More evidence of a public health leadership void

Revere: Maybe I am missing something here. My experience of the US health system was limited to a 30 minute visit to a doctor's surgery in Fort Worth for which I was charged around $50. By Australian standards, especially taking in to account comparative per capita GDP, I thought the charge reasonable. In Australia the government would have refunded about 70% of that charge, but that is our health system, for which we pay 3% of income before tax.

For hospital cover we have a much maligned "free system" which guarantees cover for "emergency" surgery, (heart attack etc) and a waiting list for non-emergency surgery. (for a hip joint, the wait might be 12 months). Paid from that same 3%.

But if you want that cataract removed, or that hip replaced this year, having insurance helps. Residents can purchase hospital insurance for about AU$250/month (family) which pays most of elective surgery & hospital costs and most incidentals. That insurance attracts a government rebate of around 30c per $1.

So how is your system so much worse? Or are your complaints similar to your complaints of political corruption, which in comparison to most other countries is miniscule? (In Australia our retired politicians seem to get hired for $1 million p/a by the organizations that prospered under their custodianship). We hear very much darker stories of corruption in Central/S America, the middle east, Africa & Asia.

For comparison of hospital costs, I believe that cataract removal in Australia would cost about AU$3k - AU$5k for both eyes. I would expect that operation to cost (adjusting for exchange rate & per capita income) about US$5k - US$8k in the USA?

bar, my insurance costs $6,000 a year and covers only catastrophic injury, which is fairly typical in the US. 47 million Americans have no insurance--can't afford it.

Having Medicaid will not save a single life.
Emergency rooms are required to treat patients regardless of ability to pay, so if you show up, you're guraranteed treatment, if it's available.

But that's a BIG IF: ER's do not have and will not have the staff or resources to handle a pandemic. People will die waiting for treatment in the ER. There will not be enough hospital beds for those who need inpatient treatment, and people will die waiting for a bed, or they'll simply be told to go home, and they'll die there.

That's the real problem that no one wants to address...not whether or not Medicaid will pay!

But a written plan makes it look like responsible people have done their job. The truth is that individual households/families will be left to face the pandemic largely on their own.

Payment is not the issue!

Leadership would be prescribing a crash public education course in basic health and biology sciences and infection control, "prescribing" full pantries of shelf-stable food,

and asking loudly why communities aren't having the public, "all" stakeholder, pandemic preparedness committees that would make public health's job easier by the time pandemic breaks out.
Don't they want as many people as possible alive, by the theoretical time an effective vaccine ever manages to be made?

Revere: Speaking of leadership... I am slowly making my way through the comments on this post at the Flu Wiki Forum, but I'd be interested in your take. It may be a long shot, but it's the most constructively optimistic idea I've seen in awhile: that a combination of stockpiling supplies, masks, and an early vaccine could significantly dampen the effect of a severe pandemic.

It might or might not be effective even assuming it were feasible, but at least it's looking forward.

bar one of the problems with the U.S. health system is that the tens of millions of people without insurance don't get preventive care or even prompt care of acute problems. Doctors are not required to see you for routine care if you don't have insurance, and even if they do, they can charge over $100 just for a ten minute office visit, never mind prescriptions and lab tests. (You were lucky to get seen for $50.) The end result is that people end up at the emergency room when their problems become acute, where even getting seen by a doctor could run over $1000. They actually charge uninsured people two to three times as much as they charge insurance companies for the very same services, because uninsured people can't get group discounts.

People get billed, and if they can't or won't pay, the hospital has to make up the cost. Meanwhile, the person may end up filing for bankruptcy. Half of all bankruptcies declared in the U.S. in a recent one year period were due to medical bills. In 2006, more women declared bankruptcy than graduated from college. Congress dealt swifty with this problem... by making it easier for corporations to file for bankruptcy, and harder for individuals to do so.

And in many cases, the acute care comes too late. Think of cancer. Treatment can run into the hundreds of thousands of dollars. Uninsured people can't afford that. And people whose insurance is through their own work, as opposed to a spouse's or parent's work, have to worry about being cut off the insurance if they're too sick to work for long enough. So even if you're insured... you're not really insured.

