Why more primary care may not improve health care quality... by Maggie Mahar

Why more primary care may not improve health care quality

by Maggie Mahar

The emphasis on primary care as the “key” to lifting the quality of U.S. healthcare may be exaggerated according to a report by Dartmouth’s Institute for Health Policy & Clinical Practice.

“Primary care forms the bedrock of a well-functioning, effective health care system,” the researchers observe. But– and this is an important caveat- “simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or lead to better outcomes.”

Wait a minute. In past reports, didn’t Dartmouth’s researchers tell us that patients fare better if they see fewer specialists and more internists?


No.  Dartmouth’s earlier studies have shown that when patients see more specialists, care is more aggressive and more expensive, but, on average, outcomes are no better—and sometimes they are worse. This, however, doesn’t mean that primary care, by itself, ensures better care, even if a patient sees her PCP on a regular basis.

As the report points out: “Primary care is most effective when it is embedded in a high-functioning system, where care is coordinated, where physicians communicate with one another about their patients, and where feedback is available about performance that allows physicians and local hospitals to continually improve.”

Policy should “focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals,”  says Dr. David C. Goodman, lead author and co-principal investigator for the Dartmouth Atlas Project.

That said, the  study’s authors (Goodman, Brownlee, Chang and Fisher) agree that primary care is essential: “Primary care clinicians, whether they are general internists, family practice physicians, pediatricians, physician’s assistants or nurse practitioners, are trained to care for the whole patient.

They can diagnose and treat a wide variety of illnesses, help patients avoid getting sick, and ensure that they get the specialty care they need. For chronically ill patients in particular, primary care clinicians serve a crucial role as coordinators of specialty care. They can also help patients control symptoms, slow the progression of their disease, and help manage acute and chronic conditions without resorting to hospitalization.”

But while primary care can do all of these things, this does not mean that it does.

Geographic variation
This new study surveys access to primary care—and use of primary care— among the fee-for-service Medicare population in different regions of the country from 2003 to 2007, only to find, once again, that geography is destiny.  As the map below reveals, Americans in some parts of the U.S. receive far more primary care than others.  During the report period, the share of patients who saw a primary care physician on an annual basis ranged from roughly 60 percent of beneficiaries in the Bronx, N.Y. and Manhattan to nearly 90 percent in Wilmington, N.C. and Florence, S.C.—about a 50 percent difference.


More primary care does not guarantee better management of chronic diseases
Yet, here is the first surprise: in those regions where patients have more access to primary care physicians, “this alone does not always keep people with chronic conditions out of the hospital, improve their chances of getting the optimal care recommended for their condition, or improve health outcomes.”

For example, when researchers looked at patients suffering from diabetes they  found no relationship between rates of blood lipid testing and eye examinations and whether these beneficiaries with diabetes saw a primary care clinician at least once a year.

There also appeared to be no connection between rates of leg amputation, a serious complication of diabetes and peripheral vascular disease, and whether the beneficiary saw an internist at least once a year. But a  patients’ risk of losing a leg did vary dramatically depending upon where he lived –the report reveals a tenfold difference in the rate of leg amputation, ranging from 0.33 per 1,000 beneficiaries in Provo, Utah to 3.29 per 1,000 in McAllen, Texas—the town made famous for over-treatment in Dr. Atul Gawande’s 2009 New Yorker story.

The report also found that having an annual primary care visit did not keep patients suffering from diabetes or congestive heart failure out of the hospital.

In this case, was a more than fourfold difference in the rate of hospitalizations among Medicare beneficiaries, ranging from 30.7 per 1,000 in Honolulu to 135.0 per 1,000 in Monroe, La. (This could be tied to the fact that Louisiana boasts more physician-owned hospitals and surgical centers than any state except Texas. Research shows that when doctors own hospitals, patients are more likely to find themselves in one of them.)

The researchers theorize that “perhaps primary care visits aren’t doing more to improve outcomes” because “the patients most in need of this care are not receiving it.”

But another possible explanation seems, to me, more persuasive:  “primary care is most effective when it is embedded within a health care system that allows the coordination of primary care services with those delivered by specialists and hospitals,” the researchers observe.  “Unfortunately, most health care providers in the U.S., including primary care physicians, are not organized to do this; many physicians work in small practices, where there is little coordination of care, and communication among a chronically ill patient’s various physicians is often poor to non-existent. Large delivery systems can also fall short in these areas. The quality of the care provided by primary care physicians also varies widely. As a result, patients in regions of the country where they are more likely to have had a primary care visit are not necessarily receiving higher quality care—or enjoying better outcomes.”

