Two years ago in one of my early posts, I wrote about the Massachusetts Health Plan. The Massachusetts plan was an effort to expand access to health care and reduce the number of uninsured and underinsured residents. The plan used a combination of government programs, incentives for companies and individuals to purchase health insurance, and penalties to enroll as many as possible in public or private health insurance programs. At the time, everyone was intrigued. However, everyone also knew this was an experiment, and, like all experiments, it would take time to learn whether this really worked.
Well, we now have some indication. A study of the Massachusetts plan has been published on the web site of Health Affairs. The report, “On The Road To Universal Coverage: Impacts Of Reform In Massachusetts At One Year,” was authored by Sharon K. Long, a Research Associate at the Urban Institute. (You can also read news reports on the study here and here.) The study is based on two telephone surveys, one taken just before the plan was implemented and the second one year after initial implementation. Each survey reached had results from approximately 3,000 households. While the report offers interesting details, you can gain a lot in this quote from the abstract:
In roughly the first year under reform, uninsurance among working-age adults was reduced by almost half among those surveyed, dropping from 13 percent in fall 2006 to 7 percent in fall 2007. At the same time, access to care improved, and the share of adults with high out-of-pocket costs and problems paying medical bills dropped. Despite higher-than-anticipated costs, most residents of the state continued to support reform.
Some specific points from the report:
The percentage of all those contacted who had no insurance dropped in one year from 13% to 7.1%. More specifically, those who had been uninsured at some time in the year previous to each survey dropped more than 4% (from 18.8 to 14.5).
There had also been concerns that there would be an effect of public programs crowding out employer based programs, either because employers would choose not to offer health plans to their employees, or because the employees would choose not to take the plans offered, in favor of government-supported plans. It appears the effect did not occur: “The share of adults overall and the share of working adults who reported that they had a coverage offer through their employer remained stable between fall 2006 and fall 2007.” It also appears that more families could identify a primary care provider, and that there was no increase in use of Emergency Rooms for nonemergency needs. The program did cost the state more than originally expected. This may be because there were more uninsured individuals than expected to incorporate into the program.
There is much more to note from this study, and from a related article, also in Health Affairs, titled "Massachusetts Health Reform Implementation: Major Progress And Future Challenges.” This article goes into more detail about implementation of the various parts of the program.
In this election year, in which access to health care is already a major issue, it is worthwhile to look at the Massachusetts experiment, as well as at similar programs in California and Pennsylvania. While one or two years isn’t a long track record, it can give some indication whether these programs are meeting individual and social needs. With that information, we can be more clear what we expect from those we elect, not only as President, but also in all the Congressional races.
Tuesday, June 10, 2008
Monday, June 09, 2008
We've Been Here Before
Care in extremis continues to be a challenge, especially when good people disagree about the patient's best interest. Two current cases that highlight the problem have come to my attention.
The first is this case from Florida. A woman has been between the hospital and a nursing home since suffering a stroke in December. Her husband believes that she is not aware and will not recover, and that she wouldn't want to live this way. He thinks her feeding tube should be removed. The patient's mother, however, believes the patient is aware and can recover (or at least recover enough). She wants the feeding tube retained. One good thing is that so far husband and mother-in-law are still cordial. A court has appointed an attorney for the patient, but so far no other third parties are involved. (Of course, it's only been a few months, and this is Florida....)
The second case is from Winnipeg. An 84 year old gentleman has been in intensive care and on life support since October. The patient is an Orthodox Jew, and his family feels everything must be done. Physicians feel care is futile. In fact, one doctor feels so strongly that he has resigned - and not just from the case, but from the hospital.
The case has gone to court, although a trial date has not been set. The hospital is coping with the loss of one intensivist, but worrying that there may be more resignations, forcing closure of the ICU. Staff feel continuing care is cruel, and want the case resolved as soon as possible. The family feels faith requires continuing care, and want the trial delayed, at least past the High Holy Days, to be sure representatives of their Orthodox community can participate.
It the Florida case sounds all too familiar, you're not alone. There are enough parallels to the Terry Schiavo case to catch everyone's attention. Although the case hasn’t gone on nearly as long, it is another case in which the patient’s husband and the patient’s parent differ in their beliefs about the patient’s awareness, prognosis, and wishes. There are also parallels between the Winnipeg case and the Schiavo case, if different ones. As in the Schiavo case, there is significant difference between the diagnosis and prognosis presented by physicians, and the family’s assessment and prognosis. In addition, the patient’s religious faith, and appropriate medical care in light of the patient’s faith, are central issues shaping the family’s decisions. And, as in the Schiavo case, this is in the courts.
I don’t raise the similarity with the Schiavo case as if to say, “See, these cases are popping up all over.” I think the fact that they’re news is in fact evidence that they’re not common, largely because in most circumstances the professionals and families can come to consensus about what the patient would wish. Neither to I want to suggest that somehow the notoriety of the Schiavo case would have brought massive change. It did result, at least in my area, in a lot of new Health Care Directives and Durable Powers of Attorney for Health Care; but I didn’t expect any single case to result in radical change in the culture.
