Health Care: Can It Work Better?

The summer's hot topic is health care. To apply a phrase-of-the-day, "This is big." Apparently Congress will recess for August without enacting reform legislation, but the underlying issues are not going to go away during their vacation.

Outcomes Don't Seem To Match Outlays

Here's a first problem with the performance of the U.S. health-care system: 16% of Americans say they have no health insurance. This is a new number, from the Gallup Poll published just last week and coming out of their daily polling for June. The latest official number from the U.S. Census Bureau covers 2007; it was 15.3%. Gallup's figure is actually down; it had reached 16.6% in May. The hardest hit in these uninsured ranks are Hispanics, of whom 41.5% are without coverage; low-income workers making $36,000 a year or less report 28.6% without coverage, and young adults ages 18-29, 27.6%. When these people get sick, they generally get some kind of care, but their situation is awkward and it's expensive for the rest of us, who actually pay their bills, through the back door.[1]

Another "big" problem. The U.S. spent 16.2% of its GDP on health care in 2007, far and away more than any other country. But life expectancy here is not far and away the greatest; our life expectancy at birth in 2005 was 77.8 years, ranking 24th among 30 major industrial countries, right behind Portugal at 78.1. Japan is the longest, 82.6 years.[2] Why on earth don't we get more for our money?

We can't begin to answer these issues constructively. About the insurance, it's easy to say "universal coverage" or "just pass H.R.3200", the bill currently working its laborious way through Congress. But we immediately run up against the cost issue, with current spending already seen as a problem and "ration" seen as an awful word that makes us all cringe.

So we offer here today two ideas, one an explanation for at least part of our problem and one a perspective toward improvement of the underlying situation.

But the U.S. Is Different

We begin by exploring one characteristic of the United States that would seem to set it apart from other countries: its vast diversity, racially and economically. We're fascinated by a 2006 study called "Eight Americas: Investigating Mortality Disparities . . . in the United States"[3]. The authors examine life expectancy and disease by race and county throughout the country. They identify eight distinct population groups with markedly different susceptibilities to various causes of death: HIV/AIDS, cancer, cardiovascular disease, crime, etc. The groups range from Asian populations that have the lowest probability of dying from anything at a given age, even better than those in Japan, to high-risk urban blacks, whose life expectancy is more comparable with that in El Salvador and Armenia. Interestingly, available information shows that insurance coverage and health facility usage vary only modestly among these groups, suggesting that attempts to improve the lots of the weaker groups may not respond to a single, standardized approach. From this analysis of how non-standard our very population is, it seems much less mystifying that our health dollars and our expectations for overall health look so different from those of other countries.

And We Have Better Results on Serious Conditions
We've chosen words carefully in describing our conclusion just now. Overall life expectancy in the U.S. may, on the face of it, seem disappointing compared with other countries. But we hasten to point out that recovery rates from specific conditions can look far better. Other information shows that five-year survival rates for cancer are much higher here: U.S. women have a 63% cancer survival rate, compared with 56% for European women. Men in the U.S. have a 66% rate, compared with 47% for men in Europe. In Canada, mortality is 25% greater for breast cancer, 18% more for prostate cancer and 13% higher for colorectal cancer. Interestingly, the use of the screening tools now increasingly familiar to U.S. adults – mammograms, PSA tests and colonoscopies – is much less prevalent in Canada. U.S. heart patients have better survival and functioning results than those in Canada. There is a 60% higher incidence of hypertension in Europe, which some attribute to less use of relevant prescription drugs there. These outcomes and others indicate that there's clearly something right about health care in the U.S. and some room for improvements among other countries.[4]