Medical cultures vary widely around the nation. In some places, doctors are more likely to work in large mutli-specialty centers where collaboration is a top priority. In other towns, solo practitioners pride themselves on their autonomy. They may play phone tag, but most don’t use electronic medical records—and if they do, these records can’t “talk” to each other.

It’s not about the supply of primary care physicians
More primary care does not necessarily mean better care.  Perhaps that shouldn’t come as such a surprise. PCPs alone cannot solve the nation’s health care crisis. If we want to keep patients out of hospitals, PCPs and specialists must work together—and they must listen to patients and their caregivers.

If we want to reduce the number of diabetics who wind up losing a leg we should look at the larger problems that affect a diabetic’s ability to manage his disease, putting poverty at the top of the list.  Indeed, the report points out that rates of leg amputation for all Medicare beneficiaries differed by a factor of 10. When researchers took a close look at 44 hospital service areas (HSAs) within a single hospital referral region (HRR)  in Atlanta, Georgia, they found a fourfold variation in leg amputation rates.

“Addressing these disparities in health outcomes will require attention to the full spectrum of health determinants,” they write, “ranging from lower levels of schooling and limited health literacy, to inadequate housing and lack of transportation, as well as lack of access to high-quality primary care that is well-coordinated with specialty care.”

That primary care is not a cure-all probably shouldn’t come as a shock. But the report’s second surprise is eye-opening:  having more PCPs physicians –more general practitioners, internists and pediatricians–does not  necessarily mean greater access to primary care: “Our findings suggest that the nation’s primary care deficit won’t be solved by simply increasing  access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage,” says Goodman.

A shortage of PCPs “may contribute to the problem in some locations,” the report notes, but “there is no simple correlation between supply  . . . and access,” says Dr. Elliott S. Fisher, a report author and co-principal investigator for the Dartmouth Atlas Project.

The study shows that, in some regions, a relatively high proportion of beneficiaries saw an internist at least once a year, even though overall primary care physician supply was low. This includes Wilmington, N.C., where there were 69.0 primary care physicians per 100,000 residents and 87.4 percent of patients had at least one annual primary care visit. Meanwhile, despite an abundant supply of PCPS in White Plains, N.Y. (101.4 per 100,000), less than 70 percent of beneficiaries saw a primary care clinician each year.

Here, I suspect that the residents of White Plains are simply more likely to go directly to a specialist, rather than consulting a primary care physician first. White Plains is a suburb of New York City, and New York boasts an embarrassment of specialists. (I know, from personal experience that I can usually get an appointment with a Park Avenue specialist within a few days—even if I am a new patient.)  Patients in the New York area tend to believe that more expensive is always “better” and of course specialists are more expensive. And while some Americans are wary of “experts,” New Yorkers tend to like the idea of consulting someone at the very top of the food chain. (Many Manhattanites consider themselves experts of one kind or another.)

In addition, primary care doctors in New York, like PCPs in Boston, may keep their waiting rooms crowded by seeing regular patients more often than doctors in some other towns. Again, this is part of the medical culture in Manhattan. If you want to re-fill a regular prescription, your doctor will insist that you come in and see him every three months. If your insurance requires that you get a referral to see an eye doctor, your PCP will tell you that you must come in for an appointment first. Even though he’s not going to exam your eyes, he’s not going to be paid for making the referral unless you see him.

As a result, it’s difficult to squeeze in an emergency—or a new patient.  If you call and say you’re experiencing chest pain, your internist will tell you to call an ambulance and go to the ER. (This happened to a friend recently, and stands as an example of the aggressive, expensive approach to health care that Manhattanites have come to expect. He was fine; it may have been indigestion.)  Boston is much like New York. A friend there told about the time he cut his hand. His internist couldn’t fit him in. His wife’s primary care doctor couldn’t see him. He wound up having his sister sew up his hand on her kitchen table.   My guess is that if my friend lived in Wilmington N.C., and he called his internist, the doctor’s receptionist would say “Come on in—we’ll stitch it up.”

