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Do violent death and accidents in the US explain its poor population health performance? Probably not.

By: wesgpc Wednesday September 30, 2009 9:40 pm

Republican Senator John Ensign of Nevada said a couple of days ago that the US would have the best performance in terms of life-expectancy and health outcomes if we subtracted out the higher rate of violent death and accidents in the US compared to European countries.

A news clip I saw said that this claim is based on a study from awhile back, but I cannot find it, whatever it is or whoever did it. But in the mean time, we can look at some vital statistics to find out whether it is a reasonable claim.

First, let’s look at overall mortality rates. This is directly relevant to life-expectancy because the life-expectancy rates that are published by vital statistics agencies are really a way of summarizing mortality rates in a given year. So, let’s look at age and sex standardized mortality rates (per 100,000 population) for 22 high income countries, broken out by all causes, violent death and accidents (traffic accidents, falls, and assault), and non-violent causes (all cause mortality minus assault and accidents).

The countries are Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Japan, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, United Kingdom and the United States. The data are for 2002, except 2001 for Canada and New Zealand. Mortality rates for Belgium are not included because it does not have enough recent data.

The average mortality rate in the US is 667, fourth highest among the 21 countries, behind the leader Denmark, and then Ireland and Portugal.

Now let’s look at violent death and falls. The US is second highest in traffic accidents (behind Portugal), twelfth (or middle of pack) in accidental falls, and first in assault. Overall, the US is fourth in violent death and accidents at 26, behind (again) Denmark, Ireland and Portugal.

The US mortality rate from non-violent causes is 640 (one death per 100k population is lost due to rounding). The US is fourth highest behind (you guessed it) Denmark, Ireland and Portugal. Assault, falls and traffic accidents do not seem to make much difference in the standings. The reason is that assault and accidents in high income countries make up only a small fraction of total mortality. The proportion ranges from a low of 1.5% in the UK, to a high of 4.0% in Italy. The difference in mortality rates between the US and leaders in life expectancy such as Japan, Switzerland, and Australia is between 140 and 200 deaths per 100,000 population, which is large compared to the mortality rate due to assault and accidents.

Of course it could be that most of the violence and accidents in the US takes place at very young ages, and if these deaths do occur at unusually young ages in the US compared to other countries, that might lower the life-expectancy at birth due to other causes enough to produce the best performance of all. For that to happen, the effect of very youthful death due to violence and accidents in the US would have to overcome its very high perinatal and infant mortality compared to other countries, and I think that is doubtful.

But there is another way to look at the problem, and that is to look at life-expectancies later in life, say at age 40 and 65. I think that is reasonable. Most assault occurs at younger ages. The US is middle of the pack of high income countries in the rate of mortality due to falls. That leaves traffic accidents, but most of those occur at younger ages.

At age 40, the life expectancy in for women in the US is tied for next to last with Ireland among 22 other high income countries in 2002 with a life expectancy 41.4 years. Only Denmark was worse.

At age 40, the life expectancy in for men in the US was tied for 16 with the Netherlands among 22 other high income countries in 2002 with a life expectancy 37 years

At age 65, the life-expectancy for men in the US is only about average out of 22 other high income countries. For women it is below average, ranked 15 out of 22 other high income countries.

I do not think that the high mortality rate due to traffic accidents, falls, and assault can explain the poor life-expectancies in the US compared to most other high income countries.

If anyone knows what report said that the US healthcare system had the best performance if you took out assaults, falls, and traffic accidents, please let me know in the commments. I would be interested in how they got to that conclusion.

Data from OECD health statistics 2007 and 2009
http://www.oecd.org/document/30/0,3343,en_2649_34631_12968734_1_1_1_37407,00.html

 

Fragmented healthcare: does insurer compeition itself increase healthcare costs and reduce welfare in the US?

By: wesgpc Friday August 21, 2009 12:32 am

Unregulated free market fanatics have been advocating a market based approach to health care reform. Part of their proposals involve more cost sharing by patients, and more competition between health insurers.

If by ‘more competition’, the conservatives mean more competition between very heavily regulated insurers to see which company can process the paper more efficiently, while patients can retain their connections with healthcare providers over the long term, then more competition might be good. This would require changes in the pricing policies of clinics and hospitals, so that one could get a binding price quote from providers before the service was delivered. It would also require a Swiss level of regulation, which would mean state and federal approval for rate increases, and in case of disputes, completely open books to federal regulators (not just the financials, but all the company’s records, data, and statistical analysis as well). It would be an public process, much more so than in the US. That is the way the commie Swiss pull it off.

