« April 2011 | Main | June 2011 »

May 2011

May 31, 2011

Doctors: Heroes or Members of a “Pit Crew”?

Maggie Mahar

Over at “Ohio Surgery” Buckeye Surgeon is not at all happy with the commencement speech that fellow-surgeon Atul Gawande recently delivered to Harvard Medical School’s graduating class. Today, Buckeye (a.k.a Jeffrey Parks, a general surgeon on the East Side of Cleveland, Ohio), summed up what he called  Gawande’s “essential message”:

“Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms. . . .   Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era)  . . . All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew.” 

No surprise, Gawande, who is a regular contributor to The New Yorker, makes his case in somewhat more eloquent terms: “The distance medicine has travelled in the [last] couple of generations is almost unfathomable,” he writes, comparing that span to the “vast quantum leap” his father made when he traveled “from his rural farming village of five thousand people [in India] to Nagpur, a city of millions where he was admitted to medical school, three hundred kilometers away. Both communities were impoverished. But the structure of life, the values, and the ideas were so different as to be unrecognizable. Visiting back home, he found that one generation couldn’t even grasp the other’s challenges. Here is where we seem to find ourselves, as well.”

Medical culture has been roiled by change, leaving some doctors who remain attached to the past dismayed. This was inevitable, Gawande says.  In the past, physicians had only a handful of remedies. “Now we have treatments for nearly all of the tens of thousands of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures, and you, the clinicians graduating today, will be legally permitted to provide them. . .

“We in medicine, however, have been slow to grasp . . .  how the volume of discovery has changed our work and responsibilities . . .” he added “The rapid growth in medicine’s capacities is not just a difference in degree but a difference in kind . . . the reality is that medicine’s complexity has exceeded our individual capabilities as doctors.”

Continue reading "Doctors: Heroes or Members of a “Pit Crew”? " »

May 26, 2011

The Top 5 Ways to Improve Primary Care (and Reduce Costs…)

Naomi Freundlich

When we dole out blame for rising health care costs the familiar suspects are hospitals, insurers, and profit-hungry drug and device makers. High-priced specialists usually rate a mention as well. But what about primary care physicians? It turns out that through excessive testing, improper prescribing and other types of unnecessary care these “gate-keepers” also contribute to spiraling health care spending. And worse, this excess treatment not only doesn’t help patients, it can actually harm them.

This week the National Physician’s Alliance released the "Top 5" ways primary care physicians like internists, family practitioners and pediatricians can reduce health care costs while also improving the quality of care for their patients. Their recommendations are surprisingly simple and in most cases advise against the overuse of certain tests and therapies. They are recommendations that should be—but often aren’t—considered the standard of care; for example, not ordering EKG’s or cardiac screening for low-risk patients; not prescribing antibiotics for a child’s sore throat until a strep test confirms infection, and not performing x-rays or CT scans on patients who have experienced fewer than six weeks of lower back pain unless “red flags” are present.

Continue reading "The Top 5 Ways to Improve Primary Care (and Reduce Costs…)" »

May 25, 2011

Democratizing Elite Colleges

Richard Kahlenberg

David Leonhardt has a superb column in this morning’s New York Times on the efforts of retiring Amherst president Anthony Marx to address economic segregation in America’s elite colleges.  The piece, which has been flagged by Jonathan Chait and Matthew Yglesias among others, makes three important points often lost in the debates about equity in higher education.

First, it matters who attends elite colleges because our leadership class disproportionately derives from those institutions.  Leonhardt cites the last four presidents of the United States, all nine Supreme Court justices, and several top corporate leaders.  These are not anomalies.  As we noted in our 2010 volume on the topic, Rewarding Strivers: Helping Low-Income Students Succeed in College, research from Thomas Dye has found more broadly that 54 percent of America’s corporate leaders and 42 percent of government leaders are graduates of just twelve selective and wealthy institutions.

