Todays #hcr Moment: Hospital Failures in Massachusetts

Crossposted from DemConWatch.

The Massachusetts health care experiment has been up and running for five years now. As I and others have been writing for years, it was a bad idea then, it's a bad idea now, and it's only going to get worse over time.

Today's problem? Hospitals. In the 1980's there were 95 hospitals in the state. Now, there are 65, and 16 of them lost money last year. In June, two of them (both over 120 years old) filed for bankruptcy. Ouch. There are currently about 6.5 million people in the state, up from 5.7 million in 1980. More people, less access.

The problem for hospitals, in Massachusetts and elsewhere, is trifold. First, reimbursement rates keep falling across the board, but especially as relates to Medicare and Medicaid. Related to that, hospital costs keep rising. Second, there is a huge difference between rich and poor hospitals, setting things up (like across America) where the rich get richer at the expense of the poor. Finally, there is the issue of “the deal”. 

Hospital costs are somewhat fixed. Labour is a huge one, and then there are the costs of things like drugs, medical equipment, supplies, food. We can talk economies of scale, and that prices are too high, but the bottom line is that when you're sick, you need care, and care costs.

More after the jump.

Then we come to the issue of rich and poor hospitals. Rich hospitals are mostly, but not always, private and for-profit. They're in “better” neighborhoods. They have the newest equipment, higher percentage of private-insurance pay patients, as well as things like private suites, on-site chefs, and in some cases 4 star hotel-like accommodations. These hospitals often work in groups: a first tier teaching hospital in a city, with tertiary feeders in richer suburbs. At the other end of the spectrum are community-based hospitals, in poorer neighborhoods, or the only game in town for 200 miles in a rural area. They have x-ray machines and maybe CT scanners, but doubtful MRIs and for sure no PET or BEAM scanners. No robotic surgery equipment, no electronic records. Often licensed professionals are replaced with aides, or “technical partners“. 

This second issue of rich and poor hospitals is exacerbated by “The Deal”. When I wrote about this back in 2009, I opened with: 

“The Deal” refers to the relationship that a large insurance company has with all of the hospitals in a geographic area. With the exception of military bases, prisons, and Indian Reservations, virtually every other acre in America has one insurance company with “The Deal.”

You can see the full article here, complete with US map showing insurance company market share. In 2009, with the exception of Florida, Oklahoma and New York, one or two insurance companies controlled more than 50% of the market. Indubitably, it's gotten worse since then.

In Massachusetts, this all comes together (to the great detriment of patients) with Partners, a very large conglomerate of hospitals that cut a deal with the Blues in 2000, driving up both hospital and insurance costs across the state, decreasing quality care across the board, and fully showing the damage The Deal will do. In this case, not just losing money, but the bankruptcies of Quincy Medical Center and North Adams Regional Hospital.

The political ramifications are far-reaching. Not just because of the parallels of the Massachusetts plan and the Federal plan. But because when Medicaid and Medicare funds are cut as part of the debt ceiling deal, more people suffer. Massachusetts is the case that proves the point that single payer is the way to go for every single rational reason there ever has been, or could be. 

Health care is not a matter of “if”, but of “when”. Everyone gets sick, or has an accident, at some point in time. The worse one's economic situation, the higher the probability of needing MORE care. I could go on for tomes about what's wrong with health care in America, and what we need to do to fix it. (Wait, I HAVE….if you put “health care” in as a tag in DCW, you'll see more than 300 articles over the past few years.) But for today, CALL. And while you're on the phone, mention that “raising taxes” is the wrong phrase, it should be “making tax cheats pay what they've owed for decades.” We need to stand up as one and do everything we can to prevent the wacko right in charge of DC from killing even more poor people. And yes, every hospital that closes leads to deaths. Just looking at emergency rooms, more than 25% have closed:

In 1990, there were 2,446 hospitals with emergency departments in nonrural areas. That number dropped to 1,779 in 2009, even as the total number of emergency room visits nationwide increased by roughly 35 percent. – NY Times.