I am, of course, speculating. And these are only anecdotes, but anecdotes can illustrate a medical culture.  In addition, Dartmouth data confirms that New Yorkers see many more specialist than patients in Iowa—though our outcomes are no better.  The problem in New York so much a dearth of internists as the fact that healthcare in New York City is so fragmented:  most of our specialists work solo or in small practices.  They value their independence. Many bristle if hospitals try to suggest “rules” or even “guidelines” for best practice. Thus, most surgeons don’t use checklists, even though there is ample evidence that a simple piece of paper can save lives.

Ultimately, this newest Dartmouth study suggests that healthcare, like real estate, is all about “location, location, location.”  As the authors put it: “This report highlights the importance of understanding health care within a local context and underscores the need to address the underlying causes of  . . . disparities both within and across regions.”

Where you live is paramount
The report acknowledges that both lower-income Americans, and minorities receive less care. Put bluntly, the quality of care you receive varies, depending on who you are.  “On average, blacks were less likely to see a primary care clinician than whites—70.4 percent had at least one annual visit in 2003-07 compared with 78.1 percent for whites.”  

But regional disparities are far greater:  where a patient lives turns out to be even more important than the color of his skin.  “In the U.S. health care system, it’s not only who you are that matters; it’s also where you get your care,” the authors report. “Regardless of race and income, patients receive care of widely varying quality depending upon where they live and the health system that provides their care.”

If you’re very lucky, you live in a place where the medical culture favors “collaboration” over “competition,” a town where general practitioners, specialists, and hospitals understand that medicine is a team sport. Too many primary care doctors labor alone—working long hours without sufficient support.

This is one reason  why being a primary care doctor is so difficult. I recall Dr. Donald Berwick, Medicare’s new director, once saying, “No doctor should be alone.”  The job is too hard. Insofar as there is a single “key” to raising the quality of U.S. health care, “co-ordination” is, I think, the word to keep in mind.

Maggie Mahar is a fellow at The Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much. She blogs at Health Beat, where this post originally appeared.

Salon: The Pyrrhic victory theory of healthcare repeal... By Andrew Leonard

The Pyrrhic victory theory of healthcare repeal

If Republicans succeed in shooting down the Affordable Care Act, could the path be cleared for stronger reform?

By Andrew Leonard 

Salon, Wednesday, Feb 2, 2011 13:34 ET

AP/Hans Pennink

Is it too soon to declare healthcare chaos? In the wake of Florida Judge Roger Vinson's ruling that the Affordable Care Act is unconstitutional, the Washington Post is reporting that some states are claiming that they can immediately stop implementing the law, while others are convinced that they are legally bound to comply until until a Supreme Court decision, and still others are declaring that they just don't have a clue.

Not surprisingly, Florida is leading the way on the intransigence front, with the state's attorney general rejecting a $1 million federal check provided to help pay for part of the implementation process.

The confusion contradicts both the assertions of senior White House administration officials on Monday that implementation would proceed without delay, and the complacency of supporters of healthcare reform whose initial reaction to the ruling was to tell everyone to calm down and wait until the legal process has fully played out.

The Justice Department is appealing Judge Vinson's decision and will certainly ask for a stay -- which would theoretically require even renegades like Florida to abide by the law -- but one gets the sense that the battle is only heating up. The states that drag their heels waiting for Supreme Court Justice Anthony Kennedy to flip a 5-4 decision one way or another might be making a winning bet.

But for some of the loudest supporters of the Affordable Care Act, like the vociferous Washington Post blogger Ezra Klein, even a ruling by the Supreme Court that the ACA is unconstitutional would not be the end of the story, but rather, would mark a major setback for opponents of reform. "Long-term," writes Klein, "conservatism could suffer no greater disaster than the death of the individual mandate."

• Continue reading

Klein's reasoning may seem counterintuitive, but he is not alone in making such a provocative claim. The reasoning is as follows: Healthcare is broken in the U.S., and must be fixed.

The ACA is based on Republican ideas designed to preserve a private healthcare insurance industry while expanding coverage. If the ACA goes down in flames, then the only remaining option would be comprehensive government-provided healthcare insurance via some sort of single-payer system, like Medicare, or Veteran's Administration healthcare, except designed to cover the entire population. In this scenario, we could kiss our private insurance industry goodbye.

The first part of Klein's argument is unassailable. Healthcare in the United States is indeed broken. The cost of healthcare has been rising at a rate faster than overall economic growth for decades. Not surprisingly, the number of people without healthcare insurance has also been rising (both in raw numbers and as a percentage of the general population). In 2000, 38.4 million Americans had no healthcare insurance. In 2009, that number had risen to 50.7 million.

