BOYCOTT WHOLE FOODS

Rebuttal to John Mackey’s Wall Street Journal  Op-Ed

“The Whole Foods Alternative to ‘ObamaCare’”

By Joel A. Harrison, PhD, MPH 

John Mackey’s editorial in the Wall Street Journal is merely a continuation of the myths propagated by the for-profit health insurance and pharmaceutical industries and the right-wing think tanks they fund. His suggestions would take us farther in the direction that has already failed.

For this rebuttal I’ll focus on the following points: 

• Healthcare IS a right in other countries.  So, what does our Constitution “guarantee?” The European Union’s Constitution includes Health Care as a Right. The U.S. Supreme Court ruled in 1936 that Article II Section 8’s “Promote the General Welfare” applied to Social Security. Medicare falls under this ruling. Though not binding, the Universal Declaration of Human Rights, signed by the United States, includes medical care as a right.  (Details and references)
• Does health reform mean a “government take-over?” Ridiculous question but NO! Free markets do not work without rules and an independent arbiter. All Bills before Congress maintain the private sector for delivery of health care, both hospitals and doctors; but include regulations such as protection from arbitrary loss of health insurance and greater transparency.  (Details and references)
• Repealing mandates on what insurance must cover & state laws which prevent insurance companies from competing across state lines. Without some minimum national regulations and means of enforcement, companies will incorporate in states with the least regulations and enforcement, leaving consumers vulnerable. In addition, administrative costs for doctor’s offices and hospitals will increase. (Details and references)
• Health Savings Accounts – Why they don’t work. 80% of health care costs for individuals in the U.S. exceed $2,500 and 73% exceed $5,000, so people would rapidly exhaust their health savings accounts. Sick and injured people trust their doctors to make appropriate decisions and neither have the skills for making the decisions nor the availability of data to base such decisions on. High deductibles leads to reductions in both appropriate and inappropriate care, e.g. blood pressure monitoring.  (Details and references)
• Medicare reform and finances – Why we will not allow Medicare to go bankrupt. Medicare has done a better job than private insurance companies in keeping costs down. Medicare covers the costliest sector of our population, altogether over 43 million Americans. Private insurance would either be denied due to pre-existing conditions or prohibitively expensive. Medicare pays for all specialty residencies and subsidizes hospitals with a high proportion on uninsured. Without Medicare, besides the human tragedy of seeing our loved ones experience both reduced quality and length of life, emergency rooms will collapse under the additional strain, hospitals will close, and many doctors will go out of business. Medicare’s cost cannot be separated from a health care system whose current projectory is unsustainable.  (Details and references)
• Wait times here and abroad (including emergencies) – Mackey’s misleading statistics. Wait times in Canada are far better than reports given here and they are investing vast sums in improving both quality and timeliness of care. Wait times in many other nations with non-profit universal health care are actually quite good. And wait times in the U.S., especially for the un- and underinsured are worse than in many other countries and, even for those with insurance, wait times exist and are deteriorating.  (Details and references)
• Medical Liability/Tort Reform – why this won’t solve the healthcare crisis. Malpractice costs are an infinitesimal portion of total health care costs. Up to 100,000 Americans die from preventable medical errors. Just five percent of all doctors are responsible for approximately 40% of malpractice suits. Truly bad doctors seldom lose their licenses. Only about 1/10^th of all medical errors that cause death or serious disability lead to malpractice suits. So-called “defensive medicine” is often just an income generator for physicians who own or are invested in labs and radiology facilities.  (Details and references)
• Healthy life styles are good but don’t save us enough. Many factors affect health, including genetics, air and water pollution, infectious diseases, commercial food interests targeting children, even in our schools, availability of recreational facilities, physical education in our schools, and longer and longer working hours. Healthy life styles are important; but almost everyone will sometime in their lives need health care. A healthy life-style can often delay the onset of chronic diseases and/or if ill or injured contribute to a more rapid recovery; but it is naïve to believe that healthy life styles can solve our health care system problems.   (Details and references)

CONCLUSION: John Mackey doesn’t know what he is talking about. In essence, he is just parroting the myths and propaganda created by the for-profit insurance and pharmaceutical industry together with their well-funded right-wing think tanks.

I don’t wish to support a platform of policies that allow private insurance companies to continue to take undue advantage of average citizens for profit, much less make it easier for them by adopting any of Mackey’s ideas.  I am joining thousands of former Whole Foods loyalists to redirect my dollars to support organic co-ops and local farmers’ markets. I hope you will join me.

Joel A. Harrison, PhD, MPH, lives in San Diego, where he does consulting in epidemiology and research design. He has worked in the areas of preventive medicine, infectious diseases, medical outcomes research, and evidence-based clinical practice guidelines. He has lived and studied in both Canada and Sweden.  Dr. Harrison is a long time advocate for a single-payer plan. For those interested in learning more go to Physicians for a National Health Program’s website at www.pnhp.org

Dr. Harrison is a Fan of the Whole Foods Boycott Action Page on Facebook.

WHAT DOES OUR CONSTITUTION “GUARANTEE”?