But if this competition means a mere fiddling with the history of US practice over the last 25 to 30 years, then it won’t work. We will just have more of the same.

First, it is a mistake to say that more market based competition is a new strategy. It is simply recommending more of the same experiment the US has tried since the late 1970s. In fact, there was a buzz word for it that I do not hear much anymore: ‘managed competition’. Managed competition was supposed to provide the benefits of insurance through various kinds of managed care health plans and insurers, with companies competing to provide better and more efficient care, tailored to different groups of enrollees. But standards of care would be mostly self-regulated through guidelines and public reporting, and patients would have the option of shopping for better and cheaper care on a periodic basis. Sound familiar?

The problem is that insurance itself and healthcare providers have been offered as a package for a long time. It has been considered an efficient way to control utilization. So, if you change an insurer, you often have to change your doctor. This occurs with both managed care and insurance policies that have various kinds of preferred or closed provider lists that determine who you can and cannot see in order to get the insurance benefits.

One of the drawbacks to managed competition is that it has resulted in tenuous connections between individual patients and their healthcare providers, and tenuous relationships between providers and the insurer. The proportion of patients who leave a an insurance company over a year is called the turnover rate, as is the proportion of providers who leave an insurance provider. And evidence is starting to come in that says this high turnover rate increases the cost of care.

Let us look at enrollee turnover.

Survey results show that people in the US switch providers more often than in other high income countries. In survey in 2004 showed that a much smaller percentage of patients in the US have stayed with the same doctor for five years or more (37%) than in Australia (50%), Canada (53%), New Zealand (56%), or England (63%).

It is difficult to get recent estimates of the average annual patient turnover rates for large health care providers anymore. Five to ten years ago, published statistics showed and average of 20% to 25%. Recent cost and financial analyses usually assume a typical rate of 20%. While I cannot find estimates for the last several years, I do hear and read frequent complaints that turnover rates remain unacceptably high, so I assume they remain about the same today as at the turn of the century.

Turnover rates far higher, as high as 40% per year, occur in public plans for the poor. These higher rates occur because people drop in and out of eligibility, and because they are often allowed to change on almost a monthly basis, due to their more transient condition and fear that locking them into a provider for any length of time will lead to exploitation.

There are several reasons for these high turnover rates. Employers may add or drop insurers and managed care organizations as part of their health insurance benefits package. Insured employees may choose or be forced to change their provider at annual open enrollment. Even if your insurer is not the same as your provider (as in staff model managed care), your insurance company my change its allowable providers for any of a number of reasons (often due to corporate financial shenanigans rather than healthcare issues). Your may have to switch insurers or change from one of its plans to another (and therefore to a different list of providers) due to an increase in premiums.

It might be said that high annual turnover rates are part of the dynamic US society and cannot be avoided. But employee turnover averages between 10% and 15%, so enrollee turnover probably does not have to be as high as it is.

How does this high turnover rate affect care? Let us look at a simple example. First look at a simple problem from society’s perspective. You are the insurer. Consider an enrollee in their mid-forties and you want to reduce their medical cost for the next 22 years, until their expected retirement and entry into Medicare, and you know the enrollee will stay with your company. Suppose you are considering a smoking cessation, or diabetes, or blood pressure, or cholesterol management program. Say the average patient has a 0.002 chance of dying each year, and a social discount rate of 2% per year is used, and the program on average will save you $50 per year. What is the cash value today of providing that program? The cash value today is $874. If you can provide this program for less than $874, it is good business to provide it. Otherwise you don’t unless you are forced to by the government, or, say, an employer as a condition of being on their list.

What is the cash value worth if you estimate that there is a 20% chance that person will change health plans each year? The cash value is about $245. If you expect a higher turnover, say 40% per year in a public program for the indigent, now the cash value is $141. Now, even if you can provide the care for $874, you cannot recover your investment. Providing the care becomes an unattractive business investment.

This example does not even consider the fact that a profit making company in the corporate world will discount future savings at a much higher rate than 2% per year, which would reduce the cash value of treatment even more.