I raise it because they do have common themes that need continued and constant attention. We could even articulate those themes again in the categories of the Georgetown Mantra.
The most important circumstance shared by this Florida case, the Winnipeg case, and the Schiavo case, is their complexity. All these cases, however simple and straightforward each might seem from one party’s perspective, in fact become complex as those parties and interests interact. It remains difficult to reach resolution; and more difficult, if not impossible, to reach reconciliation.
And in the meantime, while many speak for them and about them, the patients remain....
The first is this case from Florida. A woman has been between the hospital and a nursing home since suffering a stroke in December. Her husband believes that she is not aware and will not recover, and that she wouldn't want to live this way. He thinks her feeding tube should be removed. The patient's mother, however, believes the patient is aware and can recover (or at least recover enough). She wants the feeding tube retained. One good thing is that so far husband and mother-in-law are still cordial. A court has appointed an attorney for the patient, but so far no other third parties are involved. (Of course, it's only been a few months, and this is Florida....)
The second case is from Winnipeg. An 84 year old gentleman has been in intensive care and on life support since October. The patient is an Orthodox Jew, and his family feels everything must be done. Physicians feel care is futile. In fact, one doctor feels so strongly that he has resigned - and not just from the case, but from the hospital.
The case has gone to court, although a trial date has not been set. The hospital is coping with the loss of one intensivist, but worrying that there may be more resignations, forcing closure of the ICU. Staff feel continuing care is cruel, and want the case resolved as soon as possible. The family feels faith requires continuing care, and want the trial delayed, at least past the High Holy Days, to be sure representatives of their Orthodox community can participate.
It the Florida case sounds all too familiar, you're not alone. There are enough parallels to the Terry Schiavo case to catch everyone's attention. Although the case hasn’t gone on nearly as long, it is another case in which the patient’s husband and the patient’s parent differ in their beliefs about the patient’s awareness, prognosis, and wishes. There are also parallels between the Winnipeg case and the Schiavo case, if different ones. As in the Schiavo case, there is significant difference between the diagnosis and prognosis presented by physicians, and the family’s assessment and prognosis. In addition, the patient’s religious faith, and appropriate medical care in light of the patient’s faith, are central issues shaping the family’s decisions. And, as in the Schiavo case, this is in the courts.
I don’t raise the similarity with the Schiavo case as if to say, “See, these cases are popping up all over.” I think the fact that they’re news is in fact evidence that they’re not common, largely because in most circumstances the professionals and families can come to consensus about what the patient would wish. Neither to I want to suggest that somehow the notoriety of the Schiavo case would have brought massive change. It did result, at least in my area, in a lot of new Health Care Directives and Durable Powers of Attorney for Health Care; but I didn’t expect any single case to result in radical change in the culture.
I raise it because they do have common themes that need continued and constant attention. We could even articulate those themes again in the categories of the Georgetown Mantra.
Autonomy: Who knows what the patient would want, and can best speak for the patient who can’t speak for himself or herself? Who is the most appropriate surrogate?
Beneficence: What is in the patient’s best interest? Who is best able to determine the patient’s best interest?
Non-maleficence: Is there a point beyond which aggressive care is harmful to the patient, whether to the patient’s physical integrity, or to the patient’s dignity? Are there circumstances in which aggressive care results in harm?
Justice: How does this affect others (by, in this instance, the risk - perhaps small, but real - that an ICU would have to be closed)? What is appropriate participation from the wider community (such as the courts, or the faith community)? What respect is due to the moral integrity of providers, whether professionals or institutions?
The most important circumstance shared by this Florida case, the Winnipeg case, and the Schiavo case, is their complexity. All these cases, however simple and straightforward each might seem from one party’s perspective, in fact become complex as those parties and interests interact. It remains difficult to reach resolution; and more difficult, if not impossible, to reach reconciliation.
And in the meantime, while many speak for them and about them, the patients remain....
Thursday, June 05, 2008
Seeing Into Hearts and Minds of Chaplains
PlainViews is an online journal devoted to chaplaincy. I think it's a fine and important journal, valuable enough that it's over on your left, in my permanent links.
And sometimes there's a particular article I think worth calling to everyone's attention. Actually, today there are two. The first is "Bad Death," byRev. Kirk M. Ruehl, a chaplain with Hospice at the Chaplaincy in Kennewick, Washington. He writes, both in poetry and prose, about the idea of the "bad death" (as opposed, as you'll understand, to the "good death"). His article is moving and thought-provoking.
Which brings us to the second article. It's "Bad Death – Responses." A number of chaplains write back in response to Chaplain Ruehl's article with their own thoughts. They are also moving and thought-provoking, and can give you a sense of the breadth, depth, and sensitivity among my colleagues in this ministry.