My experience has been that bureaucracies are primarily concerned with a combination of CYA and whatever "best practices" happen to be this years fad. You write a recommendation aimed at the above rather than expectation or consideration of both administration and cost of actually implementing the recommendation. No one actually implements the damned things. What we do is to continue what we have been doing (or what we know works) and adapt the nomenclature in our paperwork to appear to reflect whatever the recommendation was. When we do decide to adopt some inovation (technological or administrative) it is generally because we see the actual need rather that having anything remotely related to last years recommendations, plans, and / or vision and mission statements. I don't peresonally know about the public health service but that is the way things happen in other bureaucracies.

carl: APHA is the voice of American public health, a large and generally progressive professional body. It can't implement anything, but it can provide leadership. Unfortunatley it isn't donig that. It has done so in the past but not recently. It isn't APHA alone. There is a huge void in leadership, also something that hasn't always been true. Can you name the Surgeon General of the US? Can you name any SG of the US, ever? (If you are like most people, the answer is "yes," usually C. Everett Koop, but also including some others). The face of public health in the US is Julie Gerberding of CDC and she is an abject failure as an agency head. Internationally Margaret Chan has a chance. We'll have to see.

Here is your current Surgeon General. Have you ever heard of him? I haven't.

Melanie: He is the Acting Surgeon General. They let the previous one's (Rich Carmona) appointment lapse without comment in July. It is now 7 months and there is no permanent SG. They could care less. The previous one was almost invisible anyway. So the official face of government public health is only Acting and not doing much of that either.

Bar-traditional for a family of four costs about 450 a month and thats with a 20 USD deductible. What UHC will do is ensure that everyone gets some sort of coverage and a government takeover. Its socialism at its finest. Does the quality of care improve? Not really. The amount of red tape that would be involved would eat up about 75 cents per dollar. On the other hand, Medicare, Medicaid, Social Security and yet another entitlement program would eat up over 1.75 for every dollar spent. Huh? 1.75? Yep, .75 more than is put in. It will become a bottomless pit. We might have started this in the 60's when everyone was young and the boomers were just coming of age but its too late now. Nothing to put in. Where are the oldies going to get the money? The oldies are starting to retire and their S.Security alone will take up every dollar ever put in and then some. . Then it burns another 1.25 above that for the next 35 years. Long broke by 2015, they will have to just print money to make it work out. INFLATION!!!! We still are coming out of Iraq next year so thats a little bit less of a drain but man we aint going to cover that with the entire military budget. Its just not possible.

Oil will be at least 200 per barrel at that time-or we will be using something else. Our one saving grace is that we can raise the price of food to the world and try to at least keep it partially sane.

Melanie-You advised you have a pre-existing condition of immense proportions and for that I am truly sorry. Will it get to the 1930's situation of people just dying on the street? I think you can count on it. Again there are those that assume that healthcare is a right. It isnt. Yes that means if I get screwed up where I cant work then I would be in deep trouble except for the boys at AFLAC and their damned goose. I also have secondary insurance if I get to where I cant work that pays about 5 million. I would have to make some corner cuts but I would get by. But these were choices I made and I am not dead. What about the Melanies of the US? I dont have an answer except for them that we SHOULD UHC those people. Able bodied and I mean people with headaches and sinus problems get shit. We need them working and making it happen and not a drain. Pandemic comes, it wont matter anyway. Those that are infirmed they will try to save but in all reality they are going to become numbers on a blotter somewhere. Reality sucks.

Revere is right this country will be a 3rd rate power in 20 years. Population paying in is now starting to retire and they are now drains on a system that is between 7 to 1 to 10 to 1 depending who you talk to about it. Hey, but really its the ENTITLEMENTS that got us to where we are now. We didnt do jack shit for the military during J. Carter and we almost had the Russians make a run into Pakistan from Afghanistan and with it the Strait of Hormuz. We need physical security before any of this other stuff can even be addressed. I am not feeling really secure right now. Al Qaeda is on the move again and thats coming from the libs in a lot of quarters. If they see it then we sure as Hell arent.

caia-You hit it on the head and it was brought up in a briefing about the number of people that would be in default if they died. There would be a glut of housing, toppling that market and the stock market with it. At the 8% the markets would lose 30% (thats an estimate) of its value in the first year. After the second year it would stabiilize and then as the supplies ran out the economies would start to rebound. The ace kicker is that we have food and the ability to produce it here. We will have to get that fully underway and keep it underway at all times during a pandemic of major proportions. Money might very well become totally worthless. I dont know but there are a lot of things to consider and if even 3 out of a list of 10 happen, we are cooked but good.