These trends are not sustainable, and explain why all the Democratic candidates for president in 2008 made fixing healthcare a primary part of their platform. Whether or not one can afford healthcare in the United States is an ongoing source of profound anxiety for millions of Americans. It is also a fiscal disaster: We cannot afford, as a society, to pay out of pocket for the costs of caring for all the people who do not have insurance but will inevitably get sick.

Klein's paradoxical optimism is based on the premise that, without any healthcare reform at all, the situation will degenerate so badly that the public clamor for a real solution will be so deafening that politicians will have no choice but to come up with a new fix.

But if the individual mandate -- the mechanism for keeping the system as much in the private sector as possible -- is deemed unconstitutional, then the only alternative will be a more radical solution. (And by radical, I mean like Canadian healthcare, or Australian healthcare.)

I'd love to believe this, but I think it misunderstands political reality. A Republican Party that made repealing healthcare reform its primary issue isn't going to win that battle, only to turn around and allow an industrial-strength, new, improved, single-payer healthcare system become the law of the land.

The private insurance industry won't go quietly into the night. Politicians who have witnessed this debacle aren't going to campaign for office on a platform of true socialized healthcare.

Yes, current trends are unsustainable -- but so are current trends on widening income inequality, and fossil fuel consumption, and government deficits, and yet the political will to deal with these problems never materializes: On the contrary, our political dysfunction just gets worse and worse.

We've been trying to come up with a comprehensive healthcare fix for decades, and Democrats only managed to squeak through a manifestly flawed solution by co-opting the insurance industry and copying conservative Republican ideas wholesale -- and in the process, generating a devastating political and legal counterreaction.

I know that there are many on the left who believe that if only Obama had pushed for a robust public option, he would have ridden a wave of public opinion right over Republican opposition, but I think that utterly misunderstands both the nature of today's Republican Party, as well as the "moderate" Democrats who would have flipped over into opposition immediately, should any such thing have been attempted.

Yes, something must ultimately be done to address the problem of healthcare in the U.S. but if the ACA is repealed, the political will to do so will be minuscule for generations. Maybe that's what Klein means by "long-term." In the meantime, the damage done to American lives by our broken, unaffordable system will be enormous. This is no time for complacency.

Andrew Leonard is a staff writer at Salon. On Twitter, @koxinga21.

malaysiakini-Azly Rahman: Class divisions in access to healthcare

Class divisions in access to healthcare

Azly Rahman
malaysiakini, Mar 22, 10
1:56pm

'Why can't all Americans have the same access to healthcare to those enjoyed by members of Congress?' is a popular question on the ObamaCare debate.

At the time of writing I am following the debate over universal healthcare for all Americans. If the US$1 trillion Bill passes, it will help insure 32 million Americans that do not have access to healthcare.

This is another controversial issue in the tradition of Democrats and Republicans. This is a good case study of one of the enduring issues of an advanced capitalist state.

I know friends who do not have health insurance and who question the human rights dimension of it - right to life, liberty, and the pursuit of happiness, endowed by the Creator who insist that 'all men are created equal' and cautioned by the Enlightenment thinker Jean Jacques Rousseau that “… everything is good in the hands of the Author of Things and everything degenerates in the hands of Man”.


From the point of view of the Democrats, the health insurance system is broken and in deep crisis. Millions cannot get proper medical health. The insurance system is predatory. Expanding health coverage and lowering prescription drug prices, and giving rebates to insurance companies are the main features of this proposal.


From the Republicans' point of view, Americans need health reform but not to the point of bankrupting the country. A Bill which covers the cost of abortion is the controversial part of it; that Americans must not pay for those who do not have the respect for life. The Bill is said to be a wrong approach that will make winners and losers in the system. Essentially it will open up other complications in virtually all aspects of the system.


Whatever the outcome of it, Americans will still be divided ideologically on this issue. The argument is emblematic of the American political philosophy: what is the role of the government vis-a-viz the social contract between the 'ruler and the ruled'?


It is a classic Jeffersonian-Franklinian debate. America has evolved into a country envisioned by Benjamin Franklin - America which is more of the big business and less on the man on the street.


Americans are taught to not trust governments; its history is that of a revolt against British colonialism famed by the slogan 'taxation without representation' and therefore 'give me liberty … or give me death', as the revolutionary leader Patrick Henry said.