Supply-Side Approaches to Health Care Dilemmas
So is there anything we can do to make our own health care system work better? We're into economics here, so we have to say that supply is important in the performance of the health care system, just as much as demand. There are two projects "out there" that are just getting started in earnest toward making health care delivery more efficient. One is electronic medical records, getting to be known by its acronym EMR. I have a P.C.P. and a gynecologist. Why do they have to have two entirely separate sets of duplicate paper? When I get a mammogram or bone density test, a standardized result can go to both of them automatically. And does your doctor now fax prescriptions to the pharmacy or the mail order service? Or does she do email with you to answer simple questions or schedule appointments? Things like this we take for granted in business have been slow to come to medicine. [I know you might have a misgiving. I'll come to that.] But they will help ever so much to streamline a growing volume of activity. To say nothing of the help it can be if you live in New York but you get sick in Anaheim – or you're retired and spend every winter in Florida.[5]

Then there's "effectiveness research". [I can hear you wince about this too. Be patient.] This is also a fine tool: it asks what treatments work best while costing least? Centralized databases give your doctor and you clear guidelines on how to fashion your treatment. Medical research is working, too, on the organization of care. Maybe if you have a stroke, you might go to a small hospital that only treats stroke; this has been shown to be effective in India. Specialized institutions might not always be the best method, but it's worth checking them out.

Both of these tools, EMR and effectiveness research, can be misused. Critics, maybe even you, fear loss of privacy and the imposition of treatments determined not by your own physicians but by bureaucrats in Washington. So clearly, safeguards must be part of any major enabling legislation. We can only believe, though, that a technology that permits online banking can keep medical records as confidential as anything else.

Along the same lines, quality assurance in medical care is vital. We've learned in our recent reading that hospital and other care errors occur in other countries, though we tend to hear critics complain mainly about U.S. institutions. Correcting and preventing these mistakes can bring significant monetary savings – and yes, we know, that's hardly the main reason for wanting such improvements.

We're also fascinated by the fact that business schools are getting more and more into medical care management. A blend of the people from Harvard and other big-name institutions who know about "process" and "workflow" with the people who know disease and treatment has to help.

We All Pay -- Through Taxes, Wages and Prices
In all of this discussion, we hardly touch on the hot-button issue, "who pays". We'll have to face the details of that only too soon. One thing we can say now, though, aside from mentioning the flashy trillion-dollar cost estimate, is that we'll all pay. If we don't pay in insurance premiums, we'll pay in taxes, or in reduced wages or in higher prices for any good or service we might buy. So the ways to fix health care all have to come back to how we can deliver quality care with a low production cost. As the world population grows, and the populations of many countries get older and older, this is vital to our continuing vitality.

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[1] Summaries of salient issues covered in Gallup Polls are available free of charge from www.gallup.com.

[2] These data are from a continuing tabulation by the Organization for Economic Cooperation and Development, the OECD.

[3] C. Murray, S. Kulkarni, C. Michaud, N, Tomijima, M. Bulzacchelli, T. Iandorio and M. Ezzati. "Eight Americas: Investigating Mortality Disparities across Races, Counties and Race-Counties in the United States". PLoS Medicine, September 2006, pp. 1513-1524. PLoS Medicine is an online, open-access, peer-reviewed journal found at www.plosmedicine.org.

[4] J. Goodman, L. Gorman, D. Herrick and R. Sade. "Health Care Reform: Do Other Countries Have the Answers?" National Center for Policy Analysis. March 10, 2009. Working paper accessed from www.ncpa.org.

[5] S. Spear and D. Berwick, "A new design for healthcare delivery". The Boston Globe, November 23, 2007. Accessed from http://www.boston.com/. Spear is a professor of management at MIT and Berwick is CEO and president of the Institute for Healthcare Improvement, Cambridge, MA.

"Fly Me to the Moon . . . . "

Commemorations of today's Moon Anniversary are oddly nostalgic. We went there and did that 40 years ago, and we haven't been back in 37 years. Fifty-four percent of our current population have been born since then. Is this merely a historical event?