So do something today. Call the White House and your reps and let them know how important it is to keep Medicare and Medicaid (and the rest of the safety net while you're at it) out of the debt ceiling deal. In case you don't have the numbers on speed dial:

White House Switchboard: 202.456.1111.
Full list of Senate numbers here.
Full list of House numbers here.

Jewish Sources on the Provision of Health Care


— Rabbi Gail Labovitz

Reposted from JSPAN in honor of the Global Day of Learning marking the completion today of Rabbi Adin Steinsaltz’s translation of the Talmud. (See Live broadcast at 2pm and various events in the Philadelphia area.)

When one starts from a worldview in which God is active in the workings of the world, it is quite possible to understand illness and physical weaknesses as God’s judgment on the ailing person, so that any intervention is a challenge to the workings of God’s will. This viewpoint has been voiced by some Jewish thinkers, from the sages of the classical rabbinic tradition, through the great bible commentators of the medieval period, and beyond. In other contexts, and in numerous sources, however, saving a life is considered to be one of the highest commandments in Judaism, so much so that almost every other commandment can be violated to further this end. This quite different perspective – one that validates medical expertise and makes the practice of healing a religious obligation – has also been present in Jewish tradition from its earliest expressions.

More after the jump.
Two verses in particular from the Torah serve as the core foundation for what has become the normative Jewish view on healing and access to healthcare. Exodus 21:19 discusses a case in which one person has injured another in an altercation. The Torah rules that the assailant must see to it that the victim receives necessary medical attention: “he shall certainly heal him.” In context, the obvious meaning is that the assailant must pay the victim’s medical costs, but the rabbis derive additional meaning from the doubling of the verb in Hebrew. Thus we read in the Talmud, Berakhot 60a and Bava Kama 85a: “It was taught in the school of Rabbi Ishmael: ‘he shall certainly heal him’ – from this source, the healer is given permission to heal.” As Nachmanides noted in his 13th century work, Torat ha-Adam, “this is to say that it is not forbidden because of the concern that the doctor might inadvertently err; also, people should not say ‘the Holy One has struck (the ill person) and is the One to heal.'” Nachmanides continues, “it is a commandment to heal, and is in the category of saving a life.”

That healing is not only permissible, but can be considered a required act for those with the necessary knowledge and training, emerges all the more strongly from a second verse, Deuteronomy 22:2. In its basic, contextual meaning, the verse tells us that one who finds lost property is obliged to return it to the original owner: “you shall return it to him.” Since the Hebrew suffix meaning “it” can also mean “him,” the rabbis reread the phrase, in Bava Kama 81b and Sanhedrin 73a: “From where do we know the requirement to return a person’s body?” – that is, save a person’s life? “The Torah says, ‘return him to himself.'” Maimonides, in his commentary on the Mishnah (Nedarim 4:4), makes explicit that this includes providing medical care: “the doctor is obligated by law to heal…and this is included in the explication of the verse, that ‘return it to him’ means to include (the ‘return’ of) his body…” Joseph Karo thus brings together these traditions to write in the Shulhan Arukh (Yoreh De’ah 336:1): “Torah gives the healer permission to heal. And it is a commandment, and is a matter of saving life. And if one withholds oneself, this person spills blood.”

We now come, then, to the question much on our minds at this moment – how is health care to be provided to those who need it, and whose responsibility is it to see that health care is provided? Both the Palestinian and Babylonian Talmuds state that a person, or at least a scholar, should not live in a town that does not have a doctor (P.T. Kiddushin 4:12 [66b]; B.T. Sanhedrin 17b). At a time when all family finances were supposed to flow through the male head of household, the rabbinic tradition ruled that husbands were expected to pay for their wives’ needed medical treatment, and this was considered an obligation as basic as providing for her daily sustenance (Mishnah Ketubot 4:9; B.T. Ketubot 52b). Clearly, individuals and families have the first responsibility to seek out the healthcare they need and to pay for it as they are able.