Second, Leonhardt correctly notes that low-income and working-class students are enormously under-represented at four-year institutions generally, and among selective institutions in particular.  Leonhardt cites The Century Foundation’s Rewarding Strivers research, conducted by Anthony Carnevale and Jeff Strohl, finding that only 44 percent of socioeconomically disadvantaged students testing in the top quartile attend a four-year college.  Twenty-four percent attend a community college, where graduation rates are much lower, and an astounding 31 percent don’t attend college at all.  At the most competitive four-year institutions, Carnevale and Strohl found, 70 percent of students were from the richest socioeconomic quartile in 2006 and just 5 percent from the poorest quartile.

Third, it is possible to alter the economic stratification in higher education because there are many highly talented low-income students who can perform well in even the most selective colleges and universities. Between 2005 and today, according to Leonhardt, Amherst increased the proportion of students receiving Pell Grants from 13 percent to 22 percent, a 69 percent increase.  At the top 146 colleges and universities, according to Century Foundation research by Carnevale and Stephen J. Rose, the proportion of students from the bottom socioeconomic half could increase from 10 percent to 38 percent, and graduation rates would remain constant.

But addressing the issue of economic disparities at selective institutions requires leadership.  The discouraging news is that most wealthy institutions have not followed Amherst’s lead.  Despite a great flurry of activity on the financial aid front, The Chronicle of Higher Education recently found that at the wealthiest 50 institutions, Pell percentages remained flat between 2004-05 and 2008-09. At thirty-one of these wealthy colleges and universities, the proportion of Pell recipients actually declined. 

Amherst shows what is possible, but as Marx moves on to his new position as president of the New York Public Library, others will need to step up to redeem the promise of higher education as an engine for social mobility.

The Medicare Shaggy Wolf Story

Maggie Mahar

You may have seen the  headline: “Dire Forecast  Sparks New Medicare Debate; Trustees' Report Used As Fodder For Political Salvos By Both Sides,” but the date may come as a surprise:  June 6, 1996.

At the time, the Chicago Tribune warned its readers: “Medicare trustees reported Wednesday that the program's financial outlook is getting worse, touching off a new round of debate over the future of the federal health insurance system for the elderly and disabled. According to the trustees, who give the program a fiscal checkup every year, the fund that pays Medicare hospital bills dipped into the red last year and will go broke in early 2001. That's a year earlier than they predicted in 1995.” 

Sound familiar? How about these warnings:

Chicago Tribune July 2, 1969: “The Medicare hospital trust fund faces bankruptcy by 1976 and taxes must either be raised or benefits reduced the senate finance committee was told today.”

Washington Post, April 1, 1986: “The Medicare hospital insurance program faces bankruptcy by 1996, two years earlier than projected last year.”

New York Times, January 20, 1985: In the last few years, when it appeared that the Medicare trust fund would run out of money in 1987-89... But the need seemed less urgent after the Congressional Budget Office issued new estimates last September indicating that the Medicare trust fund would not go bankrupt until 1994.

(Hat tip to Chicago Tribune columnist Eric Zorn who culled eighteen stories from the Tribune, the Washington Post and the New York Times over a period of four decades, each predicting that the Medicare Hospital Insurance Fund was teetering on the brink of disaster.)

But of course Medicare didn’t “run out of money” in 1994, and it won’t go belly-up now, in large part thanks to health care reform legislation.  According to the Congressional Budget Office (CBO), the Affordable Care Act (ACA) raises and saves over $950 billion. In the process, as the Medicare Trustees’ Report 2011 points out, the ACA reduces Medicare spending “by 25 percent”—without cutting health benefits, or shifting costs to seniors.

Continue reading "The Medicare Shaggy Wolf Story" »

The New Jersey Supremes Decide. . . Again

Gordon Macinnes

The New Jersey Supreme Court handed down its first edict about educating poor children in 1973. It promulgated its twenty-seventh published opinion on the issue on May 24, 2011.  At issue was whether the court’s definition of what constituted a constitutionally defensible educational opportunity for the state’s poor children had been observed by the governor and legislature in enacting the state budget. Specifically, should the state be mandated to increase funding to conform to the new school aid formula enacted in 2007, a $1.6 billion hole?