According to Mr. Mackey: “A careful reading of both the Declaration of Independence and the Constitution will not reveal any intrinsic right to health care, food or shelter. That’s because there isn’t any. This “right” has never existed in America.”

Neither does our Federal or State Constitutions include a right to education, to clean air and water, to national parks, to libraries, to public health departments, or to beach lifeguards. However, the Preamble to the Constitution does state that one of its goals is to “promote the general welfare,” and Article II Section 8 states “The Congress shall have Power to . . . provide for the . . . general Welfare . . .To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers . . .”  

So does our Constitution “guarantee” health care? We do have Medicare whose constitutionality is based on three decisions by the U.S. Supreme Court beginning in 1936 which decided the Constitutionality of the Social Security Act based on Article II Section 8’s power to provide for the general welfare states.[1] So health care per se may not be explicitly written into the Constitution; but Social Security and by extension Medicare have been ruled constitutional by our Supreme Court as an application of providing for the “general welfare.”

Mackey also writes: “Our Canadian and British employees express their benefit preferences very clearly—they want supplemental health-care dollars that they can control and spend themselves without permission from their governments. Why would they want such additional health-care benefit dollars if they already have an “intrinsic right to health care”? The answer is clear—no such right truly exists in either Canada or the U.K.—or in any other country.”

For Europeans, the European Union Constitution requires some form of guaranteed coverage to all citizens and legal residents (see below). Neither Canada, the UK, France, Germany nor many other countries that offer some form of universal non-profit health care cover everything. Some have nominal copayments, some cover all medications while hospitalized; but not outpatient medications.  So, for Mackay’s Canadian and British employees to want additional monies to cover such things as outpatient drugs and dental care does not negate the concept of health care as a right.

From European Constitution of 2004:

ARTICLE II-95

Health care

Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities. 

ARTICLE III-278

Union action shall respect the responsibilities of the Member States for the definition of their health policy and for the organization and delivery of health services and medical care. The responsibilities of the Member States shall include the management of health services and medical care and the allocation of the resources assigned to them. 

“The Universal Declaration of Human Rights was adopted by the General Assembly on 10 December 1948 by a vote of 48 in favor [including the United States]. Even though not formally legally binding, the Declaration has been adopted in or influenced most national constitutions since 1948. It also serves as the foundation for a growing number of international treaties and national laws and international, regional, national and sub-national institutions protecting and promoting human rights. The 1968 United Nations International Conference on Human Rights advised that it “constitutes an obligation for the members of the international community” to all persons.” [2]  “Article 25. (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

Joel A. Harrison, PhD, MPH 

REFERENCES

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[1] Constitution, Art. I, section 8; United States v. Butler, 297 U. S. 1, 65; Steward Machine Co. v. Davis, supra.”  (see Constitutionality of Social Security Act http://www.ssa.gov/history/court.html ). 

[2] Wikipedia, “Universal Declaration of Human Rights,”  http://en.wikipedia.org/wiki/Universal_Declaration_of_Human_Rights

Does health reform mean a “government take-over” AND WHAT ROLE DOES GOVERNMENT PLAY IN HEALTHCARE TODAY? 

Neither the current Democrat’s Affordable Health Choice Act, HR 3200, nor the single-payer bill, HR-676, involve a “government take-over” of health care. In either case, care will be delivered by the private sector. However, any form of insurance requires regulations to protect the consumer and the public in general. 

It is important to understand that we, all of us as a community, already are involved in the funding of health care to a greater extent than any other “consumer commodity.” Currently, over 65% of the cost of health care in the U.S. is paid for by taxes, e.g. Medicare, Medicaid, VA, Indian Health Service, all city, county, state, and federal employees, and any businesses contracted with various levels of government who supply their workers with health care (any contract includes total wage packet costs).[1] 

Almost all of the basic scientific research that forms the foundation for medical advances is paid for by the taxpayer (National Institutes of Health and research grants to universities). No private for-profit company is going to invest 10s of billions of dollars over 20 – 30 years with no guarantee of success. In addition, over half of all breakthrough drugs are funded by the taxpayers as well as innovative new medical procedures. Medical education is highly subsidized (tuition and fees comprise only about 10% of actual costs) and medical residencies are funded by Medicare. Many hospitals were either built or renovated through taxpayer monies starting with the Hill-Burton Act of 1946 and for many years Medicare built into their fee schedule to hospitals the cost of new equipment acquisitions so that many of the CAT scans, MRIs, etc. were funded by Medicare.[2] 

It challenges credibility to claim that anything mainly funded by taxes would fit a free-market model. F.A. Hayek, founding gestalt of Libertarian free-market economics, whose seminal book, “The Road to Serfdom,” is a continuous screed against government as the ultimate threat to freedom and free markets freedom’s guarantor, writes: “Nor is there any reason why the state should not assist the individuals in providing for those common hazards of life against which, because of their uncertainty, few individuals can make adequate provision. Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance—where, in short, we deal with genuinely insurable risks—the case for the state’s helping to organize a comprehensive system of social insurance is very strong [my emphasis].”[3] 

Joel A. Harrison, PhD, MPH 

REFERENCES

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[1] Harrison, Joel A. “Paying More, Getting Less: How Much is Our Sick Health Care System Costing You?” Dollars and Sense Magazine, May/June 2008. http://www.dollarsandsense.org/archives/2008/0508harrison.html

[2] Public Citizen. “Rx R&D Myths: The Case Against the Drug Industry’s R&D ‘Scare Card,’” July 2001. http://www.citizen.org/documents/ACFDC.PDF; William Shonick. “Government and Health Services: Government’s Role in the Development of U.S. Health Services 1930-1980,” Oxford University Press, 1995.