Take the time to read these two posts at PlainViews. They can give you some glimpses, brief but brilliant, into the hearts and minds of chaplains as they care for those who die and those they leave behind.
And sometimes there's a particular article I think worth calling to everyone's attention. Actually, today there are two. The first is "Bad Death," byRev. Kirk M. Ruehl, a chaplain with Hospice at the Chaplaincy in Kennewick, Washington. He writes, both in poetry and prose, about the idea of the "bad death" (as opposed, as you'll understand, to the "good death"). His article is moving and thought-provoking.
Which brings us to the second article. It's "Bad Death – Responses." A number of chaplains write back in response to Chaplain Ruehl's article with their own thoughts. They are also moving and thought-provoking, and can give you a sense of the breadth, depth, and sensitivity among my colleagues in this ministry.
Take the time to read these two posts at PlainViews. They can give you some glimpses, brief but brilliant, into the hearts and minds of chaplains as they care for those who die and those they leave behind.
Now That the Shouting's Died Down a Little...
perhaps we can get to the important next step.
Senator Obama will be the nominee of the Democratic Party for President of the United States. However, our government needs two branches working together to get laws passed or changed. We need both the White House and Congress together to make progress.
We've seen that illustrated over the past couple of years. We have a Democratic majority in both houses of Congress; but there have been complaints from progressive supporters that they haven't gotten much done. Well, surprise! If a Republican president isn't interested in signing legislation from Congress, it doesn't get completed, no matter how much support there is from the public. If a Republican minority in the Senate is large enough to sustain a filibuster, legislation doesn't get completed, no matter how much support there is. If we really want change, we need a new President from the Democratic Party, and a larger majority of the Democratic Party in both Houses of Congress; and specifically in the Senate a majority that can cut off a filibuster (more than 60).
That's not to say that in principle any of these things are bad. The President is a Constitutional check on the actions of Congress. The capacity of Congress to override a veto is a Constitutional check on the actions of the President. (I could add in interrelationships with the Supreme Court; but that's for a a post less focused on our votes.) A filibuster in the Senate may be a necessary challenge to a possible tyranny of the majority.
So, it's not that the rules are bad. It's not, at least in principle, that the people are bad (I can't speak much beyond principle, because I don't know them personally). So, if we want change, it's our responsibility.
Yes, ours: we're the voters. We're "the people" in this government "of the people, by the people, and for the people." We need to vote, and we need to vote thinking about what will benefit not only ourselves as individuals but all of our neighbors as well.
So, now that the candidates for President are determined, we need to focus on the other part of governing: candidates for Congress. Start paying attention to candidates for Congress, and vote so as to have a Congress that can work with the new President to accomplish the changes we want to see.
Senator Obama will be the nominee of the Democratic Party for President of the United States. However, our government needs two branches working together to get laws passed or changed. We need both the White House and Congress together to make progress.
We've seen that illustrated over the past couple of years. We have a Democratic majority in both houses of Congress; but there have been complaints from progressive supporters that they haven't gotten much done. Well, surprise! If a Republican president isn't interested in signing legislation from Congress, it doesn't get completed, no matter how much support there is from the public. If a Republican minority in the Senate is large enough to sustain a filibuster, legislation doesn't get completed, no matter how much support there is. If we really want change, we need a new President from the Democratic Party, and a larger majority of the Democratic Party in both Houses of Congress; and specifically in the Senate a majority that can cut off a filibuster (more than 60).
That's not to say that in principle any of these things are bad. The President is a Constitutional check on the actions of Congress. The capacity of Congress to override a veto is a Constitutional check on the actions of the President. (I could add in interrelationships with the Supreme Court; but that's for a a post less focused on our votes.) A filibuster in the Senate may be a necessary challenge to a possible tyranny of the majority.
So, it's not that the rules are bad. It's not, at least in principle, that the people are bad (I can't speak much beyond principle, because I don't know them personally). So, if we want change, it's our responsibility.
Yes, ours: we're the voters. We're "the people" in this government "of the people, by the people, and for the people." We need to vote, and we need to vote thinking about what will benefit not only ourselves as individuals but all of our neighbors as well.
So, now that the candidates for President are determined, we need to focus on the other part of governing: candidates for Congress. Start paying attention to candidates for Congress, and vote so as to have a Congress that can work with the new President to accomplish the changes we want to see.
Tuesday, June 03, 2008
Back to St. Andrew's Elsewhere: My Newest at Episcopal Cafe
You can read here my newest piece at Episcopal Cafe. It's part of a series this week on the Daily Episcopalian discussing the St. Andrew's draft of an Anglican Covenant. Each day there will be another piece, each written by a Deputy to General Convention, discussing some part of the St. Andrew's Draft. Take the time this week to read through them. The Covenant process will be an important topic of conversation at this summer's Lambeth Conference. We can certainly expect it will also be a topic of conversation next summer at General Convention.
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