Monday, February 16, 2009

Health Stimulus Plan, CHC's, Obama Health Reform

Here is an interchange on our SOAPM listserve (Section on Administration and Practice Management, of the American Academy of Pediatrics). We saw the stimulus bill has $2 B for Community Health Centers. I react, sarcastically. A doctor on the listserve says, hey, how do you like your Obama now? I say, I think he'll be a great president, but he is hemmed in by current plans and knowledge within health.

What I didn't go into was the seminal book by Robert Alford in the 1970's, well reviewed by yours truly, which said that the health care world was passing from the world of professional dominance to corporate dominance. This is the background for all that is happening. See especially my ongoing comments on hospitals - corporations, of course.

Also of interest is the intellectual migration of one B. Shenkin, who in his book, Health Care for Migrant Workers, Policies and Politics, advocated Community Health Centers as a solution.

Here's the interchange:

>>OK, a set-up question.

This is a time when there is a perfect storm of negative factors for the economy. Rational behavior of every private person is to save, and the great paradox of savings is, if everyone does what's rational here, there is ever decreasing demand in the economy, fewer jobs, dropping prices, even less investment, even less demand - it's not a pretty picture. So, classic Keynesian dictum is that only the government is left to put demand into the economy. The government has to do it, so people have jobs, so money can be spent, and the economy emerges from a downward spiral.

The problem with public spending is, what will the money be spent on? Some say that private choices are better choices, and for some things, they are. But the classic Galbraithian view (from the 1950's and 60's) is that public investment, very appropriate for some enterprises, is underdone in the United States. So, in general, I'd say the government has to spend and spend big, and the challenge is to find what is good to spend on.

The latter is the biggest problem. Classic liberals in Congress are loathe to examine the programs they traditionally favor, and change or eliminate them; they are loathe to appreciate that a program that succeeds on small scale might not work on a larger scale. That's the hurdle Obama faces - he has said, let's examine and adjust, but dealing with the old bulls in the House does not lend itself to discretion.

So, how should we spend public money in health care? There is no clarity here. Obama and his team look for ideas. His chief health advisor is apparently David Cutler, an economist from MIT. I don't know this guy or his work, unfortunately, but he is apparently mainstream. Mainstream now means what? Favor large organizations, favor technology (EMR's), favor organized programs. Don't put money into the private system because so much money is wasted there (which is true.) They know that reform takes a long time and it's not clear to them how to reform. They are loathe to attack the real problem children in the system, the stakeholders, because they are so powerful - the insurance companies and hospitals.

So, where do they put their money? The lobby for the CHC's are loud and powerful, and there is no opposition. There is no one from organized medicine to say, "Hey, those CHC's aren't really the answer! What about just funding primary care, and here's how to do it." There is no one there pointing the way, and the AMA is not a believable source for this question. So money goes there.

There are many loud and convincing forces supporting EMR's, and as far as I can tell, not many naysayers pointing out the problems of lack of uniform standards, etc. Everyone knows that cost is a barrier, so they figure let's put money there and cost won't be a problem anymore. We'll see how it gets distributed, but I'm not optimistic.

So, in the end, I think the Democrats are doing exactly the right thing in spending money to try to ameliorate a terrible cyclical low. The prospect of a depression is not pretty. The problem to my mind is the problem of the medical system, and the lack of a credible way of improving what is clearly a terribly wasteful system. No credible source gives a good idea of how change can come, aside from building bigger institutions.

On Sun, Feb 15, 2009 at 5:17 PM, Jonathan Caine <> wrote:

So how do you like the "change" in Washington so far? You've just been Obamafied and Pelosied. You better get used to this feeling because we've got at least 3 years and 49 weeks more of this.

BTW, did you notice that the administration is no longer are talking about "creating" jobs, but "saving" jobs. Funny thing. All of the jobs to be saved are in the public sector, however. The private sector will just have to wait.

Jon Caine MD

On Feb 15, 2009, bshenkin@GMAIL.COM wrote:

Notice also that $2 billion goes for Community Health Centers. I'm pleased to see that it has been thus recognized that care for the poor comes primarily through clinics for the poor, and not through the mainstream of medicine. Two different systems of care, long outlawed in schools, is being further ensconced in health care. Separate facilities, separate appropriations, separate systems. Separate accommodations. And I believed it has been shown in study after study that CHC's are the very embodiment of efficiency, and none are paternalistic - oh, wait, there was that recent study in Pediatrics that showed that patients do not complete referrals to community resources because of that. Never mind!

Since all doctors are rich, it would be foolish to consider that they might also serve the poor, and foolish to think that they cannot enhance their own facilities because of poor Medicaid payments. In fact, don't most doctors make about $1.2 billion, each and every one? Aren't primary care doctors the source of the malfunctioning of our health care system? That was my understanding.

I'm just wondering if fancy new buildings, ever increasing salaries for personnel at the CHC's, etc., will finally lure patients who have a real choice? You just never know.

One thing we do know - the lobbyists for the CHC's beat the pants off of our lobbyists. Wonder where they got the money?

Budd Shenkin
Bayside Medical Group
Oakland, CA<<

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