $400 a month) and you can then use the money to stash until you need medical care. But what if you're faced with the prostate cancer diagnosis mentioned earlier? Well, again, you'll be out of luck if those tax free dollars aren't commensurate with the medical treatment costs. This will be the case if your income is middle class ($50,000- 85,000) as the Fed defines it, or below.
Also, even if you're better off than that, what if employers only raise the HRA payments with inflation (now 2%)? While we know health care costs typically rise faster than inflation. For example, the cryotherapy I received in 2017 which cost $55,000 than - according to the CMS Summary sheets- would cost nearly $75,000 now. That would include the costs of the 3D biopsy, plus the cryo proper and the two anesthesia administrations.
Basically then, what Atlas and the Conservative-Corporate HRA promoters are hawking merely continues a barbaric and regressive health system for most Americans. When the earlier cited WSJ editorial claims "this is good news for workers" - well, yeah, if those workers are earning $100,000 a year and up! Or, as the same editorial admits: "the young and wealthy who don't consume many services." But would any intelligent person really want to roll the dice on that?
Incredibly, it seems to be only nurses who grasp the U.S. health care system is regressive, even at times barbaric and grafting to the point patients consider killing themselves. This as opposed to heaping huge medical bills, debt on their families. Just look at all the Type I diabetics now having to travel to Canada to get their life-saving insulin (say for $100 for a month's supply) instead of shelling out $700-800 a month in the U.S.
Let me, however, agree also that one other area that Atlas is correct is in averring that the "supply of medical providers needs to increase" and vastly! This is just basic math and common sense, which as I will show in a future post, also underlies the housing shortage and crisis. That is, no one seems to be taking into account the exploding population - which has increased in the U.S. by 45 million since 2001. The number of medical care providers, especially RNs - has not kept pace.
Look, if populations are continually growing that logically means sick conditions (as well as serious accidents) and diseases must grow with them. Even the healthiest person following a rigorous diet can get cancer or be injured in an auto accident - and then what? Go into bankruptcy or massive debt after accessing needed care? It is evident we need not only a more rational health care system but also more providers (doctors and RNs) to work within it.
In a recent NY Times account one beheld the vile scope of profit over patient care in full view as told by the caring RNs that oversee such care. For example:
"Renelsa Caudill, a Washington, D.C.-area cardiac nurse, remembers being forced to pull a cardiac patient out of the CT scanner before the procedure was complete. The woman had suffered a heart attack earlier that year and was having chest pains. The doctor wanted the scan to help him decide if she needed a potentially risky catheterization, but the woman’s insurance, inexplicably, had refused to cover the test."
And:
"Karla Diederich, also from California, remembers saying a final goodbye to her friend and fellow intensive care nurse Nelly Yap in their hospital’s parking lot. Ms. Yap was dying of metastatic cancer. She was scheduled for another round of chemotherapy, but the hospital had changed owners while she was on sick leave and she’d lost her job — and insurance — as a result. “Nelly spent most of her life taking care of other people,” Ms. Diederich says. “And when she needed that care herself, it was not there.”
Perhaps that’s because they see so much time and money wasted by the bureaucracy of the current system. By most estimates, the administrative costs of American health care surpass those of any other developed nation. Or maybe it’s because of the innumerable avoidable medical crises they constantly find themselves confronting. Patients go into heart failure because they can’t afford blood pressure medication, or gamble with their diabetes for want of insulin, then turn up in the hospital needing care that’s far more expensive than any preventive measure would have been.
Nurses, who encounter the system daily for years or decades, have hundreds of experiences, and they know better than most how brutally such stories can end. Ms. Diederich, quoted in the Times piece, asserts: “It’s barbaric. Crucial medical decisions are being made by businessmen whose primary goal is to make a profit. Not by medical professionals who are trying to treat their patients.”
It comes as no surprise that both HSAs and HRAs fit into this model. As the author of the WSJ Exchange piece notes in respect to the coming of HRAs in January:
"What's clear about this landmark change is it will make a complicated process more complicated."
And what will be the result of that? Well, what the wonks call "adverse selection". A concept in economics, insurance and risk management describing a situation where buyers and sellers have different information which is known as "asymmetric information."
Thus those who avail themselves of HRAs will possess vastly lower information than the businesses, employers who offer them. The net result? They are bound to lose - in their finances, as well as quality of care.
This elicits the question of whether there is a better, more rational system - say which allows those who wish to keep their private insurance, but also doesn't bankrupt millions who can no longer afford it. The answer, to me, would be the German health care system which has the following key features the Democrats might wish to examine:
-All workers contribute 7.5% of their salary each week which is matched by their employer. The money goes into a public health insurance pool ensuring everyone gets coverage.