[3] F. A. Hayek. “The Road to Serfdom (Fiftieth Anniversary Edition),” Chapter 9: Security and Freedom, page 133. The University of Chicago Press, 1994.

Repealing mandates on what insurance must cover & state laws which prevent insurance companies from competing across state lines:

Mackey writes: “Repeal government mandates regarding what insurance companies must cover. These mandates have increased the cost of health insurance by billions of dollars. What is insured and what is not insured should be determined by individual customer preferences and not through special-interest lobbying.”

People cannot possibly be expected to accurately anticipate health care needs. Creating individually tailored policies will drive up the underwriting and administrative costs of insurance, one of the driving forces behind our already excessively expensive health care system. The idea of insurance is to spread the risk. If, for instance, all policies do not cover maternity care, then premiums will rise for those wishing such coverage. Smaller pools and additional administrative costs would result. In addition, society will end up paying the cost of uncovered care for many and others will face bankruptcy. In other words, Mackey’s proposal would, indeed, drive up the costs of care.

Mackey also writes: “Repeal all state laws which prevent insurance companies from competing across state lines. We should all have the legal right to purchase health insurance from any insurance company in any state and we should be able use that insurance wherever we live. Health insurance should be portable.”

Mackey’s proposal could potentially increase costs. Increasing the number of insurance companies in a market will add to the administrative costs of health care. Doctor’s offices and hospitals will have to add staff to deal with all the new plans, their deductibles, and their networks as well as the negotiations with the different companies.

I agree that health insurance should be portable; but with certain caveats. The current House Bill, HR 3200, requires the following:

• Prohibits premium variances, except for age, geographic area, or family (vs. individual) enrollment.
• Prohibits cancellation of coverage except for evidence of fraud.
• Limits annual out-of-pocket expenses to $5,000 for an individual and $10,000 for a family.

Additional requirements would be policy language understandable to the average consumer; clear and fair appeals processes; reserve fund requirements; prompt reimbursement of providers and hospitals, and neither denials nor excessive premiums for those with pre-existing conditions.

However, some states have regulations with strong protections for consumers and aggressive enforcement while others do not. If we could establish one set of strong consumer protections nationally, then allowing companies to compete across state lines would be acceptable. Currently, which state would the consumer turn to for help if they have a grievance against an out-of-state insurance company? Mackey’s proposal as it stands would leave the consumer vulnerable.

Joel A. Harrison, PhD, MPH 

HEALTH SAVINGS ACCOUNTS and WHY THEY DON’T WORK:

Mackey writes: “Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs). The combination of high-deductible health insurance and HSAs is one solution that could solve many of our health-care problems. For example, Whole Foods Market pays 100% of the premiums for all our team members who work 30 hours or more per week (about 89% of all team members) for our high-deductible health-insurance plan. We also provide up to $1,800 per year in additional health-care dollars through deposits into employees’ Personal Wellness Accounts to spend as they choose on their own health and wellness.

Money not spent in one year rolls over to the next and grows over time. Our team members therefore spend their own health-care dollars until the annual deductible is covered (about $2,500) and the insurance plan kicks in. This creates incentives to spend the first $2,500 more carefully. Our plan’s costs are much lower than typical health insurance, while providing a very high degree of worker satisfaction.”

I have been shopping at Whole Foods for over 20 years, first when doing my post-doctoral training in Houston, then when working in Dallas, then in Philadelphia (called Fresh Fields), and now in my hometown of San Diego. In all that time I can’t recall seeing anyone but young employees. Perhaps, there are a few older employees at their corporate offices? Since the odds of someone young experiencing a catastrophic health problem is small, the Whole Food approach gives a false impression. For those who have studied economics, the “fallacy of composition” is the term used for the logical fallacy of arguing that what is true for the parts is also true for the whole. In the study of economics, this takes the form of assuming that what works for parts of the economy, such as households or businesses, also works for the aggregate, or macro-economy. 