Nor is a medical provider allowed to overcharge for treatments or for medicines in a case of dire need, a rule codified in the Shulhan Arukh (Yoreh De’ah 336:3): “One who has medications, and another person is sick and needs them, it is forbidden to raise their prices beyond what is appropriate.” Yet because receiving needed medical care can be a matter of life and death, and saving life is a religious and moral obligation, numerous sources suggest that doctors have an obligation to provide medical care in all cases, even to those unable to afford it on their own. The Talmud, in Ta’anit, praises the model of Abba the blood-letter: “He had a spot outside (of his workspace) to put coins; those who had put some in, but those who did not have could come in and sit without being ashamed.” But this approach is an ideal. Certainly, it could leave physicians in an untenable position, obligating them to care for all in need, but not yet insuring that their own needs to make a reasonable living will be met.

I turn, then, to a much more recent source, a modern responsum by Rabbi Eliezer Waldenberg, published in 1985 (Ramat Rachel, no. 24; published in vol. 5 of Rabbi Waldenberg’s collected responsa, Tzitz Eliezer). He begins by writing that the provision of needed medical care is of such significance that a bet din may, in fact, compel a doctor to provide free medical care to a patient unable to pay, and that it is not the responsibility of the court or the community to reimburse the doctor. However, he then modifies this ruling in a very important way, applying it only when there is just a single doctor in the locale. Where there are multiple doctors, no one doctor can be compelled to provide services not demanded of the others. Rabbi Waldenberg thus suggests several means by which a community might provide for its members, including paying for the medical care from communal charity funds, or creating a system whereby doctors equitably share the case load on a pro bono basis. His preferred system, where the community has the means, is to provide a monthly fee for doctors in exchange for seeing any patients in need. What is most significant about Rabbi Waldenberg’s responsum, then, is not that he provides the Jewish answer for the way in which a community should provide medical care for all. What he does tell us, though, is that providing such care, in the final analysis, is most certainly the responsibility of the community as a whole. It is thus not surprising that Jewish rabbinic and lay organizations across the denominational spectrum have agreed that we must seek the goal of an equitable system of access to healthcare in America.

Finally, I would like to conclude with the words of Maimonides, himself a physician in addition to his many other achievements. In Hilkhot De’ot (4:1), what we might call the Laws of Personal Development, he writes: “Health and wholeness of the body are among the ways of God, for it is impossible that one can understand or know anything of the knowledge of the Creator when one is ill. Therefore one must distance oneself from things that harm the body, and conduct oneself in ways that create health and wellness.” A failure to promote health when we have the ability to do so impedes our chances of achieving our full spiritual and personal potential. And as for the individual, so for the community made up of those individuals.

Additional Primary Sources:

On Exodus 21:19, see also the commentary of Ibn Ezra (both “long” and “short” versions)
On Bava Kama 85a, see also the commentary of Tosafot (who challenge Ibn Ezra’s understanding)
Kiddushin 82a, and the commentary of Rashi
Rambam, Mishnah Torah, Hilkhot De’ot 4:23; Hilkhot Nedarim 6:8
Ramban, Commentary to the Torah, to Leviticus 26:11
Shulhan Arukh, Yoreh De’ah 336:1-3
Otzar Midrashim, Temurah (the story of Rabbi Akiva and Rabbi Ishma’el)

A (Very) Partial List of Helpful Secondary Sources:
Elliot N. Dorff and Aaron L. Mackler, “Responsibilities for the Provision of Health Care,” Responsa 1991-2000: The Committee on Jewish Law and Standards of the Conservative Movement, 319-36; also available on-line at http://www.rabbinicalassembly….
David M. Feldman, Health and Medicine in the Jewish Tradition
Jill Jacobs, There Shall Be No Needy: Pursuing Social Justice through Jewish Law & Tradition, chap. 7
Fred Rosner, Biomedical Ethics and Jewish Law
Fred Rosner & J. David Bleich, eds., Jewish Bioethics
Laurie Zoloth, Health Care and the Ethics of Encounter: A Jewish Discussion of Social Justice

Trivedi and Gerlach Speak On Wide Range of Issues

Publisher Dan Loeb speaks with Congressman Jim GerlachDr. Daniel Loeb

Every election year since 2006, Temple Beth Hillel Beth El’s Israel Advocacy Committee, Men’s Club and Sisterhood invite the Congressional Candidates for Pennsylvania’s 6th district  to speak to the community, and this year was no exception. Incumbant Republican Congressman Jim Gerlach was followed by his Democratic challenger Dr. Manan Trivedi as they both addressed the crowd and took questions on a wide range of issues.