- When a German is hospitalized no bill is sent to his -her address afterwards. The money will have already been deducted from the income to over the amount of the procedure will be known beforehand - no surprises (see next item).
- The system imposes strict limits on out-of-pocket costs so there is no such thing as a "surprise" medical bill which seems to be the norm in the U.S.
- Germany regulates drug prices and medical costs through an independent agency. This system applies realistic and rational standards so Germans do not have to choose between buying food, keeping heat on, or buying meds. The independent agency is comprised of doctors, insurance companies, patients and lawmakers. Hence, there is input from all stake holders.
The clueless may well scan the preceding attributes and conclude the system can't be as good as the U.S. hodge-podge, but they'd be totally wrong. As my long time German friend Reinhardt has said: "I would wager we are a much better system than the one Americans have. In fact, if I were in the U.S. I'd likely have been dead years ago because of the unaffordable costs of drugs, treatments." Point taken and WHO and other stats support his claim.
Let's also acknowledge the Germans have the oldest health care system in the world so they must be doing something right. The U.S. - both sides, red and blue- could learn from it. And look, anything we find has to be better than the HRAs pushed by the finance and 'zero government' input mavens.
See also:
And:
by Dr. Sanjeev K. Sriram | June 13, 2019 - 6:16am
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And:
Barbara Ehrenreich is trying to get more oldsters to just accept death instead of getting more and more screening tests in old age which often pave the way for treatments that can have more dire consequences than the disease they're designed to control.
Jeez, I don't know. I did my best some two weeks ago to convince oldsters in a prostate cancer forum (Team Inspire) to stop getting PSA screening tests, and they greeted me like I had the plague. What the hell gives? All I was trying to do is get the nation's medical costs down and we know geezers use up more expensive medical care than any other demographic, up to $500m / yr. of which $150 million is spent in the final month of life. Consider: In the 10 years since the financial crisis that works out to a total of $1.5 billion spent in the final month of life.
Why not just be done with that crap and as Barbara Ehrenreich puts it (The Nation, 'The Great Equalizer', October, p. 32):
"No matter how much effort we expend, not everything is potentially within our control, not even our own bodies and minds. In death we will once again be equals - and so an egalitarian politics also means accepting this outcome.
You can think of death bitterly or with resignation, as a tragic interruption of your life, and take every possible means to postpone it. Or, more realistically, you can think of life as an interruption of an eternity of personal nonexistence, and seize it as a brief opportunity to observe and interact with the living, ever surprising world around us."
Of course, most Americans are squeamish in terms of death - even discussing it, tending toward euphemisms- and more likely to buy into the codswallop of the longevity researchers. That would be a clique of life extension quacks and fanatics (many of whom have M.D. or Ph.D. behind their names) who believe many of us could even live to 142, e.g.
http://brane-space.blogspot.com/2015/03/no-this-baby-wont-be-living-to-142.html
Ehrenreich herself got her wake up call in the course of writing her last book, 'Bright -Sided' in which she used her own breast cancer diagnosis as the basis for a striking critique of the whole "positive thinking" twaddle. In this case, puncturing the trope that people with cancer (like me, prostate cancer) are most likely to survive if they keep thinking optimistically about recovery.
Then in her latest book; 'Natural Causes: An Epidemic Of Wellness, The Certainty Of Dying, And Killing Ourselves to Live Longer' , she blows the lid off - revealing the body's macrophages as the ultimate 3rd column enemy. While in normal conditions they are the body's 'blue collar workers' - disposing of dead and injured cells, acting as a vanguard of defense, they can also quickly deviate into a more sinister role - as when they aid and abet cancerous growth. In that case, "they serve as cheerleaders of death accumulating at the site of cancerous tumors and encouraging their growth".
Beyond a certain age, in fact, the battle against mortality becomes essentially futile. In the case of prostate cancer it arrives with what's called "castration resistance". That is, despite the fact testosterone levels have plummeted from hormone therapy, the PSA continues to rise. No further PSA testing will provide any useful info, say to save your life. (One of the reasons for this resistance is that prostate cancer cells are capable of making their own testosterone, hence driving prostate specific antigens higher. Macrophages in action!)
As the latest AARP Bulletin notes ('Should I Get Tested?', November, p. 21), citing research by Kenneth Lin, M.D., based at Georgetown Medical Center:
"No study has shown a decrease in overall mortality with PSA screening for men of any age".