“Health savings accounts (HSAs) are promoted by insurers as the ‘consumer-directed’ solution to the health care crisis, and by some conservatives as a way to make individuals more ‘responsible for their health care choices.’ Advocates of HSAs contend that health insurance ‘disguises’ the true cost of health care. Patients with health insurance, advocates say, see the health services they receive as being ‘free,’ and therefore overuse them, causing health care costs to rise. Health savings accounts purportedly solve this problem by forcing consumers to purchase health services ‘with their own money.’ When patients pay for care out of private accounts, the theory goes, they will cut back on ‘frivolous’ health services and demand price competition from doctors, hospitals, and other providers, thereby lowering costs. Patients with a serious injury, illness or chronic disease, however, will rapidly deplete their HSA savings. Patients don’t decide what to “buy,” they rely on doctors and nurses to guide treatment decisions, and hospitals to have all necessary personnel, equipment, and supplies at the ready. The information to compare prices and quality (such as when car shopping) does not exist and would be extremely unreliable anyway, since the easiest way for a provider to improve quality and lower price would be to shun the sickest patients. Finally, patients are poorly equipped to “shop around” for health care at the time in their life they are most vulnerable and in need of guidance and compassionate care.” [1] 

“A small share of people accounts for a significant share of expenses in any year. In 2004, almost half of all health care spending was used to treat just 5 percent of the population, which included individuals with health expenses at or above $13,386. Just under a quarter of health spending (22.5 percent) went towards the treatment of the 1 percent of the population, which included individuals with health expenses at or above $38,688 in 2005. Because the onset of disease [or injury] is unpredictable and can require intensive technology and time to treat, the distribution of health spending is highly concentrated.”[2]  Further, 73.6% of healthcare was for expenses greater than $5,191 and 80.3% of healthcare for expenses greater than $3,735. Given that health savings accounts usually come with a high deductible plan with a deduction of either $2,500 or $5,000, between 73.6 and 80.3% of costs exceed the deductible (ibid). 

“Cost-sharing deterred contact with the medical system across the entire spectrum of illnesses and problems seen in the outpatient setting. . . . We found no evidence that the imposition of cost-sharing led individuals to make appropriately selective decisions about the problems for which they will seek care. Not all complaints and symptoms require medical attention, so cost-sharing does reduce ostensibly inappropriate use of ambulatory care. It appears to invoke a considerable risk of foreclosing medical diagnosis and treatment for conditions in which such intervention can be expected to be effective and to benefit the patient (p. 78).”[3] 

In summary, health savings accounts will not affect overall healthcare spending, will increase administrative costs, and could actually lead to costlier care by reducing beneficial health care visits. Even so-called “frivolous” visits for, e.g. the common cold, can detect high blood pressure or a missed childhood vaccination. For a more complete discussion of health savings accounts see Physicians for a National Health Program Fact Sheet: “Health Savings Accounts – No Savings,” at http://www.pnhp.org/facts/hsa.pdf  

Joel A. Harrison, PhD, MPH 

REFERENCES:

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[1] Physicians for a National Health Program Fact Sheet: “Health Savings Accounts – No Savings,” at http://www.pnhp.org/facts/hsa.pdf

[2] Kaiser Family Foundation, “Health Care Costs: A Primer,” August 2007, http://www.kff.org/insurance/upload/7670.pdf

[3] Lohr, Kathleen N. et al., “Use of Medical Care in the Rand Health Insurance Experiment: Diagnosis- and Service-Specific Analyses in a Randomized Control Trial,” reprinted from Supplement to Medical Care, vol. 24 (8), September 1986, S1 – S87, http://www.rand.org/pubs/reports/2006/R3469.pdf

Medicare reform and Medicare finances: 

Medicare is subject to the same cost pressures as the private sector. Yet, Medicare has done a better job of containing costs than the private sector.[1]

Medicare’s administrative costs are approximately 3% compared with the private sectors 15%. Unfortunately, the Bush administration and Republicans pushed Medicare Advantage to get seniors into various forms of managed care. The Medicare Payment Advisory Commission found that Medicare could save approximately $17 billion per year by eliminating this program which, in essence, just gives creates additional profits. The Medicare Modernization Act of 2003 which created the Drug Benefit Program, Medicare Part D, forbade Medicare from negotiating with the drug companies, something that all for-profit insurance companies, the military, the VA, and Medicaid are allowed to do. Estimates put savings at $20 billion per year if Medicare negotiated the same prices as the VA.

Medicare does suffer from fraud; but fraud is endemic to the entire U.S. health care system, far more than in other systems.[2]  

Medicare is not facing bankruptcy. It will, however, have a shortfall, that is, revenues coming in will be less than expenditures in a few years. But our GDP will also have grown so that, as a percentage of GDP, we will manage. On the other hand, our entire current health care system’s projected cost increases are unsustainable.

For those who like to pick on Medicare, a few facts are in order. Medicare covers the most expensive segment of our population: Seniors, AIDS patients, patients with End-Stage Renal Disease, patients with Amyotropic Lateral Sclerosis (Lou Gehrig’s Disease), and people disabled by illness or injury for two years. No for-profit insurance company will cover these people. They represent the quintessential pre-existing conditions. The total number of Medicare Beneficiaries in 2008 was 44,831,390 (15% of U.S. population).[3]  Perhaps, a few may obtain insurance at exorbitant costs, probably with a rider to exclude any pre-existing condition; but the vast majority would not be able to obtain private coverage. Vouchers for private coverage would be prohibitive.

Imagine the consequences if Medicare were to fail. Besides watching our loved ones face premature disabilities and death, anticipating the same for ourselves, our already overcrowded emergency rooms would collapse under the added burden. Medicare pays additional monies under the Disproportionate Share Program to hospitals who treat high percentages of the uninsured and/or poor. These hospitals would be the first to close followed by many more hospitals closing and doctors offices going out of business. And since Medicare pays for all residencies, in the future we would have fewer specialists.