Americans went to war and bankrupted the nation. It was a Republican war. That drained trillions of dollars, perhaps contribution to the near-collapse of the American Empire, as many a Complexity theorist would propose. The Butterfly that flapped its wings in Baghdad, near Saddam Hussein's mansion has contributed to the turmoil in the Obama Office.

Rights of all Malaysians


But what is the situation in Malaysia, as we have evolved as a modern state enculturalised by happenings in other advanced countries such as the US?


How do we care for the sick? Essentially is there also a class system in our healthcare system? Do the poor get the same treatment as the wealthy members of parliament or those in the list of billionaires?


With the proliferation of private hospitals, are we creating the foundations of a class system that will inherit the problems the Americans are trying to resolve?

Or is this merely a natural progression of an economic system that is also predatory in culture - that the rich will be richer and the poor growing in numbers?


With the urge for Malaysian private hospitals to venture into 'medical tourism', will our good doctors abandon their Hippocratic Oath in favour of professional hypocrisy?


Marx would say that we are defined by the economic condition we are in - we are homo economicus. I suppose how we live and how we die and how we are taken care of in-between this period of 'borrowed time', depends on how the state defines what human rights mean vis-a-viz our ability to pay for healthcare and how we lived our lives as a economic beings.


We must consider that each human being is a cog in the wheel of Capital. Those who own the machines of production oftentimes influence policies through political-economic arrangements.


A wealthy country such as Malaysia that prides itself on tall buildings and a growing number of billionaires ought to start reflecting on the need to ensure that each citizen will have affordable healthcare.


One wonders what the limit of wealth creation is and where the moral dimension is in capitalism, when the rich control the lives of the poor.


By shaping ideology and creating installations to change the social relations of production - and by doing this through the control of mind, media, machinery, and materials - we expect that wealth is to be shared. Socialism for the rich must be replaced with capitalism for the poor.


It's 11pm here in New York. The historic Bill has just been passed, 219 to 212 in the House. God bless the life of 32 million more Americans. Let Malaysia learn from this victory!

DR AZLY RAHMAN, who was born in Singapore and grew up in Johor Bahru, holds a Columbia University (New York) doctoral degree in International Education Development and Masters degrees in the fields of Education, International Affairs, Peace Studies, and Communication. He has taught more than 40 courses in six different departments and have written more than 300 analyses on Malaysia. His teaching experience spans both in Malaysia and in the United States and in a wide range of teaching context; from elementary to graduate education. He currently resides in the United States.

Jon Barron: The Healthcare Disaster

The Healthcare Disaster

Date: 01/25/2010
Posted By: Jon Barron

 Everybody has a different position on this bill, so you would naturally think that at least one of them had to be correct. Unfortunately not! As it turns out, everyone is wrong and heading for a world of hurt.

And for those of you living overseas who are not directly affected by the bill, you are nevertheless screwed by the same demographics that undermine things here in the U.S. -- probably even more so.

Since I can't win here, let's just jump into the fire. I obviously can't cover the bill in detail (the Senate version alone is over a 1,000 pages), and for similar reasons, I can't cover the arguments of all parties involved. But I can identify the key features of the healthcare solutions being proffered, and highlight the key arguments pro and con of the parties involved. Since the Senate looks to be the dominant bill in any reconciliation, I will start by focusing on the features found in that bill:

Key features of the Democratic healthcare bill

• Every single citizen who is financially able will be required to buy into a "qualified" private insurer health plan. Willful failure to do so will be punished by fines of up to 2% of income. Families of four earning up to $88,000 would be subsidized by the Federal Government.
  