At present there is much forward-looking activity at NASA, among other countries and in the private sector. So in honor of the occasion of human beings touching another land not on Earth, we'll focus just briefly on the aims and benefits in that work. We want to bring it to your attention because the lead-times are long, and there's danger that these projects can get lost in the budgetary shuffle. A new director for NASA, retired Marine General and former astronaut Charles Bolden, took office just on July 17, even as a commissioned study of human space flight priorities is in process.

The most recently articulated NASA goal is a manned outpost, a kind of colony, on the moon by the early-to-mid 2020s, just about 15-or-so years from now. Toward that end, two lunar spacecraft were launched last month; one of those, the Lunar Reconnaissance Orbiter (LRO) returned pictures last week of the vehicles left on the moon by the Apollo program. A first test of Ares-1, the launch vehicle for taking people back to the moon, is due later this year. Besides NASA, there are similar active efforts in China, India and Russia.

We were surprised to learn that there's a long-run, but very important resource on the moon, an isotope called helium-3. There are only about 10 kilograms of it on Earth, but substantial quantities on the moon. When fused with deuterium ("heavy hydrogen"), this chemical produces massive amounts of pollution-free energy; it is nuclear, but not radioactive. Roughly 25 tons, a single space shuttle payload, of helium-3 would produce enough electricity to power the entire United States for a full year. The technology for generating the fusion reaction is at least a generation away, but several sources we read cite helium-3 as a significant provision that can be available in quantity by the time the supply of petroleum on Earth plays out. That alone might justify the trip back.

But there's more to space exploration than this. The scientists remind us that most fundamentally, we can contribute to our own evolutionary longevity by establishing human settlements in other places. 2009, Darwin's anniversary, seems like an appropriate year to consider that. People have always explored, if only to see what's on the other side. Our work on the International Space Station has shown that it is well named, "international"; isn't it interesting that we work so well there with Russian astronauts, even flying in each other's shuttles. After our own shuttle is retired next year, we will depend on them and others to transport our people and goods there until our next mission begins in 2015 (or so). Reaching out beyond ourselves is so vastly important. It lifts our spirits and heightens our vision. We can use that anytime, but especially right now.

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A couple of sources:
Harrison H. Schmitt. Return to the Moon: Exploration, Enterprise, and Energy in the Human Settlement of Space. New York: Copernicus Books & Praxis Publishing Ltd. 2006. Schmitt's tone is perhaps overly definitive, but this is the book currently on looking ahead in space.

Paul D. Lowman, Jr. "Why Go Back to the Moon?" NASA. January 14, 2008. See the display, too, of products in everyday living that have developed out of the space program.

Stephen J. Dubner. "Is Space Exploration Worth the Cost? A Freakonomics Quorum." January 11, 2008. Well, Dubner did pick all of his commentators from the same side of the argument. But their arguments sound good to us!

Dean Irvine for CNN. "Mining the Moon for a Nuclear Future". CNN.com. December 18, 2006.

What I Did at General Convention

This article is about the General Convention of the Episcopal Church. Even if you are an economist or otherwise not an Episcopalian, read through it anyway. There's more here than church jargon . . . .

The General Convention of the Episcopal Church meets every three years to conduct the business of the denomination; it was in Anaheim, California, and ran from July 8 to yesterday. It may seem obvious that this gathering of people from all over the United States and several other places in the world would be much more than a business meeting. Indeed, it has many facets – a real Hodgepodge, as our Geranium Farm colleague Debbie Loeb might say. I participated in four different ways.

We went in the first instance to host the Geranium Farm luncheon, which took place Saturday, July 11. About 100 people came and ate and played in a raffle; a bunch of them went home with prizes that included souvenirs of northern Italy and some lovely arts and crafts items. Barbara Crafton was able to take more than $500 back to the beneficiary, St. James, the Episcopal Church in Florence. Barbara entertained us with stories of Italy and Peter Casparian, a previous rector there who now serves in Oyster Bay, New York, showed wonderful photographs, accompanied by Andrea Bocelli recordings. Barbara concluded by singing for us the Italian national anthem and leading us in ours. A fine time was had by all. See Debbie's Hodgepodge page for some pictures of this and other Convention scenes.