For this is the sausage making that goes into the design of benefits. Statements like “We cannot pay for some one to lose weight just in time for another company to reap the benefits”, or “We cannot afford to pay to produce former smokers for our competitors.” are heard. It sounds callous, but everything needs to be boiled down to how many pennies or dollars a set of programs adds to the per enrollee cost per month (the Per Member Per Month, or PMPM cost). If an insurer increases the PMPM too much, then it risks being dropped by employers, who usually have to pick up some of the tab. Or, if the employer accepts the additional cost, then the insurer may lose enrollees at the next open enrollment period. If too many of the added benefits are disease management programs for the chronically ill, and this is advertised during open enrollment month, then the insurer fears adverse selection: their benefits package may attract too many sick people.

Aggressive and effective disease management and preventive care programs that pay for themselves in the long typically cost at least 50 cents PMPM at the beginning, and often close to a dollar PMPM. If you add up all the programs you should be doing that are profitable from social perspective, then you may have an increase in several dollars PMPM, and the execs start getting very nervous. Especially if the programs will not break even over the next two to five years. And I think five years would be for only a very forward looking company.

A common problem of benefit design is trying to stuff all the disease management and prevention programs and benefits that are cost-effective from society’s point of view into a cost structure that has to be bare bones due to lightly regulated competition. After all, much of the PMPM goes to care that must be delivered for emergent conditions that demand attention and that cannot be avoided (at least at the benefit design stage, I have no direct knowledge of what goes on in executive suites in rescission and denial of claims decisions –those were very far above my pay grade. My pay grad was zero anyway, since I was a lowly statistician working with govt and private public health groups. )

These disease management and preventive care programs operate at a very thin margin. A few years ago PMPMs rangeed from $110 on up for employer plans, depending on the health of the employees and the generosity of the coverage. So, even for the very lowest PMPMs, you get nervous with marginal increases of just two or three percent.

And note what happens as the person approaches entry into Medicare? Sometime in their mid-sixties, their turnover rate becomes 100%. Entry into Medicare is important for determining the profitability of providing preventive and long term care, because the private insurer gets no benefits at all after that date. “We just can’t provide that care, we can’t get the investment back in time, and pretty soon, they are Medicare’s problem.” is something else that I have heard.

Some people will swear up and down in public that this is just not true. But some people will also say in private that if you go broke, you can’t provide any care at all, and it is surely better for our good company to stay in business than our sleazy (or bumbling) competitors down the road.

Many managed care health plans and some insurers understand this is a problem, and are willing to try cooperative approaches. People will say “If the other companies do everything they are supposed to do, we will too.” I believe that they are sincere, but the problem is in how to do it. One solution is public reporting of plan quality and performance. The HEDIS and CAHPs programs of the National Committee for Quality Assurance (NCQA) (http://www.ncqa.org/tabid/59/Default.aspx) provides public information on plan quality, but their surveys cover only a third of the population insured in the US. These programs are based on surveys, and while the surveys are conscientiously audited, some believe (including me) that they use crude quality measures (probably unavoidably, due to the limitations of surveys)

Large business customers of insurers and health plans have dealt with this problem by banding together into business purchasing groups that seek to improve the quality of care offered by the plans above what lightly regulated competition provides. There are several national umbrella organizations for these business healthcare purchasing groups which are organized by state. I think the largest is the National Business Coalition on Health (http://www.nbch.org/index.cfm), which has member organizations in over 30 states. But his effort mainly affects benefit packages for large corporations.

So this means that the smoking cessation therapy, the weight control, exercise, diabetes, blood pressure, cholesterol, etc. control program may just not get offered. Or, they may be very vaguely described in promotional literature, or boxes may be ticked of for surveys, but no money is spent for a real program.

And this leads to the problem that, even if that currently enrollee is not covered over the long run by a particular health plan or insurer, chances are that he or she will around long enough for society to pay the bills.

Is there any evidence that this turnover increases costs? Well, some new evidence may point in that direction.

A paper by Scanlon et al finds that competition does not increase quality, but it does decrease price. I do not think that does not tell us much about quality, since it uses rather crude survey data, but it does suggest that price pressure due to competition is real.

