For all the hoopla over whether or not a goverment-run public insurance option will be included in national health reform legislation, a new analysis by reporters at Kaiser Health News finds that the public option may, in fact, only play a “miniscule” role in expanding health care in the U.S. The report says:

Of the 30 million Americans likely to purchase insurance through exchanges created by the legislation, only six million — or one fifth — would enroll in a public insurance plan, according to a Congressional Budget Office analysis of the House bill. Viewing it another way, the six million using the public option would amount to only two percent of the 282 million Americans under the age of 65 who are projected to have health insurance by 2019, when the legislation is fully implemented.

And that number could shrink because states may decide to opt out of a public insurance plan, an escape clause that’s likely to be included in the Senate plan.

“The politics of this issue is totally disproportionate to its likely impact one way or another,” said Bruce Vladeck, a former administrator of the federal agency now called the Centers for Medicare and Medicaid Services.

This just in from Martha Bebinger, who is on a yearlong Nieman Fellowship at Harvard: The Nieman Foundation Guide to Covering Pandemic Flu. It’s written by and for journalists, but it’s an excellent resource for anyone interested in flu (and who isn’t these days?) It covers every possible angle, from the science and history of flu, to pandemic preparedness and crisis comunication. And there’s a great glossary.

Kaiser Health News reports on a new study out of Johns Hopkins Children’s Center in Baltimore that found an estimated 17,000 children may have died unecessarily due to lack of health insurance. The study, which looked at mortality over 20 years and was published in the Journal of Public Health, found that uninsured kids were 1.6 times more likely to die that children with health insurance.

Dr. Daniel E. Forman

Everyone in health care pays lip service to prevention. Wellness programs are all the rage among employers. But Dr. Daniel E. Forman, director of cardiac rehabilitation at the Brigham and Women’s Hospital, and Dr. Philip A. Ades, director of cardiac rehabilitation and prevention at the University of Vermont College of Medicine, assert that in reality, prevention efforts are undervalued, and physicians that focus on prevention are marginalized by the medical community. Among other problems, prevention and rehab programs are meagerly reimbursed. But the overarching obstacle, they say, is there remains, “a preference for hospitals and caregivers to promote expensive, high-tech procedures that garner prestige and immediate profit in a fee-for-service healthcare model.”

Dr. Philip A. Ades

This post, jointly written by Dr. Forman (who is set to launch the Brigham’s new cardiac rehab center in Foxborough later this month) and Dr. Ades, focuses on cardiac rehabilitation, where the economic divide between prevention and aggressive treatment is particularly stark. It offers an important lesson for policy makers trying to revamp a system so profoundly entrenched:

The capacity of interventional cardiologists to dramatically avert death during an acute heart attack by deploying coronary stents has led to disproportionate financial and political prioritization for what is only one aspect of therapy for coronary artery disease (CAD). In fact, the underlying atherosclerotic process, which involves the thickening and hardening of the artery walls, is a lifelong and diffuse disease, starting in one’s early life and progressively worsening over decades as cardiac risk factors and their detrimental impact accumulate. So even while urgently placed stents can save the lives of heart attack patients by restoring vital blood flow through a discrete arterial blockage around the heart, they do little to moderate the overall progression of disease. With or without stents, there remains a powerful mandate for prevention as the most fundamental aspect of CAD management, i.e., only prevention (exercise, nutrition and medications) can moderate progression of the atherosclerotic process to minimize cardiac symptoms, heart attacks and other coronary events.

Nonetheless, in contrast to the glamour and heroics associated with an acute intervention to stave off death, the lifelong self-discipline and medical detail needed for effective CAD preventive therapy rarely commands similar attention or resources among patients or even their physicians. Given today’s national discussion regarding health care costs, it seems particularly important to emphasize that CAD prevention can extend life and prevent costly cardiac procedures and hospitalizations for acute coronary events. Nonetheless, cardiac rehabilitation and other cardiovascular prevention programs are often undersized or even closed as there remains a preference for hospitals and caregivers to promote expensive, high-tech procedures that garner prestige and immediate profit in a fee-for-service healthcare model.

JM is a clinical case that exemplifies the ironic dynamics that replay themselves on a regular basis in our best cardiovascular centers. He is a 54-year-old male with several weeks of chest pain (CP) that occurs when he exerts himself. While he was not on any medication for his chest pain, he arrived at the hospital during one of his episodes, and within minutes he was referred for an emergency catheterization. The catheterization images showed diffuse coronary artery disease including a discrete 70% lesion in one vessel. A coronary stent was recommended by the cardiologist. The CP resolved. The bill was over $25,000 for this successful procedure. Read more…

Scott Hensley, writing for NPR’s health blog, details the bizarre case of Harvard scientists sickened by tainted espresso over the summer. He writes that six scientists and students were hospitalized in August after drinking coffee spiked with sodium azide, a chemical used to keep bacteria from growing where they shouldn’t. One victim, a researcher in the pathology lab, is quoted saying the group will now start patronizing Starbucks.

New York Times columnist Paul Krugman declares that national health care reform will pass, and it’ll be pretty good too. His analysis is based on an assessment of Massachusetts’ reforms (despite real problems with affordability and cost controls, our system, with near-universal coverage, is still fairly popular). Krugman writes:

Conservatives insist (and hope) that reform will fail, and that there will be a huge popular backlash. Some progressives worry that they might be right, that the imperfections of reform — what we’re about to get will be far from ideal — will be so severe as to undermine public support. And many critics complain, with some justice, that the planned reform won’t do much to contain rising costs.