We worshipped. At the Sunday Eucharist, somewhere between 5,000 and 10,000 from the Convention and the Los Angeles area came together. A tradition of the Convention, this service is the United Thank Offering Ingathering (UTO); Episcopal Church Women representatives from every single diocese trooped across the dais to present vouchers totaling more than $7 million from mite box collections since the last Convention. The collection that day added almost $28,000 more. Imagine it: something happens in your life and you feel thankful, so you drop a dime or a quarter into your UTO box. More good things happen then as a result. The Presiding Bishop is a wonderful preacher, and her sermon highlights some of the many uses this money is put to. Please do read for yourself, here.

The service was spirited and happy. A formal choir offered Mozart's Ave Verum Corpus during Communion and Elisabeth von Trapp (yes, she's who you think she is) sang Peace, Perfect Peace. We boomed out some good old hymns. We thought the closing hymn was O Zion, Haste, but after that, as we moved out of the rows into the aisles, the musicians struck up Sweet, Sweet Spirit, and we verily danced and shouted our way out of the hall.

We worked. The House of Deputies consists of four clergy and four lay persons from every diocese. There are two legislative sessions each day; at the Monday morning session, the certified attendance was 832. If you are a Deputy, but you want or need to skip a session, you authorize an Alternate (almost an equal number of those are present) to replace you. One of my Volunteer jobs was to assist at a registration desk where credentials paperwork is conducted to "certify" this switch. On Sunday, some traded off so they could go to Disneyland, then on Monday morning, they had to unswitch. Later Monday, some who had been there for a week already needed to do laundry, so our crew helped them switch again. There were about 100 switches each of those two days.

I also served one session in the House of Deputies. Only "certified" (see above paragraph) Deputies are allowed inside the gates of the demarcated "floor" of the House. Volunteers are assigned to guard the gates; not even a Bishop is permitted inside, unless they have some specific functional Convention staff role. So I was a "gate page", complete with a pink ribbon hanging from my badge, which highlighted this designation.

I was privileged to hear debate that morning about the acceptance of a new bishop for the Diocese of Central Ecuador. Debaters from Ecuador, Puerto Rico and Colombia spoke in Spanish and had their remarks translated over the loudspeaker system. Some Deputies who speak other languages were given headphones to hear simultaneous translation throughout the proceedings, just like at the U.N. That bishop's election was ratified early in the afternoon session.

We played and had fellowship. Even elevator rides in the hotel were times for chat; I ran into one of the Ecuadoran speakers in an elevator later Monday who told me the final results. And we all teased and jostled each other in good fun. Sunday evening, I went with Barbara Crafton to a dinner gathering of Episcopal Communicators, a press-oriented group; I talked with some there about the future of the New York Times and learned about the Deputies' actions that day concerning Hispanic ministries and the MDGs.

The Convention's theme was Ubuntu, an African term for our interconnectedness with each other: "I in you and you in me" the logo says. I didn't attend the "mission conversation" sessions on this concept; I was too busy, out and about, practicing a social form of Ubuntu. I saw a former rector of my home parish right away on my arrival; I saw a former seminarian who was there as a clergy deputy from another diocese; I met Mr. Schori, the Presiding Bishop's husband, who runs around everywhere taking pictures; I met associates from the church headquarters at 815 Second Avenue and from the Long Island diocesan staff. I met people from San Joaquin, the faithful ones who are renewing the Episcopal Church there after dissidents finally broke away altogether; the "remnant" are strong, determined and happy people.