Randolph & Melanie, thanks for the info. In Oz we have a form of universal health cover called Medibank, which costs 3% of ebt, and provides treatment at the big "public" & teaching hospitals Then we have medical insurance companies selling insurance for private hospitals & costing an extra $250 up to $400 /mo (depending on "excess").

I believe that Social security in Australia is quite generous by European or US standards. Nearly all pensions are means tested. Unemployment pension lasts until the recipient is employed, however there are quite strict "attend employment interview" requirements, and malingering to obtain the bullet will also cause loss of the pension for a period.

We have "permanent disability" pensions together with availability of a "carers" pension.

The demographic (ageing) profile in the US is comparatively quite healthy. You should see the demographics in W. Europe or Japan. I would imagine the picture in China would be grim. For the USA the demographic problem is not too serious & the solution is obvious: raise the retirement age & allow immigration or work permits to Hispanics, (think of it as payback for the "Munro Doctrine"). Hispanics are hard workers and mostly not terrorists. W.Europe recently expanded it's workforce by absorbing Eastern Europe. The earlier European solution of allowing migrant labour from Asia & Africa seems to have resulted in the development of an endogenous terrorist problem.

I don't believe the US will be a third (or even second) rate power in the next two decades. The US will prevail because the political system is flexible, power is fragmented and corruption is contained. The US is the utopia for the poor around the world and will have it's pick of immigrants.

Nations like China and Japan are not stealing US wealth, they are contributing to it. They do the hack work and leave it to the US to do what it does best, which is originate ideas. (about everything.)

caia. I must say the picture that you paint of the US health system is grim. I have privately speculated that US healthcare problems began when a union organizer negotiated the first medical insurance scheme for members. That was the beginning of your two tier system. Doctors are human; they would rather deal with patients for whom payment is guaranteed, so they charge double or treble for walk ins. I would imagine that the word would spread quickly if a doctor did not charge that premium.

bar,

We are the only country in the industrial west which treats health as a benefit rather than a right (see Randy, above.) Tying health care to employment hasn't worked out very well.

In my metropolitan area, finding a doctor who will even see you if you don't have insurance is nearly impossible. That isn't two-tier health care, that's NO health care.

Its very simple and goes with really three basic assumptions. First is that HC is a right. Even witchdoctors charge for their services so its not really a right. Second-Who pays for it? Some guy who will be tasked (taxed) in his young 20's when he should be making future taxpayers? That will ensure that he/they will not be able to afford to make new taxpayers. The system is going to be in a shambles on just the Medicare alone costs, not to mention UHC and Soc.Security. Too many outflows. Then they will tax the Soc. Security checks that everyone gets now. Double taxation on money you put in and against your will at that. You dont have the right to opt out of S.Security. You make an income, you have to pay. No choice in the matter.

Finally, what if the system does collapse? If a bird bug or other point of source problem kicks our asses these plans are all going to be in the dump and millions will die because they were on the government dole. No way for them post of a collapse to make money, generate heat/light/food or to buy it.

We worry about pandemic. I worry about post pandemic. I can get thru a pandemic, but maybe not post..

mrk:Health care intervention is a socially approved act whenever an individual acts against the current witch doctor theory of disease, e.g. if I kept wild pet rats running free in my house, or allowed a child to attend school with an open ulcer, I would expect intervention.

I consider myself well and truly told (see above) that the US health system is a slow motion train wreck. My own instinctive response is that "too much intervention by way of regulation is the problem".

Unlike yourself, Randolph, I believe the biggest problem is surviving the pandemic. People who have experienced good government would want to have it restored, and it is the military people among us who will do that job. Even with an 80% fatality rate, post pandemic USA would retain enough skilled personnel (military, engineers, doctors, lawyers, agriculturalists) to supervise restoration of our society from the wealth of ruins. So just have a loose military organization, and post pandemic (if you survive) you set up a guided democratic state and invite people to join.