Is Medicare Underpaying Doctors? A doctor at Congresswoman Maxine Water’s town hall August 22^nd in Los Angeles said that Medicare actually pays more for some services than private insurance and that private insurance pays no better overall. However, even if in some instances Medicare pays less, do doctors lose money on Medicare patients? 

Airlines often offer half price or less for standbys for last minute boarding. Since they only need to fill a percentage of the seats to cover costs, another percentage to gain profits, then any monies received from the remaining empty seats just add to their profits. Standard economics says that as the number of patients increase, the average costs, including fixed costs (office expenses, including building, equipment, and staff), decrease. Currently, approximately 10% of doctors’ billings are to cover the excess administrative costs of dealing with our fragmented for-profit system. Why should Medicare fees cover the excess administrative overhead?[4] 

Imagine what would happen if all the patients currently on Medicare ceased to be insured. Would doctor’s incomes then go up? So, as far as I can tell, the claim that doctors lose money on Medicare patients is simply a statement that they don’t make as much as they would like.

Joel A. Harrison, PhD, MPH 

REFERENCES:

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[1] White, Joseph, “Markets and Medical Care: The United States, 1993-2005,” Milbank Quarterly, 2007, Vol. 85, No. 3, pp. 395-448, http://www.milbank.org/quarterly/8503feat.html

[2] Malcolm K. Sparrow. “License to Steal: Why Fraud Plagues America’s Health Care System,” Westview Press, 1996 

[3] Kaiser Family Foundation. “Total Number of Medicare Beneficiaries 2008,” http://www.statehealthfacts.org/comparemaptable.jsp?ind=290&cat=6 

[4]  Woolhandler, S. et al. “Costs of Health Care Administration in the United States and Canada,” New England Journal of Medicine, Vol. 349, 2003, 768-75, http://www.pnhp.org/publications/nejmadmin.pdf

Wait times here and abroad (including emergencies):

According to John Mackey, “Although Canada has a population smaller than California, 830,000 Canadians are currently waiting to be admitted to a hospital or to get treatment, according to a report last month in Investor’s Business Daily. In England, the waiting list is 1.8 million.”

How would Mackey rate the wait times of our rapidly approaching 50 million uninsured (see below for consequences) or our 20+ million underinsured, altogether twice the entire population of Canada?  And it is estimated that at least 22,000 Americans die every year due to lack of health insurance.[1]  I think these figures should be included in any estimates of wait times! 

In addition, what does it mean to be waiting?  For example, if I were to list all Americans scheduled for hospitalization or treatments, except for emergency cases, then anyone not immediately hospitalized or treated would be on my list. Think about it. How many people do you know who needed a hip replacement, cataract, or coronary bypass surgeries were immediately hospitalized? When not a life-threatening situation, many Americans with excellent health insurance still wait weeks and sometimes months for surgery with no negative consequences.

Below are several studies showing that wait times in other countries are much better than our vested interests’ propaganda mill would have us believe:

A recent study found the following for Canada and England: [2]

For Canada: “Median self-reported waiting times were about:
Four weeks for a specialist visit for a new illness or condition in 2003 and 2005; Three weeks for a selected nonemergency diagnostic tests (angiography, MRI, and CT scans) in 2003 and 2005; Four weeks for nonemergency surgery in 2001, 2003, and 2005. 

For England: “Numbers of long-waiting patients have declined:
Inpatient treatment: number waiting more than 6 months for treatment fell from about 265,000 in March 2000 to about 12,000 in November 2005; Outpatient treatment: Number waiting more than 13 weeks fell from about 390,000 in March 2000 to about 40,000 in September 2005.”

Both Canada and England have been pouring monies into improving both the quality and timeliness of care (see references below). In the U.S., though we spend twice as much as either nation, we rank poorly on most outcome measures [3]  “and while waiting times in Canada and England are coming down, in the U.S. they are increasing as reported by a recent article in USA Today:

In a recent article in USA today: 

 “They say patience is a virtue, but for those who need health care, it’s a necessity. And if you live in an urban area, you could be waiting several months to get an appointment with specialist or family doctor. 

A study by Merritt Hawkins and Associates shows that appointment wait times have increased on average by more than a week since the survey was last conducted in 2004. 

Merritt Hawkins, a consulting firm that specializes in recruiting physicians and other health care professionals, surveyed more than 1,150 medical offices in 15 cities. The survey measured average appointment wait times in family practices as well as four specialties: cardiology, dermatology, obstetrics/gynecology and orthopedic surgery. 

The survey found that, on average, wait times have increased by 8.6 days per city. Boston had the longest wait, averaging 49.6 days, followed by Philadelphia with 27 and Los Angeles with 24.2. The shortest was Atlanta with an 11.2-day wait. 