As was the case in the first debate between Gerlach and Trivedi, there was a small incident before the beginning of the event as the Gerlach campaign asked that the event not be filmed, and all recording equipment was removed. The second debate was televised and can be seen on the PCN website. This forum was not a debate format as the candidates appeared sequentially.

Israel


Both candidates spoke passionately of their support for the Jewish State. As a decorated veteran Lt. Commander in the U.S. Navy, Trivedi said

“I was ready to die for Israel because that is what allies do for each other.”

Both candidates were pessimistic about the current peace negotiations. Gerlach said he “saw no signs of a breakthrough there”. Trivedi blamed the Palestinian leadership “We need someone who can come to the negotiating table without preconditions.” Gerlach cited “Gaza’s extreme poverty and lack of educational opportunities which fosters hatred of Israel.” He added that the neighboring Arab countries could do something about the situation in Gaza but they are not interested.

More after the jump.
Trivedi cautioned that we should let Israel take the lead in the peace process. The United States he said “can facilitate, but should not take over” or “draw borderlines”, adding that he was “still waiting for a Palestinian Authority which can deliver on its promises.”  

Trivedi spoke of his Indian heritage which gives him reason to be vigilant yet optimistic. His family and friends who were affected by the terrorist attack last year in Mumbai remind him of the danger posed by terrorist groups like al Qaeda and Hamas who Trivedi insisted we “cannot negotiate with”. Yet he also recalled lessons from his parents’ hometown in India.  Ahmedabad was a city plagued by rioting between its Hindi and Muslim communities following the independence and partition of India in 1947, but the Indian government seeded economic development, and once everyone was more secure financially, suddenly they were less concerned with religious differences with their neighbors.

Gerlach responded to a hypothetical situation proposed by Steve Feldman (Director of the ZOA in Philadelphia) in which the administration were to impose a particular peace proposal by a fixed deadline. “Israel needs to make its own determination of what is a good agreement that it can sign on to. If Obama moves beyond that we can use the appropriations process – the power of the purse.”

Gerlach concluded

“There is strong bipartisan support for the State of Israel, and I imagine this will continue.”

Iran

Both candidates praised the recently passed Iran sanctions. Gerlach was disappointed that Obama has not yet employed the full range of sanctions available. Trivedi concurred. He saw the Iranian sanctions were having a real effect, but he said we need to implement all of the available the sanctions as quickly as possible since “centrifuges do not wait for negotiations.” A questioner asked how he would respond to military action by Israel and Iran. Trivedi said all options have to be on the table including the military option, adding that

“The only thing worse than the military option is a nuclear Iran.”

Afghanistan

The former Soviet Leader Mikhail Gorbachev recently warned that winning a war in Afghanistan is impossible. Gerlach was asked how he would vote on withdrawing troops from Afghanistan. Gerlach said “I would have to vote ‘no’ because I want to hear from General [David] Petraeus” who is reviewing the United States’ strategy in the region. Gerlach doubted whether Hamid Karzai’s government could stand long without our support.

Trivedi disagreed with Obama’s “surge” of 30,000 additional troops in Afghanistan. “I do not think they will cure the ills of Afghanistan.” Trivedi added that he does not trust the Karzai government, and he lamented Obama’s failure to address the opium problem in his “surge speech” since the opium drug trade is endemic to many of the problems in Afghanistan and has corrupted the Karzai administration. Trivedi observed from his experience in Iraq:

“The Military has smart power: nurses, engineers, …

“We can facilitate nation building but we can not impose democracy. It has to well up from within.”

Party Loyalty and Extremism

Both candidates tried to distance themselves from the leadership of their parties.