But the experience in Massachusetts, which passed major health reform back in 2006, should dampen conservative hopes and soothe progressive fears.

Ceci Connollly, of The Washington Post, offers a nice political analysis of President Obama’s quick trip to Boston, and why he very intentionally steered clear of promoting Massachusetts’ health care reform efforts during his speech at MIT. Connolly writes:

The president’s critics say his reluctance to spotlight the Massachusetts model is real-world evidence that his vision would not work on a national scale. High costs have forced the state to trim benefits for legal immigrants and prompted one safety-net hospital to sue over a $38 million shortfall.

Obama’s allies — and even one prominent adversary — see a more nuanced picture that offers guideposts for federal lawmakers as they finalize decisions on a bill that could reshape one-sixth of the economy.

“The mistake in the direction Washington is taking is to assume that getting everyone insured will reduce costs,” said former governor Mitt Romney (R), who signed the Massachusetts bill into law three years ago. “In fact, it is going to add costs.”

By enacting a plan that requires individuals, businesses and the government to contribute to the cost of health care, the state has had phenomenal success in expanding coverage.

Carol Pryor, policy director at The Access Project, a Boston non-profit, offers practical suggestions to help eliminate medical debt among state residents:

In a previous post, I talked about some of the unfinished business of health reform in Massachusetts. While celebrating the successes of health reform, I noted that one in five state residents still had medical debt in 2008, indicating that some people in the state are still struggling with health care costs.

This includes people who make slightly too much money to qualify for Commonwealth Care and do not have access to other sources of insurance. For this group private insurance policies, when premiums and out-of-pocket costs are taken into account, are often not affordable. The second group is lower-income employees whose employers offer inadequate insurance. Although they have incomes similar to other state residents who qualify for Commonwealth Care, they have few of the protections provided by the subsidized plans, such as the elimination of deductibles and limits on cost sharing. In addition, system complexity is a serious barrier to care – people often do not find out about programs available to assist them or find out about them after it is too late to qualify for help.

In a recent issue brief, Six Ways to Reduce Medical Debt in Massachusetts, The Access Project identified some measures that could help people struggling with medical bills. Some of these actions could be taken now, while others might require improvement in the state’s economic situation. However, it is important that the problems faced by these state residents are not forgotten and that policies that could help them remain on the table. Here are some suggestions for reducing medical debt in the state.

–The Connector could exercise the option, included in Chapter 58, to allow low-income workers whose employer-sponsored plans are deemed unaffordable to enroll in Commonwealth Care. This would provide all low-income residents in the state with the same consumer protections and coverage options available to those with Commonwealth Care plans.

–Consider out-of-pocket costs, such as deductibles and co-payments, when determining the affordability of available coverage. Just looking at premiums is insufficient. The Commonwealth Choice non-subsidized plans can have deductibles of up to $4,000 for a family. Employer-sponsored plans can also have high levels of cost-sharing. Low-income workers and people making slightly more than the Commonwealth Care eligibility limits often cannot afford these costs. Read more…

A new poll in The New England Journal of Medicine finds that a large majority of doctors in Massachusetts are supportive of the state’s health care reform efforts. NEJM reports:

Of 2135 practicing Massachusetts physicians who responded to the poll, 70% said they support the Massachusetts Health Care Reform Law, whereas 13% oppose it (see Table 1). The levels of support among primary care doctors and among specialists were similar. When asked about the law’s future, 75% indicated that they want the law to remain in place — 46% with some changes, and 29% as is. Seven percent favored repealing the legislation.

As Dennis D. Keefe, CEO of Cambridge Health Alliance, struggles with his personal health problems, he’s gained a new understanding of how complicated and difficult real reform will be:

It looks like Congress will soon pass a health care reform bill and send it to the President before the end of the year. However, “stabilization,” rather than “reform,” might more accurately describe the bill’s goal as the government tries to get better control of its health care spending.

Real reform doesn’t come from a single bill or signature. While our state’s landmark health insurance access law has insured an astounding 97.3 percent of residents, it nevertheless has done little to control spiraling costs. We’re already on to Phase II by considering a radical change to the way physicians and health care providers are compensated. This may ultimately be an even more substantial transformation, yet still may not signify true reform.

Real reform requires a massive societal attitude change and a realization of our true goals.

I pondered this over the summer while dealing with personal health issues. Diagnosed with Type 2 diabetes several years ago, I was given the traditional regimen of medications meant to alleviate and slow the advancement of this progressive disease. The medications – four in all – worked well at first and like millions of other diabetes sufferers I felt I had been given the magic bullets necessary to combat the disease. I could still eat whatever I wanted, and added only small doses of exercise to my daily activities.

Over time, though, my hemoglobin A1-C count – the true indicator of how well one’s diabetes is controlled – showed I was losing the battle. More aggressive treatment was needed.

But that didn’t mean more magic bullets or medication changes. It meant actually listening to my doctor. It meant truly changing my lifestyle. Now, after losing nearly 30 pounds and embarking on a healthy diet and exercise regimen, I’ve cut my need for medication by half. My goal is go completely off the meds within the next six months. Read more…