In all cities among all the specialties, the wait was 20.5 days.”[4] 

One study found that “among . . . six countries, Americans, along with Canadians, were more likely to say they waited six days or more for an appointment with a doctor or had trouble getting care on nights and weekends.[5] 

It is a myth that Canadians wait longer than Americans to see doctors. In fact, according to the U.S. Congressional Research Service, Canadians average 6.1 doctor visits per year while Americans average 3.9 and the average time per visit is longer in Canada.[6] 

In addition, average wait times to see specialist are quite reasonable. Keep in mind that there is a difference between emergency care and care for a condition such as a deteriorating hip that has taken a life-time to develop. Waiting a few more weeks in Canada to get high quality care at no cost at point of service, regardless of your income, is worth it. Statistics and projects on improving wait times in Canada are available on the web.[7] 

Emergency Care: According to studies on emergency care in the U.S. by the Institute of Medicine: “Another consequence of overcrowding has been a striking increase in the number of ambulance diversions. Once considered a safety valve to be used only in the most extreme circumstances, such diversions are now commonplace. Half a million times each year—an average of once every minute—an ambulance carrying an emergency patient is diverted from an ED that is full and sent to one that is farther away. In 2004, according to the American Hospital Association (AHA), nearly half of all hospitals—and close to 70 percent of urban hospitals—diverted patients at some point during the year. Each diversion adds precious minutes to the time before a patient can be wheeled into an ED and be seen by a doctor, and these delays may in fact mean the difference between life and death for some patients. Moreover, the delays increase the time that ambulances are unavailable for other patients.” [8] 

Many factors contribute to the above; but the main reason is that hospitals lose money on the un- and underinsured, so they close their emergency rooms. In addition, those emergency rooms that remain open are overcrowded with un- and underinsured patients, many who have conditions that could have been prevented or chronic conditions that have worsened due to lack of ability to afford a regular doctor. Emergency care is much better in many countries with universal non-profit health care systems since they are not overburdened by uninsured and/or those with preventable conditions.

Joel A. Harrison, PhD, MPH 

REFERENCES:

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[1] Urban Institute. “Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality,” January 2008, http://www.urban.org/UploadedPDF/411588_uninsured_dying.pdf

[2]  Willcox et al. “Measuring And Reducing Waiting Times: A Cross-National Comparison Of Strategies,” Health Affairs.2007; 26: 1078-1087 Commonwealth Fund Summary, http://www.commonwealthfund.org/usr_doc/Willcox_measuringreducingwaitingtimes_1045_itl.pdf?section=4039

[3] Response to DON”T FIX WHAT ISN’T BROKEN,” East County Magazine, June 21, 2009, http://www.eastcountymagazine.org/?q=node/1429

 [4] Erin Thompson, “Wait times to see doctor are getting longer,” USA Today, June 3, 2009, http://www.usatoday.com/news/health/2009-06-03-waittimes_N.htm, Merritt Hawkins & Associates. “2009 Survey of Physician Appointment Wait Times.” http://www.merritthawkins.com/pdf/mha2009waittimesurvey.pdf

 [5] Karen Davis et al. “Mirror, mirror on the wall: An update on the quality of American health care through the patient’s lens.” The Commonwealth Fund, April 2006, http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2006/Apr/Mirror–Mirror-on-the-Wall–An-Update-on-the-Quality-of-American-Health-Care-Through-the-Patients-Le.aspx

 [6] Chris L. Peterson and Rachel Burton. Congressional Research Service Report for Congress. “U.S. Health Care Spending: Comparison with Other OECD Nations,” September 17, 2007, http://assets.opencrs.com/rpts/RL34175_20070917.pdf

 [7]  Canadian Institute for Health Information. “Wait Time Tables: A Comparison by Province,” 2007, http://secure.cihi.ca/cihiweb/en/downloads/aib_provincial_wait_times_e.pdf; Health Council of    Canada. http://www.healthcouncilcanada.ca/en/;

    Health Council of Canada, “Rekindling Reform: Health Care Renewal in Canada, 2003 – 2008,” June 2008. http://www.healthcouncilcanada.ca/docs/rpts/2008/HCC%205YRPLAN%20(WEB)_FA.pdf;

    Health Council of Canada. “Wading through Wait Times: What Do Meaningful Reductions and Guarantees Means? An Update on Wait Times for Health Care,” June 2007. http://healthcouncilcanada.ca/docs/rpts/2007/wait_times/hcc_wait-times-update_200706_FINAL%20ENGLISH.pdf;

    Rachlis, Michael M.. Public solutions to health care wait lists. Canadian Centre for Policy Alternatives, December 2005. http://www.policyalternatives.ca/documents/National_Office_Pubs/2005/Health_Care_Waitlists.pdf;

    Sanmartin, Claudia et al. Waiting for medical services in Canada: lots of heat, but little light. CMAJ, May 2, 2000, Vol. 162, No.9, pp 1305 – 1310. http://www.cmaj.ca/cgi/reprint/162/9/1305;   

    Wait Time Alliance for Timely Access to Health Care. http://www.waittimealliance.ca/index.htm; 

    Wait Time Alliance. “April 2007 Report Card,” http://www.waittimealliance.ca/images/report_card.pdf

 [8] Institute of Medicine, “Future of Emergency Medicine in the United States Health System,” Report Brief, June 2006, http://www.ena.org/practice/future/IOM/Documents/IOM_FutureEmergencyCare_8_PageSummary.pdf

Medical liability – Tort Reform:

Mackey writes: “Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year. These costs are passed back to us through much higher prices for health care.”