Manan Trivedi said he did not support Obama’s support of Human Rights initiatives in Israel, applying the Nuclear Non-proliferation ban to Israel or Biden’s insistence of a housing freeze in Jerusalem. Trivedi criticized the implementation of the stimulus bill, disagreed with the surge in Afghanistan and felt that the health reform bill did not address costs.

Trivedi concluded

I will take a good idea whether it comes from a tea party supporter or a left-winger or anything in between. We need a new breed of leaders who have no political chips to cash in.


Matt Hirsch asked Gerlach if there were any issues on which he disagreed with Republican House Minority Leader John Boehner. He cited several votes where he opposed the Bush administration: Overriding Bush’s veto of S-CHIP and supporting stem cell research. In fact, during Gerlach’s first three terms he built a moderate record by voting strategically: voting with his party when his vote was needed and voting with his moderate district when it was not. In this Congress, the Republicans have insisted of party discipline in order to avoid giving a hint of bipartisanship to legislation passed by the Democrats. Accordingly, the Philadelphia Jewish Voice followed up and asked for a more recent example where Gerlach opposed his leadership in the last two years. Gerlach said he supported his leadership on all of the major pieces of legislation: namely in opposing the stimulus package, health-insurance reform and cap-and-trade energy policy. Indeed Gerlach has been much more consistent lately in voting with his leadership though he did vote last July to extend unemployment benefits opposed by the Republican leadership.

Gerlach was also asked to comment on the impact of the tea party movement. Gerlach cited several local tea party groups who he said were “very engaged”. He praised them for “stepping up as citizens” and said “this is a good thing”.

Neither candidate eluded to alleged excesses in the tea party such as racism, rejection of principals such as civil rights or the Separation of Church and State, violence against Lauren Valle in Tennessee and the “citizens arrest” of a reporter in Alaska.

Tax Cuts

The 2001 and 2003 Bush taxes cuts expire at the end of this year. Unless Congress takes action during the lame-duck session or takes retroactive action next year, tax rates will revert to the levels they were at during the Reagan and Clinton administrations. For the richest Americans this would raise their marginal tax rate from 35.0% to 39.6%.

Jim Gerlach said that he along with the entire Republican caucus and “about 50 moderate Democrats” in the House of Representatives favor making the Bush tax cuts permanent. He doubted whether Pelosi would have the political strength to address this issue during the lame-duck session following the upcoming mid-term election. Gerlach also wanted to address the Alternative Minimum Tax which was never indexed and is catching more and more middle-class Americans.

Gerlach’s campaign was distributing “fact sheets” at the synagogue claiming that “Manan Trivedi opposes extending tax relief which will result in the largest tax increase in American history, roughly $2,000 per Pennsylvania family,” but in reality Trivedi  “supports extending tax cuts for all but the über-wealthy.” Trevedi said we needed to return to the old rates only for the portion of taxable income exceeding $250,000 per year. Keeping those tax breaks would cost Americans 700 billion dollars which Trivedi said “we cannot afford.” Economists have observed that tax breaks focused on the richest 2% of Americans “will not stimulate the economy” since “we have a demand side problem not a supply side problem.”

Spending

The Federal Budget for the new fiscal year has not yet been passed so the government is acting under a Continuing Resolution until December 3. Gerlach doubted the new budget would be passed in the lame-duck session but was confident that another Continuing Resolution would be passed to avoid a government shutdown before the new Congress could act on the budget in January.


Gerlach said “the current deficit spending is 20% of gross domestic production whereas historical it has been around 18 to 19%.” In reality, the deficit was 9.91% at the end of last year and it will grow to 10.64% based on the proposed budget which is less than the figure Jim Gerlach cited but still well above deficits seen since the end of World War II.

To solve this problem, Gerlach intends to draw on his experience as a State legislator where the budget had to be balanced. “Only the Federal government does not have a balanced budget requirement”. Calling the current situation “unsustainable”, Gerlach called for a Balanced Budget Amendment to the United States Constitution with exception in times of war or other national emergency similar to that proposed in during the Lyndon B. Johnson Administration. Similar amendments failed to pass the House by the required two-thirds majority in 1982, 1997 and 2005. Once the amendment passes Congress, it would then have to be ratified by 38 states before going into effect.