Research by Fang and Gavazza show that people in industries with higher turnover rates have increased health care costs during retirement, pointing to underprovision of medical care that would reduce long run costs. This study looks at employee turnover rates, but I think it gives evidence relevant for enrollee turnover in a healthcare plan as well. Quoting from the paper’s abstract:

When employers offer health insurance, the contracts have higher deductibles and employers’ contribution to the insurance premium is lower in high turnover industries. Moreover, workers in high turnover industries have lower medical expenditure and undertake less preventive care.

And the authors make the link themselves in the conclusion:

A very rough back of the envelope calculation suggests that on average every additional dollar of health expenditure during working years may lead to about 2.5 dollars of savings in retirement. While such calculations are necessarily rough, it does suggest potential channels to help solve the crisis of ever-rising health care costs in the U.S.

Finally, the results in this paper provide a strong link between the institutional features of the U.S. health care market, the incentives to invest in health it generates, and health outcomes. We believe that the interaction between private and public provision of medical care in the U.S. might be particularly subject to the dynamic externality we consider.

Finally to wrap things up, I will mention the recent paper discussed in the blogs by Sood et al, that give evidence that higher health care costs hurt economic performance in the US.

So, with the current system we are caught in trap. When one insurance company dominates a state or region, there is little competitive pressure for them to do a good job. Where there is competition that lowers price, the regulatory and institutional environment may reduce the current quality, and increase the long run costs of care, through the very process of competition itself.

Sources

Fang H and Gavazza A, Dynamic Inefficiencies in Employment-Based Health Insurance: Theory and Evidence. NBER working paper 2007.
Free copy at
http://www.idei.fr/doc/conf/pha/conf_2008/gavazza.pdf

Scanlon D, Swaminathan S, Lee W, and Chernew M. Quality and Efficiency
Does Competition Improve Health Care Quality? HSR: Health Services Research 43:6 (December 2008).
Found through the health-care economist blog:
http://healthcare-economist.com/2009/01/30/does-competition-improve-health-care-quality/

Sood N, Ghosh A and Escarce J. Employer-Sponsored Insurance, Health Care Cost Growth, and the Economic Performance of U.S. Industries. HSR: Health Services Research 2009, in press.
http://www3.interscience.wiley.com/journal/122434573/abstract
I forgot the blog where I first saw this paper, so can’t give credit.

Health insurance bigger sharks than casinos? Heavily protected from lawsuits, they ask the feds for a 35% copay policy for enrollees

By: wesgpc Thursday August 20, 2009 9:39 pm

Watch the clips below, and then contact the media and then please ask them why Wendell Potter has not been on their shows to share his knowledge and experience about health insurance in the US.

The amazing news in the first clip below is that the health insurers have asked the feds to set up a 35% copay policy for their enrollees (that is, that all of us will have to pay). That is nice work, if you can get it.

I just watched the clip above at the Balloon-Juice blog and thought it deserved wider exposure. Wendell Potter used to be an executive at a major insurer, and he knows how it works, because he was one of the executives deeply involved behind the scenes.

In the clip above, Wendell Potter talks about the death of Nataline Sarkisyan after Cigna initially refused her a liver transplant. Apart from that sad story, Potter has interesting things to say about the insurance industry’s protection against lawsuits through several laws, the most important of which is ERISA (it is explained in the clip).

To be fair and balanced, there are some state and federal laws and regulations that allow free riding by people when they get sick, which is unfair to the insurers and to policy holders. But I think that the insurance industry gains far more from laws like ERISA than they lose. I have been puzzled why their unusually strong legal protections have not been discussed more in the health care debate.

FDL is the only place I have seen any discussion. There have been two diaries/posts on the legal environment of health insurance in the US: the one below, and another that claimed insurance companies had unusual exemptions from antitrust law (sorry, I cannot find it now). I aint no lawyer and can’t vouch for the claims of these posts. For example, I think ERISA severely limits what state governments can do.

The True Health Insurers’ Enablers? Our STATE Insurance Commissioners?
By: WarOnError Thursday August 20, 2009
http://seminal.firedoglake.com/diary/7396

But that is not the point. The point is why are these issues not discussed in the media? Why do the advice and knowledge of sober, experienced and informed people from medicine, epidemiology, public health, law, and dissident viewpoints from inside the health insurance industry itself, seem to be censored from most of the mass media? Why do we have to listen to insane and ignorant spoutings of political operatives, hacks and bad faith politicians day after day?