According to a recent CBO study: “Some so-called defensive medicine may be motivated less by liability concerns than by the income it generates for physicians or by the positive (albeit small) benefits to patients. On the basis of existing studies and its own research, CBO believes that savings from reducing defensive medicine would be small. . . it found no evidence that restrictions on tort liability reduce medical spending” [1]. In addition, they found that malpractice cost represented “less than 2 percent of overall health care spending” (ibid).

Studies undertaken by the General Accounting Office and the Department of Health and Human Services found that physicians who hold a financial interest in medical laboratories and other diagnostic facilities order tests that range from slightly fewer to more than twice as many as those ordered by doctors without such ownership interests.  In addition, the services ordered by self-referring physicians are usually more expensive than the same services performed at independent labs.[2] 

A 1983 survey by Blue Cross and Blue Shield of Michigan, as reported in the Wall Street Journal, found that “diagnostic laboratories owned by referring physicians charged almost double the fees of other labs and did nearly twice as many tests on the average patient.”[3] A University of Arizona research team used insurance claim records to analyze the frequency and costs of diagnostic imaging ordered during 65,517 episodes of outpatient care by 6,419 physicians.  Hillman and colleagues found that doctors who used their own equipment ordered diagnostic imaging much more often and charged more per procedure than doctors who sent their patients to an independent imaging facility:  “The combination of more frequent imaging and higher charges resulted in mean imaging charges per episode of care that were 4.4 to 7.5 times higher for the self-referring physicians.” [4]

According to a study by the Institute of Medicine up to 100,000 people die each year in the U.S. due to avoidable medical errors! A larger number suffer permanent disabilities and unnecessary suffering. [5] 

Studies estimate that 1% of doctors are responsible for about 18% of medical malpractice and 6% up to 58%. Unfortunately, given the current “philosophy” of our state medical boards together with their being underfunded and understaffed, it is almost impossible to take away a medical license. Given that doctor are human, albeit extremely intelligent, they obviously can suffer from addictions to alcohol and drugs, psychiatric problems, Parkinsons, and some, despite the rigors of medical school and residency, just shouldn’t be practicing medicine. [6] 

A large study conducted by Harvard Medical School where they reviewed medical errors in the largest hospitals in the Greater New York City area found that only 1 of 8 avoidable serious medical errors, most resulting in death, lead to a lawsuit. A similar study using a slightly different methodology conducted in California 10 years earlier gave almost identical results. However, “expressed in the form of ratios calculated from the sampling weights, the chances that a claim would be filed by a patient with an identifiable injury was not 1 in 7.6, but rather only 1 in 50” (p. 73).[7] 

Neil Widmar reviews research where among other things he presented defense lawyers (those who represented doctors in malpractice suits) and simulated juries with various malpractice cases. The result was that the defense lawyers actually awarded significantly more to the victims than the juries did. On interviewing the jurors, they said they were reluctant to destroy a doctor’s career because of “one” error. However, Widmar relates a case where the jury awarded 10s of millions of dollars. The doctors in the case had testified one by one that the child in question was not severely handicapped and would be fine with some therapy. When the child was brought into the courtroom, it was obvious the severity of his case. The jurors, when interviewed, were angered by the arrogance and lack of remorse shown by the doctors. The trial judge reduced the punitive damages; but retained the several million dollars awarded for lifetime medical treatment and care and future lost wages while agreeing with the jury’s outrage.[8] 

While some medical specialty premiums, e.g. neurosurgeons, may pay premiums as high as $300,000 for liability insurance; imagine an avoidable error that reduces a good student to a semi-vegetative state requiring medical and custodial care for the remainder of their lives costing $5 million or more. Or imagine the bread-winner of a family. These premiums, as high as $300,000 come from a neurosurgeon’s gross billings which are probably close to $2 million per year or higher. Plus, the $300,000 is tax deductible. In addition, such premiums are not the norm for most physicians, just specialties such as obstetrics and neurosurgery where the damage done to a patient can be devastating and the risk ever present. Family physicians and internist pays far less. 

So, defensive medicine is often more about profit than fear of malpractice and altogether accounts for a small amount of our overall health care costs.

Many avoidable medical errors cause harm to patients. However, medical errors are more than just the fault of individuals. They are a system problem. One hospital had several deaths due to use of the wrong drug during surgery. Each vial had to be signed for by several people, starting with the pharmacist. Given the stresses of working in medicine and the long hours, despite multiple check points, the drug got through. Anyone who understands probability will recognize that getting 50 heads in a row with a perfectly balanced coin will occur, albeit rarely. The hospital changed the system. Different size and shape bottles were adopted and the dangerous drugs were put in a separate refrigerator. Currently, the number of deaths from medical errors is the equivalent of a jumbo jet crashing every other day, year in and year out. Hospitals are now adopting for surgery what flight crews do, reading off a check list, marking the limb to be amputated, etc.