• States will set up exchanges to make shopping for an "affordable" plan easier.
• Every business in America (with 50 employees or more) will be required to provide a "qualified" plan for employees and pay upwards of 72% of the cost. Failure to do so will result in an 8% increase in payroll tax.
• Theoretically, the above measures would extend coverage to an additional 31 million Americans and provide healthcare coverage for approximately 94% of all Americans.
• Insurers would no longer be able to deny coverage for pre-existing conditions. However, it appears this will not be fully implemented until 2014. Insurers would, however, be allowed to charge more for senior citizens.
• Some of the costs will be offset by a 40 percent tax on insurance companies that provide "Cadillac" health plans valued at more than $8,500 for individuals and $23,000 for families. In addition, there would also be a hike in Medicare payroll taxes on families earning over $250,000.
• Insurers will be required to spend 80-85% of their premiums on actual healthcare as opposed to profits. The current "average" is 74%. For insurers, the offset comes from the government mandate that millions of healthy, young people will now be required to pump their money into the insurance pool.
• The Federal Government will promote competition among insurers to drive down costs -- details unspecified.
• Preventative care will be promoted to drive down healthcare costs. Preventative care here does not mean diet and lifestyle changes, but more frequent medical testing so that people can get on lower cost drugs sooner and thus delay the need for more expensive surgical procedures.
• Medicare is not actually being cut, but a permanent reduction in the annual payment adjustments for some Medicare services, including inpatient hospital services and ambulatory care would save a theoretical $500 billion a year. How these services would still be provided at current levels without paying for anticipated inflationary increases is not explained. It should be noted that the Mayo Clinic just closed the doors of one of its Arizona clinics to patients on Medicare because they couldn't afford to keep providing services at current levels of reduced fees -- let alone after a further $500 billion reduction. In addition, there are unspecified calls for cutting spending…sometime in the future. Unfortunately, many of the best ways of cutting costs have been sidelined by deals cut with the pharmaceutical industry, the health insurance industry, and hospital bosses in exchange for their support.
• The anticipated cost to the Federal Government for all of these changes is estimated at $848 billion, near term -- although long term savings are promised.

Democratic reasons for the bill

• It covers most of the 50 million Americans currently uninsured.
• Although, it costs more money over the next ten years, it theoretically reduces costs after that -- thus saving the current system from inevitable bankruptcy.
• It shifts costs to those better able to afford it.

Where it fails

I'm not here to argue morality or big government VS small -- merely to talk about the financial viability, and here the Democratic version fails. The simple fact is that the bill contains no real cost cutting measures -- merely vague promises. In fact, most routes for cost cutting have been bargained away in exchange for support. But even more importantly, it ignores the simple demographics, which I've been talking about for several years now -- and will cover once again at the bottom of the newsletter.

Bottom line

By the day, it's looking less and less likely it will pass. At the moment, I'd put its odds at less than 50/50. The good news in non-passage is that it's not a good bill, and would definitely cost money short term -- although, it would open the door for tweaking and improving over the coming years.

The bad news is that it's the only game in town that even looks to address some of the major issues facing healthcare in the U.S. If it goes down in flames, we'll be stuck with the status quo, which ultimately is far, far worse. And because of the demonstrated political costs involved in taking on healthcare, it is unlikely anyone will seriously look at the issue again for years.

The Republican Plan

The Republicans don't actually have a plan -- more like a wish list, with no specifics as to how the details should be implemented. The key wishes include:

• Rejection of virtually all aspects of the Democratic Plan
• Establish Universal Access Programs that expand and reform high-risk pools and reinsurance programs to guarantee access for all Americans to affordable healthcare.
• Enact liability reform to end junk lawsuits against doctors and hospitals.
• Prevent insurers from cancelling policies.
• Allow Americans to shop for coverage across the country -- rather than just within the state they live.
• "Encourage" small business health plans, innovation, healthier lifestyles.

Analysis

It's not really a plan (pretty much by design), so there are no details to analyze -- or to attack (and that's the point). As a wish list, it's certainly nice, but with no details, it's meaningless. And like the Democratic plan, it fails to address the underlying demographics that would guarantee that it too is ultimately unaffordable.

The bottom line

The Republicans didn't take healthcare on when they were in office for eight years, and would be even less likely to take it on when they come back in office -- given the demonstrated political costs of the last year.

Their wish list is just that -- an attempt to offer something that sounds good in opposition to the Democrats and with no details that can be attacked. In effect, the Republican position amounts to tweaking the status quo.

What the "Tea Party" wants

• Kill the Democratic Plan.
• No new taxes.
• Reduce government debt.
• Don't touch anything that currently exists -- especially Medicare.

Analysis

It's hard to argue with the basic premises underlying the Tea Party -- smaller government, more responsible government, and some fiscal sanity. But as with the Republicans, a basic premise and wish list is not actually a position. And without an actual position and its accompanying details, there's really nothing to analyze.