In other words, in terms of the statistical data applied to a vast population of men spanning the age spectrum (of whom 1 of 6 get prostate cancer), the PSA test doesn't make a dime's worth of difference. I take that back, it makes a lot of money for the urologists and testing labs (est. $760m a year, according to one research report on controlling costs for these tests)
Besides which (ibid.):
"The screened groups had much higher rates of complications, including impotence and incontinence. Indeed, the chief sponsors of PSA testing are diaper manufacturers."
(Aside: Of course the preceding presumes one acts on the screening result. Also, at least one PSA test ought to be taken by every guy 50 or older to at least get a baseline for future reference. My arguments here mainly apply to 70 or over guys who get screening tests 2 or more times a year - often paving the way for more severe treatments, with more complications - e.g. urinary stricture, fistula etc.)
With this info in hand from a separate source- an email from the UC Berkeley (n a Cancer Health Alert) I posted the following to the 'Team Inspire' Prostate Cancer Forum under the header: "Stopping PSA Tests After Age 70":
"Most experts agree that people with a life expectancy of 10 years or less don't need routine screening for cancer. One problem is that overscreening can lead to overdiagnosis and overtreatment. For instance, a screening might find a slow-growing cancer that wouldn't cause any harm within a person's lifetime if left undetected, a situation that's common with prostate cancer. If that's the case, it's not worth the burden and anxiety caused by testing and the potential for more—possibly invasive—follow-up procedures.
Yet, according to published studies, too many older adults continue to undergo unnecessary cancer screenings despite age- and health-related recommendations from professional groups.
Three groups that have weighed in on prostate cancer screening are the National Comprehensive Cancer Network (NCCN), the United States Preventive Services Task Force (USPSTF), and the American Urological Association (AUA). Following are their current recommendations for when to stop:
•The NCCN recommends ending routine PSA screening at age 75 for all but very healthy men with a significant life expectancy, who are most likely to benefit from detection of aggressive tumors.
•The USPSTF discourages men 70 and older from undergoing prostate cancer screening.
•The AUA recommends against screening men who are 70 and older. However, it notes that men of that age who are in excellent health and have a life expectancy of at least 10 years may benefit from the test.
Other professional organizations have also issued guidance on PSA screening. Clearly, there are no hard-and-fast rules. You and your doctor can use the screening recommendations as a guide, but the decision should be tailored to your overall health, personal preferences, and personal values."
The responses were fairly immediate and included such choice rejoinders as:
"What are you a politician running for office? An insurance company agent? I am sick of you guys coming in here and trying to tell us to try to control costs and not to get these tests! I don't care how much they cost, even if I'm 78 I am gonna get them! Maybe I want to live to 95!"
"I'm in no position to contradict medical science on this, but 70 seems a bit young. Yes, it leaves a "life expectancy" of 10 years (in 2018, living in the U.S., given today's technology), but healthy people with good genes and healthy lifestyles routinely live well into their 90s. My G4+5 was discovered when I was 59. What if it had been 12 years later? Answer: a horrible death from PCa, diagnosed only after I became symptomatic, and far too late to treat it."
"I'm in favor of knowing what's going on if there's a good chance that making a decision based on that knowledge could make an important, positive difference. "
"Of course, I'm not in favor of overtreatment, especially of PCa because of the horrific effects on patients' QoL. To me, it's bizarre that something like ADT exists in the world; it's almost as if it's from the 16th Century, before reason and science began to enter human discourse (if she drowns, she was innocent; if she survives, she's a witch)."
This 72-year old - who cited the savagery of ADT - is spot on. (ADT is among the most barbaric of therapies given it basically destroys what makes a man a man, biologically, i.e. https://www.youtube.com/watch?v=KtIfsvQh2qI )
In a later post he did note a better alternative - with less horror inflicted on the male body: using transdermal (Estradiol) patches.
The 75-year old who invoked "good genes" is living in fantasy land. The latest research, with data extracted from some 400 m people, discloses that genes are responsible for less than 7 percent of life expectancy. This trumps the (up to ) 30 percent from previous studies. (He does have a point in getting tested at age 59).
The character who thought I was a politico ("running for office") or insurance co. person out to gut his right to get as many screening tests as he wants is just plain paranoid. I suspect he maybe needs some brewskies or MJ candy.
Re: The Estradiol patch mentioned, this may also be one of the few options left for me if the cancer spreads. The latest PSA - at my primary care doc's orders - saw a spike from 2.1 last Oct. to 4.0 last month. So it increased at the rate of 0.1 ng/ml per month for 6 months, since my focal cryotherapy in July last year. It then increased at nearly 0.2 ng/ml per month since the previous test in April.
So I am back at the watchful waiting stage and will definitely get an MRI once it hits 6.0 - if it does. My PC doc was gratified to hear that!