Gerlach was asked specifically what he would cut in order to balance the budget since entitlements, the military and interest make up 84% of the budget. Gerlach said that all areas of spending have to be under consideration including Medicare and Social Security. Gerlach also pledged to look at defense spending as well.

Manan Trivedi countered that “we need to cut spending, but we need to do it with a surgical knife, not a sledgehammer.”

From Trivedi’s experience in the military, he agrees with Secretary of Defense Robert Gates that we need to be more efficient and eliminate unneeded weapon systems. In Iraq, Trivedi saw contractors paid five times more to do half of the work of an enlisted serviceman.

Trivedi called Washington DC an “evidence-free zone” suggesting that by observation we can fund best-practices and drive costs down for a wide range of government programs.

Trivedi sees getting the economy back on track as critical to reestablishing fiscal discipline. Trivedi’s jobs plan will eliminate the 260 billion dollar loophole for companies that ship job oversees.  His jobs plan features tax incentives for small businesses which he called “the motor of our economy.”

Trivedi emphasized stimulating sectors of the economy which have a ripple effect and will provide long-term benefits for the economy. One example was the clean energy economy. Trivedi said we should work on smart grid, wind turbine and solar power technologies. “We are not doing the things the Chinese are doing, and they are going to be the leaders” in green technology and not us if we do not step up to the plate. Similarly, Trivedi wants to invest in infrastructure such as tunnels, roads and light rail here in the Sixth Congressional District and around the country in order to provide jobs right now and continue to create jobs in the future.

Health Care

Gerlach was asked if he would defund the Health-Insurance Reform which he voted against. He said he favored repealing the bill and replacing it with a new one without the “onerous new taxes.” (Gerlach did not explain how he would overcome the anticipated Presidential veto in order to repeal the bill.) Gerlach emphasized buying insurance across state-lines and working on tort reform as a way to drive down costs. He would also work to slow down and delay implementation of certain provision of the Health-Insurance Reform Bill. He did not expect an immediate solution, and expects this to remain an issue for next several administrations.

Trivedi looked at ease on the subject of Health Care and spoke with expertise not only as a battalion surgeon and as a primary care physician, but also as an expert on Health Policy. He received a Masters degree from UCLA in Health Policy and went on to serve as health policy advisor to the Navy Surgeon General and was an Assistant Professor of Medicine at the Uniformed Services University of Health Sciences.

Gerlach’s handout claimed Trivedi supported a “socialized single-payer medicine scheme.” However, Trivedi denied the allegation.

Trivedi said the Health-Insurance Reform bill was not perfect: it did not address costs and it was too long, but he would have voted for it because it was a step in the right direction. He compared it to other pieces of landmark legislation (such as civil rights legislation which still left many people unable to vote). These bills aspire to historic change but need to be improved over time.

Trivedi rejected repealing the bill as a step in the wrong direction.

“It would cost millions of dollars when we need to balance the budget. This would reintroduce insurance companies into the doctor-patient relationship. This would eliminate guaranteed coverage for those with preexisting conditions.”

Trivedi gave one of his own patients as an example who was unable to obtain coverage even though she was cancer-free because her medical files mentioned the word “cancer”.

To contain costs, Trivedi said we need evidence-based health policy to help drive down costs since “30% of medical treatment makes no difference in outcomes.”

Temple Beth Hillel-Beth El’s Rabbi Neil Cooper asked Manan Trivedi about coverage for mental health. Trivedi answered that “mental health is part and parcel of health care.” He lamented that mental health care has been unfairly stigmatized for generations and as a result post-traumatic stress disorder (PTSD) had not been treated as pro-actively as it should. During his work with the Navy’s Surgeon General, Trivedi drew on his own experience with combat medicine to become one of the early researchers to investigate the unique mental health issues affecting our troops returning from Iraq and Afghanistan.

Israel Action Committee chairman Lee Bender concluded the event by urging everyone to get out and vote next Tuesday.