I think the rules limit me to two embeds per post, but I recommend doing a youtube search "Wendell Potter", and watch his appearances. He seems to have only appeared on PBS and the the ‘liberal’ shows on MSNBC, and some special productions, including one from Brave New Films.

I think this man’s wide and long experience in the healthcare industry, and his obvious thoughtful, moderate and very reality based perspective should be on other networks. The media contacts are below.

ABC News
http://abcnews.go.com/Site/page?id=3068843

CBS News
http://www.cbsnews.com/htdocs/feedback/fb_news_form.shtml?tag=ftr

CNN
http://www.cnn.com/feedback/

NBC and MSNBC news shows
http://www.msnbc.msn.com/id/10285339/
Chris Matthews
http://www.thechrismatthewsshow.com/html/contact.html

Have the Swiss ‘death panels’ hurt their elderly?

By: wesgpc Wednesday August 19, 2009 12:21 am

The Swiss have ‘death panels’, in the parlance of the demagogues and their crazies. In the real world terms, the Swiss use comparative effectiveness analysis to determine what should be covered by their national basic comprehensive health policy. Not only for outpatient drugs, but for medical tests, and equipment, and sometimes procedures. The current system has been in operation in its present form since 1996.

As we will see below, the Swiss comparative effectiveness program shows no evidence of harming the elderly at all. In fact, their recent performance in providing long life to the elderly is better than ours. I doubt the demagogues or the crazies can be persuaded by the facts, but perhaps people who are rational, but worried by the lies, can be persuaded. So if you know of some on in that category, please spread the word. It also might be interesting to ask the media why they cannot report any facts about how comparative effectivess analysis has worked in other countries, rather than broadcasting sensational nonsense.

The Swiss national cost-effectiveness panel classifies outpatient drugs, tests and medical devices into four categories: a) indispensible, b) needed for good medical care, c) conditionally necessary, and d) unneeded. Items in category a) and b) are automatically covered by the basic plan. Items in category d) are excluded from coverage. Items in c) are given a cost-effectiveness analysis and included if the cost of acquisition is acceptable.

Medical procedures are given a formal cost-effectiveness analysis if a private insurance company asks for one.

Supplemental insurance policies are available for those who want more goods and services to be covered. and benefits for those are determined by the individual insurers on the private supplemental insurance market.

The Swiss approach is stricter than the plan proposed for the US, and than the existing one in Germany. It is similar to the approach used in Australia (the Australian program only covers drugs, but it covers all drugs, not just outpatient).

Let us see whether the Swiss ‘death panels’ have killed off the elderly since 1996.

The average life-expectancy of men at age 65, for years 1993 to 1995, was 16.0 years in Switzerland and 15.4 in the US, for a difference of 0.6 years. For the years 2004 to 2006 it was 18.2 in Switzerland and 17.2 in the US for a difference of 1.0 year.

The average life-expectancy of women at age 65, for the years 1993 to 1995, was 20.3 years in Switzerland and 19.0 in the US, for a difference of 1.3 years. For the years 2004 to 2006 it was 21.8 in Switzerland and 20.1 in the US for a difference of 1.7 years.

The life expectancy of the elderly in Switzerland is higher, and has been growing consistently faster, than in the US.

A previous post showed that the facts contradicted the lies about ‘death’ panels in Australia and Germany (http://seminal.firedoglake.com/diary/6766). The life expectancy of the elderly in those two countries has been growing faster than in the US. This post shows it is also not true in Switzerland.

And it makes sense, when you think about it. The use of comparative effectiveness analysis is to aid doctors in using the cheapest methods first, whenever they have a choice. That means that there will be more resources available for everyone. It does not have to lead to rationing. And the issue of it leading to rationing is an absurd objection in the US anyway, since our private insurers deny care all the time with little or no accountability. It would be far better to have a public process to evaluate treatments.

In fact, a recent 2006 OECD/WHO report criticizes Switzerland for not using cost-effectiveness analysis enough in shaping its policies. Even though many preventive and health screening programs (including breast cancer screening in middle age women) have been found to be cost-effective, the Swiss have been slow in implementing them. The report concluded that if Switzerland acted more often on its own cost-effectiveness program’s guidelines, it could reduce costs and increase its population health.