In the end, the Devil is in the details. For example, when it comes to healthcare, the basic premises of the Tea Party are mutually contradictory. Not passing a healthcare bill is not the same thing as leaving healthcare untouched and not having to pay higher costs. The simple fact is that demographics will change healthcare no matter what government does or does not do. If no bill is passed, increasing cost (healthcare costs went up over 10% in 2009 alone with no help from government) will mandate one or more of the following:

• Higher taxes. If Medicare isn't cut back, rising costs will force higher taxes and/or fees to pay for it.
• Less healthcare. No matter how much taxes rise, it won't be enough, so Medicare will have to be scaled back. And not just Medicare, insurance companies too will steadily exclude more and more treatments and drop more and more people from their system…to protect their bottom lines.
• Rationing of healthcare. In fact, we already have that -- with the insurance companies acting as "death panels" that decide who and what gets covered now. And as costs rise, it will only get worse.
• Increased debt -- both personal and government.
• And ultimately, more government involvement.

Bottom line

In other words, not passing a good healthcare bill will bring about exactly those things that the Tea Party is arguing against. They will come by stealth. They will come independent of which party is in office. They will produce little benefit since they will be unplanned. And they will come surely as night follows day because of the underlying demographics.

There's an old saying that applies here: be careful what you ask for; you just might get it.

The rest of the world

In some ways, Europe, China, South Korea, and Japan are facing the exact same demographics we face in the United States -- but even more so. And these demographics will put intense pressure on the ability of governments to continue to provide the kind of national healthcare their citizens have come to depend on.

So, without further ado, what are these demographics?

The demographics of healthcare

When it comes to demographics, we're talking about age and self-inflicted illness. Most governments are aware of the coming age issues, although they have not figured out how to address them yet. But it is the changing nature of illness that presents the biggest problem -- and most governments haven't a clue about what's happening here.

Age

The age issue is simple. All healthcare plans, private or national, existing or proposed, are giant Ponzi schemes. They depend on ever larger numbers of new, young healthy people pumping money into the system with no need to pull money out in the near term so that the older sicker population can use that money to take care of themselves.

Again, it doesn't matter whether the money is being given to private insurance companies or governments, the principle is the same -- an ever larger number of young, healthy citizens supports a smaller number of older sicker citizens.

And like all Ponzi schemes, it works as long as no one upsets the apple cart. But the moment there are no longer enough "new," young, healthy people to keep priming the pump, or those "new" contributors need to pull their money out before their time, the system collapses.

And that's the situation we now face.

Outside the countries of Japan and South Korea, Europe is aging faster than any other part of the globe. In 2006, 21 percent of Europeans were older than 60 years of age. By 2050, nearly 34 percent will be above 60. Quite simply, you're talking about a dramatic reduction in the number of young, healthy people priming the pump and a dramatic increase in the number of senior citizens drawing from the well. The only solution is an equally dramatic increase in the amount of taxes that the young, healthy workforce will have to pay in order to sustain the system.

And that's if the younger, healthier population doesn't have to pull its money from the Ponzi scheme before its time. But in fact, they will. That's the self-inflicted disease demographic I mentioned, and that we'll explore in more detail in a minute. For now, just understand that an aging population means more people drawing on the system and fewer people paying into it. The only way to keep the books balanced is for those paying in to pay more…or to reduce the amount of care that senior citizens are getting.

That covers Europe. But as I said above, Japan and South Korea are actually aging even faster. As for China, it too is aging rapidly, largely as a result of government policy that mandated smaller families. In fact, in China, the current ratio of 16 elderly people per 100 workers is set to double by 2025, then double again to 61 by 2050, according to the Washington-based Center for Strategic and International Studies. But it's not just established countries that are aging. Countries such as Mexico are projected to reach developed-world levels of old-age dependency by the middle of the century.

As for the United States, it too is aging, but more slowly than many countries in the developed world. But that "more slowly" is based on a couple of questionable premises. First, a significant factor in keeping the U.S. population "young" is teenage pregnancy. Despite the promotion of "morality" in the U.S., the U.S. actually leads much of the world in teenage pregnancy. Unfortunately, children born to teenage mothers are much more likely to become welfare babies and "draw" money from the system as children and young adults, rather than contribute to it. In other words, they exacerbate the problem, not make it better.

Immigration

If a country's population isn't replacing itself fast enough, there's one other way to keep the population young -- immigration. This has been one of the prime factors that has pumped new, young, healthy workers into the system thereby continually pumping up the pool of young taxpayers to support it. In this regard, the U.S. has in the past been far friendlier to immigrants than Europe, Japan, China, and South Korea, for example -- and thus delayed the aging of the country. However, that is changing.