Most notably, I met a young man who was politicking on the sidewalk connecting the hotel with the Convention Center. He works for Disney. He explained that Disney wants to take away their workers' free health insurance; the proposed replacement plan would cost individuals at least $500 a month, far more than those hourly employees can manage. The workers would be demonstrating Tuesday, he said, would I join them? I would be gone by then, but a number of Episcopalians accompanied these folks to the Disney offices to make themselves heard. I did sign his petition. We'll come back to this health insurance issue – and very soon – but what mattered just then was that the young man, who had his cute 3-year-old son out there with him, said that he had been oddly touched by these Episcopal convention-goers. He was a lapsed Catholic, he told me, and he had found us remarkably understanding and kind people. He could tell we have a good spirit. Maybe he'd have to find his local Episcopal church so he could get his family connected. We ministered to him – and his recognition of us and our mission moved me: I think that's Ubuntu in action.

American Revolution: A Government Overturned in 1774

Our previous Independence Day articles have highlighted the role of common people in the American Revolution. We have learned from Pulitzer Prize historian Gordon Wood about the way the whole structure of society was changed, allowing social and economic mobility, in contrast to the fixed hierarchy that had prevailed throughout the world for centuries. We learned from renowned economic historian T.H. Breen how the American people, especially the women, effected meaningful boycotts against imported merchandise to avoid paying taxes over which the American colonists had no voice. It was the middle-class Americans who shamed the well-to-do into conformity, not the other way around.

We can also learn that it was common people in rural areas of Massachusetts who actually overturned the British regime and established their own popular self-government – in the summer of 1774, nearly two years before the Declaration of Independence.

Ray Raphael tells this story in The First American Revolution, published in 2002 by The New Press. Raphael, a history writer, also authored A People's History of the American Revolution and other works. His research for this one was supported by the National Endowment for the Humanities.

Massachusetts Government and the Massachusetts Government Act
The aftermath of the Boston Tea Party was a trying time in Massachusetts. The English Parliament set out to punish the people through the passage of the Coercive Acts, which many of us know better as the Intolerable Acts. The most hurtful of those were the Boston Port Act, which closed the port, and the Massachusetts Government Act, which tried to take away the rights of the populace to choose their own government officials.

We heard from Breen how people in other colonies supported the Bostonians through aid and cooperation in non-importation programs and other actions. But the people of Massachusetts themselves did more than wring their hands and whine.

Local and provincial governmental bodies, including several layers of courts and a bicameral legislature, all had their membership chosen through direct or indirect election by qualified voters. Every male who owned property or business of a minimum size was entitled to vote, and some three-quarters of the adult male population met the standard. This basic system had been established in the Charter King William had granted to the colony in 1691 and in a subsequent constitution. While many offices were occupied by the most substantial property owners (who could afford the time away from their work or business to conduct these affairs and often held more than one office each), the people were quite conscientious in their electoral duties and voter turnouts were high. The Town Meeting was heavily attended in most communities, making and implementing substantive policy decisions.

The Act Overrides the People's Will
The Massachusetts Government Act sought to undo the electoral process. It took the selection of officials – the courts and the legislature – away from the people and put it into the sole hands of the Royal Governor. The prized Town Meetings could only gather with the Governor's permission, and the scope of their decision-making was now tightly constricted.

The people all across Massachusetts instantly saw this as an abrogation of their rights, both as British subjects and as spelled out in the Charter and the Constitution. They were furious. Their franchise has been revoked, and if they could lose their vote by simple fiat, what could happen to their property and their businesses?

The Act took effect August 1, 1774. Courts, with judges now named by the Governor, were scheduled to hold sessions beginning in mid-August in various towns around the Province. A House of Representatives, reconstituted with the Governor's appointees, was to convene in October. The Governor made appointments to these bodies, and the appointed judges and councilors traveled to Boston to take an oath of office.

The People Are Not Happy
In the towns, the reaction was swift and concrete. The people would have nothing to do with these presumptive officials; the gentlemen selected by the Governor would of course support his positions and policies, so they were now seen as enemies of the people. As the newly sworn officials started back home, some were warned that they would not be warmly received there. Crowds met some of them on the way or surrounded their homes. Some, seeing danger, decided not to return home and in fact could never return as long as they remained allied with the Governor. Some had property destroyed.