Note that this diary is not an argument that comparative effectiveness analysis was the sole cause of the better recent performance in Switzerland. It is intended to simply confront lies about ‘death panels’ and comparative effectiveness analysis with the facts. The liars say that comparative effectiveness analysis (as with voluntary end of life counseling) leads to rationing and death to the elderly. The facts flatly contradict that lie. There is no evidence that they do, rather the facts suggest, though do not prove, just the opposite.

A final note: since I have been flogging comparative effectiveness analysis, some may wonder if I have a personal interest in drumming up business, since I am in the healthcare biz. I hate doing cost-effectiveness analysis; they are long, boring, complicated, and very exacting projects. I have done my share and hope to never have to do another, unless I find one that I think is interesting (but I doubt it).

Second, anyone in the healthcare knows that US medicine runs on comparative effectiveness analysis, even though many will deny it. Get on Google scholar or PubMed and type in "cost effectiveness" (over twenty thousand articles) or “comparative effectiveness” (hundreds). Many of these studies are financed by industry in order to persuade insurers, doctors and hospitals and clinics to use their drugs and other products. The problem is that the quality of these studies is difficult to evaluate. Since they are widely used in the US anyway to determine whether a drug should be used, it would be better to have more public input and examination of how they are done. It would be better to establish which studies are reliable, and disseminate that information, rather than allow industry studies of uncertain qaulity to influence medical practice.

Sources

Banta H and Wit G. Public health services and cost-effectiveness analysis. Annu. Rev. Public Health 2008. 29:383–97.

Do comparative effectiveness programs cause elder genocide? Shocking Results
By: wesgpc Wednesday July 29, 2009
http://seminal.firedoglake.com/diary/6766

Gress S, Niebuhr D, Rothgang H and Wasem J Criteria and procedures for determining
benefit packages in health care: A comparative perspective. Health Policy 73 (2005) 78–91

OECD Health Statistics 2009.
http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html

Switzerland. OECD Reviews of health systems. OECD and the World Health Organization. 2006.

Switzerland. Health Care Systems in Transition report. European Health Observatory on Health Care Systems. World Health Organization Europe. 2000.

Those low UK breast cancer survival rates: Will conservative proposals for reform lead the US to the UK’s problems?

By: wesgpc Sunday August 16, 2009 10:17 pm

I am not a cancer specialist or epidemiologist, though I have worked on a few cancer prevention and screening projects. But I have not found anything in the US press that examines the issue of evaluating a whole nation’s health care system on the basis of breast cancer. I have not seen any articles examining what the implications of such a comparison would be for the health reform debate in the US. I am a health economist, for whatever that is worth (not much apparently, from what I have seen of their influence on the debate). In any case, I was curious, so I decided to look into it. This post is a report of my little investigation. If anyone thinks I have missed something, or an expert in the field happens by, please leave a comment.

But before that, let us debunk the whole idea of judging countries’ health care systems based on outcomes for just one disease. It is dishonest cherry picking, and sound-bites based on it deserve no place in an informed debate.

I think breast and prostate cancer were chosen to demonstrate the ‘absolute bestness’ of the US healthcare system in every respect by looking up recent studies (for example, the CONCORD study (1) which looked at six different cancer/sex combinations), picking the one or two where the US performed best, and then picking another country that did not perform so well to use as a bogeyman. That is a clearly biased and dishonest procedure. The results for breast cancer in the CONCORD study do not say that the financing of the health system is crucial in determining survival rates for common cancer, since Canada, France, Japan, the US, and perhaps even Cuba performed best in one category or another (though, the results for Cuba are uncertain because some of its data

What did Jefferson tell us to do if an opposing faction decides to “refresh the tree of liberty” with blood?

By: wesgpc Friday August 14, 2009 1:26 am

I wonder how many of the misguided wingnuts who intimidate and strive to thuggishly silence their fellow citizens have read the whole passage? They may be comforted by what seems to be stirring phrase, when torn out of context, but they shouldn’t. They misunderstand its meaning, and misunderstand their fate if they give in to violence.

Jefferson told the rest of the citizenry what to do in the face of any such violent watering. Jefferson’s advice to the peaceful is much more arduous than striking out in ignorant violence, but we cannot shrink from his instructions. It is our duty as patriotic citizens to remember the words that surround that disturbing phrase, and act on them if necessary.

Here is Jefferson’s supposedly stirring and inspiring quote:

The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants. It is its natural manure.