New Jersey is litigation central when it comes to equity in school funding. As a result of Abbott v. Burke, New Jersey’s highest spending districts are its poorest. 

Continue reading "The New Jersey Supremes Decide. . . Again" »

May 23, 2011

Medicare Breaks the Inflation Curve

Maggie Mahar

The S&P recently released data tracking the growth of health care costs which showed that over the year ending March 2011, Medicare spending rose at an annual rate of 2.78%—the lowest rate posted for the Medicare Index in its six-year history. (Hat-tip to Kent Bottles for calling attention to this report on Twitter. This news is, as Bottles says, “very important”, not to mention timely, given the deficit debate in Washington.)

By contrast, over the same 12 months, health care costs covered by commercial insurers rose by 7.57%.  Still, as the chart below shows, even these costs (tracked by the “commercial index”) have been falling, down from a peak inflation rate of nearly 10 percent in the 12 months ending in July 2010 to 7.5% in the 12 months ending March 2011.

Continue reading "Medicare Breaks the Inflation Curve " »

May 18, 2011

You Can’t Save Medicare Just by Raising Taxes. But You Could Save Medicaid That Way.

Harold Pollack

(Cross-posted at the Reality Based Community)

Ezra Klein notes today that one can’t save Medicare through revenue alone. Although I support selected tax increases to address Medicare costs, we must actually confront the program’s unsustainable cost growth in the coming decades. That won’t be easy from any perspective, but it must be done.

Ezra quotes me as saying: “One unintentional benefit of health-care reform would be that if we get health-care financing on a better footing, we would stop killing all sorts of social programs that do more on the margins for health than health care does but are being starved for resources.” I strongly endorse that view. Current and future Medicare recipients should accept reasonable cost controls as part of needed health reforms.

Medicaid, though, is another story. Per-recipient, Medicaid costs have been growing more slowly than costs have been rising elsewhere in the medical economy. The Congressional Budget Office forecasts relatively disciplined Medicaid cost growth for decades to come. One implicit reason for Medicaid’s relatively modest projected cost growth is the realization that recipients lack the political heft to resist painful measures that constrain spending.

Cost control is not the most important challenge facing Medicaid. Indeed I would like to see the program spend more, for example by paying competitive rates to medical providers. I would also like to see expanded services for long-term care. As TCF's Greg Anrig has often observed, the key Medicaid budget challenge is to provide the federal supports and the additional tax revenue required to put the program on a better financial footing.

We often lump Medicare and Medicaid into a single bucket of “health entitlements.” We shouldn’t do that. Both programs face serious challenges, but the challenges are very different.

May 17, 2011

Why Aren't We Talking More about Unemployment?

Neil Bhatiya

The National Journal has an excellent new study on how the major print media covers economic news. Over a two-year period (April 2009 to May 2011), according to staff reporter Clifford Marks, instances of headlines and ledes mentioning “unemployment” declined drastically in the five newspapers which were surveyed, while uses of “deficit” rose, peaking at 261 at the end of December 2010, when the President’s National Commission on Fiscal Responsibility and Reform released its report. As Marks makes clear, these numbers reflect the success of conservative messaging in “changing the narrative of economic policy from one dominated by talk of fiscal stimulus to one now in lockstep with notions of fiscal austerity.” The strength of that narrative is expected to rise as the United States met its statutory debt limit on Monday.

This messaging persists despite polling that suggests the public’s attention hasn’t followed that of newspaper reporters or political pundits.  Gallup’s most recent poll (Americans’ Economic Concerns Reach Two-Year High) demonstrates that people rate the economy in general and unemployment/jobs above the federal budget deficit/federal debt and that, even among self-identified Republicans, only 17% rank the federal budget deficit as the “most important problem” facing the nation (the economy ranks first at 38%, followed by unemployment at 24%). Polling analysis by Century Foundation Senior Fellow Ruy Teixeira found similar public dissatisfaction with prioritizing deficit reduction over the economic security of ordinary Americans.