But there was no "mob rule" in the towns. There were crowds of hundreds or even thousands, but in the vast majority of instances, there was no violence, certainly against persons. Some of the people carried arms, and some shots were fired, but those came mainly from friends and associates of the officials, not the patriot crowds. What the people wanted was for the officials to renounce their new offices, to resign and admit they had been wrong to take an oath supporting an autocratic government. The crowds operated democratically. They voted leaders to represent them in negotiations with each of these would-be officials and then they waited patiently, often massed around an official's home, while the discussions and a letter-signing took place. The now deposed official was often made to read or recite his resignation so everyone could hear for themselves.

These events occurred almost spontaneously around the Province. According to Raphael, the most prominent activity was in Worcester, seat of Worcester County. West of there, in Berkshire County, it was thought people were relatively indifferent, and in Hampshire County, in and around Springfield, people were known to be more loyalist, leaning toward the Crown's positions. But in fact, the boldest and most decisive resistance movements were initiated in those locations.

They Don't Take It Lying Down; They Hold Sit-Ins
It was, perhaps, the birth of the "sit-in". As the Governor's chosen judges prepared to open court in Great Barrington on August 16, the people of Berkshire County filed into the Court House; they kept coming and coming until an estimated 1,500 were jammed into the courtrooms and hallways. The judges couldn't even get into the building. There could not possibly be court that day, and indeed, a British-led court never held session in Berkshire County, Massachusetts, again.

Soon after, a similar development happened in Springfield. The people were closing down the court system. In succeeding weeks, these events were repeated all together in seven of the nine mainland counties of Massachusetts.

Then, in October, instead of an official session, delegates elected by the people to a province-wide legislature gathered in Salem; when the Governor did not appear at this meeting, thereby refusing to recognize this extra-governmental organization, the group reconvened as a Provincial Congress, first in Concord and then Cambridge. This body established standing committees and a regular meeting schedule, according to which it could conduct the necessary business of being a government anyway. It even fashioned a plan to collect operating funds and named its own treasurer; notably, the major budget item was the acquisition of armaments and ammunition. These people were serious and there was more to come.

Gage Gives Up in the Countryside; British Government Is Over
The Governor, by now Thomas Gage, whom we know better as a British general in the War to come, was basically powerless to stop all of this. Raphael emphasizes that the numbers of patriots were simply too great, far exceeding the size of the British garrison in Boston; he cites Gage's correspondence with Lord Dartmouth, the Secretary of State for the colonies, in which Gage describes the waning British role and rule outside of Boston. The city, by contrast, with a heavy military presence, remained under closer Royal control.

Raphael tells this story in fluid prose that conveys tension and suspense – what would happen each day when courts were due to convene? Would the people back down? Would Gage send troops to force the issue? There was, of course, no Internet, radio or phone: how did the groups in each town communicate with each other? Where were the big names, the Adamses, James Otis and others? What happened afterward? – after all, Paul Revere's ride came just a few months later. We commend this engaging narrative to your own following.

Let us say this one more time: the British never conducted the affairs of government in these towns again. The people, the common, ordinary people of rural Massachusetts, overthrew British rule. They accomplished what we might call The First American Revolution.

Raphael argues that the very nature of this story is the main reason it is never heard. There was no big name leader, no specific individual or group for publicity and history to get their hands on. The best known patriot in Worcester, for example, was Timothy Bigelow, a blacksmith who had attended the local district school but had certainly not been to college. He did write and speak very well. But he had hardly any greater status than anyone else. So these events, an effective and nearly bloodless revolution, just happened. From Raphael's conclusion:

"In January 1775, Lord Dartmouth found it difficult to believe that Governor Gage had lost out to 'a tumultuous Rabble, without any Appearance of general Concert, or without any Head to advise, or Leader to conduct.' Dartmouth failed to comprehend the power of the people to act in their own behalf, and even today, the revelation that ordinary people, 'without any Head to advise,' toppled the British-controlled government in Massachusetts engenders blank, incredulous stares."