Thanks to 9/11 and changing attitudes in general, the current citizenry of the U.S. views immigrants less favorably than in the past. In addition, the economic disruption of the last year has made the U.S. a less attractive destination for many immigrants. The upshot is that immigration is down in the U.S., and the immigrants who are coming in are the older family members of immigrants who are already here -- rather than the young, healthy, opportunity seeking, "new" immigrants needed to support the Ponzi scheme. The bottom line is that in the coming years immigration will less and less be a factor in slowing down the aging of America.

Self-inflicted disease

And now we come to the big one, the elephant in the room no one wants to talk about -- self-inflicted catastrophic illness. Over the years, I've written many times about this issue -- always ending with the same conclusion:

No amount of tinkering and funding can stop the inevitable train wreck barreling towards us -- unless there's a major paradigm shift. No matter where you live or what healthcare system you function under, the demographics are undeniable. The American model is headed for disaster. But so is the French model. How can any healthcare system survive up to half its population living for 20-30 years with severe diabetes (as predicted by the CDC), let alone the other half suffering from cancer, heart disease, osteoporosis, Alzheimer's disease, and MS? There isn't enough money in the world to cover it.

And every time I return to the issue, the numbers have only gotten worse. Let's take a quick look at some of those numbers.

Diabetes

Literally just days ago, The Medical News published the latest analysis which showed that the cost of diabetes and pre-diabetes reached $218 billion in 2007, with the exploding number of cases of type 2 diabetes responsible for the majority of the costs. And those numbers are three years old!

Update them for today -- and over the next ten years -- and you're looking at an average of a quarter of a trillion dollars a year over the next ten years in the United States alone. Do the math and that's $2.5 trillion dollars unnecessarily spent on a just one self-inflicted disease over the next ten years whether a healthcare bill passes or not. If people in the United States didn't give themselves diabetes through diet and lifestyle choices, the savings alone would 100% cover:

• All costs associated with any healthcare bill including covering all those currently uncovered.
• 100% of the cost of the bank bailout.
• 100% of the cost of the stimulus plan.

And that's with no new taxes, and that's just one disease.

As for heart disease, it's estimated that anywhere from 50-80% of heart disease is the result of dietary and lifestyle choices. (Personally, I put the number at 90%.) How much does that cost us? The cost of heart disease and stroke in the United States, including healthcare expenditures and lost productivity from deaths and disability, is projected to be more than $475 billion in 2009. As the U.S. population ages, the economic impact of cardiovascular diseases on our nation's healthcare system will become even greater. So again, using the conservative estimate of around 50% of that cost being self-inflicted, you're looking at another quarter of a trillion dollars a year in unnecessary costs per year.

And then there's cancer. Overall, environmental factors, defined broadly to include tobacco use, diet, infectious diseases, chemicals, and radiation, are believed to cause between 75 and 80 percent of all cancer cases in the United States. And that's not even considering the percentage of breast cancers caused by hormone replacement therapy (still commonly used) and yearly mammograms.

And what are the costs associated with preventable cancer? The estimates are all over the map depending on how you look at the numbers. But at the low end, you're looking at close to a quarter of a trillion dollars a year (again) back in 2000 -- and at the high end, just under a trillion dollars a year in 2000.

So, let's add the numbers up.

At the low end, you're looking at $750 billion a year paid in the U.S. for the three major self-inflicted catastrophic diseases. Over the next 20 years, that's $15 trillion. Now you're talking about not just paying for healthcare, but literally paying off the entire national debt -- with no new taxes!!! On the other hand, if we continue to head down the road we're on, we're looking at ever higher taxes, ever greater debt, and a disintegrating healthcare system.

And every other country in the world can look forward to the same scenario.

Conclusion

Like a broken record, I keep repeating:
Pretending that any tinkering of the world's current healthcare systems can produce a viable solution to this problem of compounding demographics is the equivalent to rearranging deck chairs on the Titanic.

At some point, our children will be left drowning in debt. The bottom line is that the only way that healthcare can survive -- the only way you can survive -- is if you take back control of your health and start doing those things that allow your body to stay healthy without the need for healthcare.

Or to put it another way, the only way to save healthcare is to stop relying on it, use it only for the exceptional, and take care of yourself.