Another option, which I suggested in a later post, was first broached by Dr. Betrand Tombal, Chairman of the Division of Urology at the Cliniques universitaires Saint Luc and Professor of Urology at the Université Catholique de Louvain (UCL) in Brussels, Belgium. This was based on an interview given in the online journal Prostapedia Therein, Dr. Tombal indicated he advised patients with soaring PSAs to try the ADT or other hormone therapies, and if side effects (abbreviated SEs) proved too much to just stop them. A final alternative I also cited - based on recent research (published in the Scientific American text on Prostate Disorders) is to just wait to commence ADT until there is actual cancer metastasis.
This sounds crazy in a sense, but as I learned (p. 70):
"Starting hormone therapy before a man has symptoms of cancer metastasis is a mistake. This take is underscored by the fact that hormone treatment doesn't cure prostate cancer and it causes side effects such as erectile dysfunction, hot flashes, type 2 diabetes, weight gain, heart disease and osteoporosis."
IN a related study, it was found that the rate of deaths for those 70-plus on hormone therapy was twice as likely to be from myocardial infarction than the cancer. All of which elicits the question of how do you pick your time (and mode) of croaking? Because it is coming, and if you're past 70 with aggressive prostate cancer, probably before you hit 80 or 82.
Those guys talking about living into their 90s or to at least 95 are also in economic la-la land . Most Americans today haven't even got sufficient money to live to 75 far less 90 or 95. As a recent article in MONEY magazine noted (November, p. 44):
"At just 2 percent inflation the gallon of milk that cost you $3.75 today will cost you $6.79 in 30 years."
If you think that's a lot, think of the cost of medical and dental care, rents, home prices, or buying a car. Or of anything - any kind of product. Where are all these guys going to get the money, especially as corporations today want no part of them?
Despite the dismal economics, all the guys over 70 on the survivor group were adamant that giving up PSA tests would be like "driving without a gas mileage indicator". Which, of course, is bull pockey. One character nicknamed "Cycling guy" actually bragged at having four focal cryotherapies, e.g. with estimated cost at $55,000 each mostly paid by Medicare.
For which the risk of fistula, hemorrhage etc. increases each time. Then, when those treatments didn't work he bragged about getting an orchiectomy (removal of the testicles) He swore he prevented turning into a freak (with gynecomastia) or eunuch by getting testosterone shots later and claimed his significant other regards him like John Holmes reincarnated. He then had the temerity to post: "Gee, guess I'm one of the lucky ones!" But not so fast there, Bud.
In the end, irrespective of how resolute he is in fighting this cancer, Cycling guy will lose - that is, once the macrophage "death cheer" creeps in - and it will. By that time, it is likely he (or rather the gov't) will have spent some half a million bucks - including for hospice care- to grab maybe 3 extra years of life. Is this foolishness?
Yeah, I think so, but that's me. I am still wrestling with what choices I may have to make in the coming year - and also whether living an extra year or two is worth it - as a mental vegetable with huge "man boobs", 5x higher cardiac risk, diabetes and shrunken genitals ("they are reduced to prepubescent stage" according to one researcher).
In the end, what's missing in the conversation for all these screening tests - including the predictable docs' demands for expensive follow up treatments- is how to deal with death in American culture. That is, re-educating citizens not to continually run away from it or obsess over absurd longevity ideations. This take was validated most recently in the same MONEY magazine issue, (pp. 41-50) , showing a 100-year old geezer (Orville Rogers) who runs every day and lives the "life of Riley" at a retirement center, e.g.
Folks, do not be deceived by such fanciful longevity B.S. This guy is the exception and not the rule, especially as he "retired at age 60" according to the piece. Which then went on to admit retirement planners are losing sleep over the amount ($195k) most 65 year olds currently have socked away.
Most important, since nature often operates randomly and isn't guided by individual choices, we need to act in concert to equalize health outcomes for all citizens. Alas, that may mean - to enable younger people to get the care they need- we oldsters let go of the fantasy of trying to live to 95 or 100. Besides, just because 5 or 6 percent can do it - like good ol' Orville- doesn't make it a valid aspiration for us all.
Contemporary society, as Ehrenreich writes, is "so deeply invested in the idea of an individual conscious self that it becomes both logically and emotionally impossible to think of a world without it." In Ehrenreich's view there is one time-honored balm for the anxiety of approaching self-dissolution. And it isn't more chemo, more lab tests more cryotherapy or getting your balls cut off to fight prostate cancer at age 79. No, it is "submergence of oneself into something larger than oneself".
For most Americans, like the guys in the prostate cancer forum, a truly alien concept.