Now read what Jefferson wrote immediately before it. Jefferson was in Paris, reading a draft of the proposed US Constitution. He objected to some aspects of the federal government, particularly the executive, that he felt were too strong. He begins by wondering what danger of anarchy existed in the US to justify such a seemingly strong central government (and I am sure he feared a president who could inhabit office any length of time would raise a standing army, one of his pet horrors). Then he reflects on the recent Shay’s Rebellion, that had rattled the American aristocracy (including Madison, who was close to panic for awhile):

Yet where does this anarchy exist? Where did it ever exist, except in the single instance of Massachusetts? And can history produce an instance of rebellion so honorably conducted? I say nothing of its motives.

Already there is reason for pause: Jefferson views the conduct of the rebellion ‘honorable’ -given the dishonest and thuggish intimidation by some the shouters, one hopes the honor increases a bit before anything happens. Jefferson did go on to discuss their motive, and his thoughts should give much more pause to those who threaten violence:

They were founded in ignorance, not wickedness.

Jefferson goes on to placidly discuss civil violence in a bland and serene way, that I find disturbing:

God forbid we should ever be 20 years without such a rebellion. The people cannot be.

Enough primary care docs in the US for health care reform? Little data; I trust reform more than corporations to solve any shortages

By: wesgpc Tuesday August 11, 2009 12:16 am

The claim that health care reform will cause a disastrous doctor shortage is another scare tactic of the health care reformers.. I posted a column a few days ago with Official Numbers claiming that a shortage was unlikely:

New health reform scare: univeral coverage will cause a doctor shortage (I don’t buy it)
By: wesgpc Tuesday August 4
http://seminal.firedoglake.com/diary/6914

A commenter questioned the column’s relevance because it did not focus on primary care, and said that was the real scare claim being peddled by opponents of reform.

I focused on the total health care force (docs, nurses, dentists and pharmacists) because there is considerable substitution of effort between these professions. I felt the total labor workforce was the most important issue.

But, the commenter may have a point. Now I have heard news reports focusing on scare stories about shortage of primary care doctors (though it is surprising that such a mundane issue could survive the absurd but inflammatory ‘death panels’ nonsense).

The problem with primary care is that there are few numbers that address the question directly, partly because of the problem mentioned above: substitution between professions.

If one wanted to misuse statistics, one could say “Well, heck, the US ranks 6 out of 22 countries (all of which have have at least hear universal care except for the US) in density of general practitioners per thousand people. The US has more general practitioners per resident than most high income countries, so there is obviously no problem.”

If we look closer at my favorite list of countries with outcomes that are at least as good as those in the US, we see that New Zealand and Switzerland do well with fewer general practitioners than the US, though two (Australia and France) use more. Canada has about the same density.

1.6…….France
1.4…….Australia
1.0…….Canada
1.0…….United States
0.7…….New Zealand
0.5…….Switzerland

Source: OECD health statistics 2009
http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html

The problem with these

Our current US healthcare system has a better cost control method than killing old people: kill them off before they get old

By: wesgpc Sunday August 9, 2009 11:09 pm

The performance of the United States health care system and society in terms of life expectancy is very poor, far below the average of other high income countries. It is poor in terms of level of life expectancy in years of life. It is poor in terms of average annual growth rate in life-expectancy. So, it is poor in terms of both achievement and progress. It is certainly not the best in the world.

The performance is poor for both sexes. It is poor at birth, at age 40 and at age 65. It is poor compared to the average performance of other high income countries and the performance of other specific countries that could be models for US health care (IMHO: Australia, New Zealand, and Switzerland). It is poor compared to other systems that could be adapted into good systems for the US, but may be politically infeasible here (Canada and France).

Table 1 shows recent ten year average growth rates of life expectancy for other high income countries, for the US, the rank of the US average growth rate among high income countries, and the rank of US life expectancy, in that order.

Table 2 shows the same statistics for recent five year average growth rates. Tables 1 and 2 show that the average growth rate in life expectancy in the US has been below the average of 22 high income countries for both the ten and five year periods, with exactly one exception.

The sole exception, shown in Table 2, is that the average five year growth rate (to 2006) in life expectancy for women at age 65 in the US rose to slightly above average of other high income countries, though the rank of the US was still only mediocre: 8 out of 22 countries. Seven countries had higher growth rates: Denmark, Finland, Greece,