Continue reading "Why Aren't We Talking More about Unemployment?" »

What to Think about Cornel West....

Harold Pollack

This is cross-posted at the Reality Based Community

I never know what to think about Cornel West. He shows that one can combine an astonishing range of brilliance, erudition, and humanity with an equally astonishing range of pomposity and self-involved grandstanding. Today’s headlines provide a case in point.

Chris Hedges quotes Professor West below:

I think my dear brother Barack Obama has a certain fear of free black men… It’s understandable. As a young brother who grows up in a white context, brilliant African father, he’s always had to fear being a white man with black skin. All he has known culturally is white. He is just as human as I am, but that is his cultural formation. When he meets an independent black brother, it is frightening. And that’s true for a white brother. When you get a white brother who meets a free, independent black man, they got to be mature to really embrace fully what the brother is saying to them. It’s a tension, given the history. It can be overcome. Obama, coming out of Kansas influence, white, loving grandparents, coming out of Hawaii and Indonesia, when he meets these independent black folk who have a history of slavery, Jim Crow, Jane Crow and so on, he is very apprehensive. He has a certain rootlessness, a deracination. It is understandable.

“He feels most comfortable with upper middle-class white and Jewish men who consider themselves very smart, very savvy and very effective in getting what they want,” he says. “He’s got two homes. He has got his family and whatever challenges go on there, and this other home. Larry Summers blows his mind because he’s so smart. He’s got Establishment connections. He’s embracing me. It is this smartness, this truncated brilliance, that titillates and stimulates brother Barack and makes him feel at home. That is very sad for me.

This offends and self-immolates on so many levels

Continue reading "What to Think about Cornel West...." »

May 13, 2011

A Little Perspective on the New Social Security Trustees Report

Greg Anrig

The headlines about the new annual report on the finances of Social Security, along the lines of “Running Out of Money Faster,” create the impression that something dramatic has happened since the previous report was released last August. But the bottom line remains anything but alarming: even if no changes are made to Social Security, it will be able to continue to pay out promised benefits in full until 2036. After that point, payroll tax revenues would be sufficient to finance 77 percent of promised benefits, declining very slightly thereafter. The 2036 depletion date is a year earlier than in the last report and six years earlier than the most optimistic forecast in 2004. But by way of perspective, the Social Security trust fund depletion date was projected to be as soon as 2034 back in 1999 and even earlier in previous years.

The excitable media reporting that invariably accompanies these reports is a bit comical because the year-to-year fluctuations are usually an outgrowth of mundane actuarial tweaks as number crunchers synthesize new data and adjust their guesses for the future accordingly. In this year’s report, as the trustees put it: “Changes in mortality projections, due to new starting values and revised methods, are the most significant of several factors contributing to the increase in the deficit. These mortality changes resulted in lower death rates for the population age 65 and over. Adding to this negative effect are near-term lower levels of net other immigration and real earnings than assumed in last year’s report.” You can check out Table II.D2 in the report to see how small the technical adjustments are that lead to the overblown media coverage.

Dean Baker of the Center for Economic and Policy Research highlights the impact of the adjustments in life expectancy projections: "It is interesting to note that while the Social Security Trustees assume a big jump in life expectancies for retirees today compared with their assessment last year, they actually assume less progress in future decades. The 2010 Trustees report assumed that between 2010 and 2080, life expectancy at age 65 for men would increase by 4.2 years and by 4.1 years for women. By comparison, the 2011 report assumes an increase in life expectancy over this period of just 4.0 years for men and 3.9 years for women. By having more improvement in life expectancy now and less in later years, the near-term finances of both Social Security and Medicare look somewhat worse."

 Social Security will remain on strong financial footing for many years to come and can be sustained indefinitely into the future with relatively minor adjustments. Eliminating the cap on earnings subject to the program’s payroll tax in its own right would nearly the trick, although there are many other options. Nothing meaningful has changed, yet again.