We need to get rid of the approximately 5% of “bad” doctors, suspend doctors, requiring retraining or therapy for those deemed capable of change, and, at the same time, work on changing system errors.[9]

 Joel A. Harrison, PhD, MPH 

REFERENCES

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[1] Congressional Budget Office. “Limiting Tort Liability for Medical Malpractice,” Economic and Budget Issue Brief, January 8, 2004, http://www.cbo.gov/doc.cfm?index=4968&type=0

[2]  Bacon, Kenneth H.. “Maryland Doctors Who Invest in Labs Seek Costlier Tests,” Wall Street Journal, June 2, 1989, p. B6.

[3] Waldholz, Michael and Bogdanich, Walt. “Warm Bodies: Doctor-Owned Labs Earn Lavish Profits in a Captive Market,” Wall Street Journal, March 1, 1989, p. A1.

[4] Hillman, Bruce J., et al. “Frequency and Costs of Diagnostic Imaging in Office Practice: A Comparison of Self-Referring and Radiologist-Referring Physicians,” New England Journal of Medicine, Vol. 323 (23), Dec. 6, 1990, p. 1604

[5] Institute of Medicine. “To Err is Human: Building a Safer Health System.” 1999, http://www.nap.edu/openbook.php?isbn=0309068371 (PDF EXECUTIVE SUMMARY) 

[6] Public Citizen. “The Great Medical Malpractice Hoax: NPDB Data Continue to Show Medical Liability System Produces Rational Outcomes,” June 2007 http://www.citizen.org/documents/NPDB%20Report_Final.pdf  

[7] Weiler, Paul C.  et al. “A Measure of Malpractice.” Harvard University Press, 1995 

[8] Widmar, Neil, “Medical Malpractice and the American Jury System: Confronting the Myths about Jury Incompetence, Deep Pockets, and Outrageous Awards. University of Michigan Press, 1995. 

[9] Bogner, Marilyn Sue (Ed.). “Human Error in Medicine.” Lawrence Erlbaum Publishers, 1994;    Groopman, Jerome. “How Doctors Think.” Houghton Mifflin Publishers, 2007; Leape, Lucian L. “Error in Medicine.” JAMA, December 21, 1994, Vol. 272, No. 23, pp 1851 – 1868.

Healthy life styles:

Mackey writes: “Unfortunately many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.

Recent scientific and medical evidence shows that a diet consisting of foods that are plant-based, nutrient dense and low-fat will help prevent and often reverse most degenerative diseases that kill us and are expensive to treat. We should be able to live largely disease-free lives until we are well into our 90s and even past 100 years of age.”

Healthy lifestyles would probably reduce or, at least, delay the onset of heart disease, cancer, stroke, and other medical conditions. According to one paper, the reduction in cardiovascular disease would add 1.3 years of life-expectancy.[1] Another recent article pointed out that, though prevention would increase the quality of life for many, the benefit-cost ratios for some preventions would be positive; but for others the costs of prevention vs. later treatment would not be cost-effective.[2]  The consensus is that prevention and a healthy diet is a good thing; but the cost savings are far lower than Mackey would like to believe. However, there are additional flaws in Mackey’s reasoning:

1. Our genetic programming, predisposing people to various medical conditions. In addition, our very chromosomes seem to be programmed for a maximum life-span. For those interested read up on telomeres, the ends of chromosomes that determine the number of times they can divide.
2. Our life-styles and commercial interests work against healthy food choices. Children are inundated with food commercials. Some school cafeterias around the nation are beginning to prepare healthier foods and the kids like them; but, it is more costly and more time-consuming. In addition, with decreasing budgets, schools have earned money by allowing vending machines. Once tastes and fat cells have developed, they are difficult to change. Would Mackey support more funding for schools and banning food commercials aimed at children?
3. When I was a kid we had five hours of physical education per week. Unfortunately, PE has been among the first to feel budgets cuts. Would Mackey support more funding for physical education programs in our schools?
4. Community recreation centers are seeing their budgets cut. Would Mackey support more funding for community recreation facilities?
5. Most families have both parents working long hours allowing little time for supervision of kids or for preparing healthy meals.
6. Cancer and other diseases are affected by pollutants in our environment.[3]
7. Healthier foods are often costlier. Most Americans can’t afford to shop at Whole Foods. Perhaps, Mackey would support government subsidies for fruits, vegetables, and additional taxes on less healthy foods, e.g. sugar content, fat content, etc?

Increasing life-expectancy depends on multiple factors, diet plays a role; but not near what Mr. Mackey would like to believe.[4]

Joel A. Harrison, PhD, MPH 

 REFERENCES:

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[1]  Richard Kahn et al. “Impact of Prevention on Reducing the Burden of Cardiovascular Disease,” Circulation, 18, 2008, pp. 576-585, http://circ.ahajournals.org/cgi/content/full/118/5/576

[2] Joshua T. Cohen et al. “Does Prevention Save Money?” New England Journal of Medicine, Vol. 358 (7), Feb. 14, 2008, pp. 661-663, http://content.nejm.org/cgi/content/full/358/7/661 

[3] Devra Davis, “Secret History of the War on Cancer,” Basic Books, 2007 

[4] Riley, James. C. “Rising Life Expectancy: A Global History,” Cambridge University Press, 2001.