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The Young and The Relentless

Saturday, September 12, 2009
Young adults from 18 to 34 years old make up more than half of the nation’s uninsured population—largely due to the fact that they tend to have lower incomes. For those in their 20s and 30s who do have health insurance, peace of mind isn't necessarily part of the deal.

Recently, public radio’s Terry Gross interviewed two young women who were diagnosed with cancer in their 20s. The “Fresh Air” segment was planned around the theme of healing through humor and the notion of “cancertainment” becoming popular among young patients.

The conversation turned quite serious, though, when Gross asked her guests -- writers Iva Skoch and Kairol Rosenthal -- about their health insurance.

In short, they said, the hurdles and hassles of dealing with health insurance were so overwhelming they had little time or energy to focus on healing. They had to put their thoughts about having cancer, undergoing treatment, and positive healing, on hold while trying to survive their insurance nightmares.

One ended up rejecting care in the U.S. and seeking cancer treatment in another country – one considered far less advanced than the United States. The other had to muster up super-human strength to fight for her coverage.

Here are some condensed snippets of the interview with Skoch and Rosenthal. It’s worth listening to the entire broadcast -- or reading the transcript -- to get a sense of what these young women have gone through. And yes, parts of the interview are funny – the parts after they talk about insurance.

Skoch (pictured at right): “I went to the doctor (in New York) and my diagnosis (of colon cancer) was covered. But I’m originally from Prague, which has socialized medicine, and I decided to go and get treatment there, simply because I honestly was not able to deal with all the billing issues.

Just from the first week after being diagnosed, I had a stack of bills about two inches. I constantly dealt with people from insurance companies, trying to figure out what I have to pay, what I don’t have to pay. I was going through this life-changing experience, and it seemed like all I could focus on was these billing issues. So that was ultimately what made me decide to go back to the Czech Republic and get treatment there.

I got great care. It is different than being treated in the U.S., and I think the biggest difference is that it’s a very efficient kind of care. It’s really all business. So I think that was probably the biggest difference, (no) bedside manners.

And I really did not have to wait…because I think everybody felt that I was young, and they needed to push me ahead. So I really did not have to wait any more than I wait when I go to see my doctor in the U.S.

Part of my treatment was taking Avastin, which is a very new drug, and it’s not actually chemo. It’s a bio-based drug that basically starves your tumors from blood supply. In the U.S. a lot of insurance companies don’t want to cover it because it costs tens of thousands of dollars. (In Prague) it was never an issue of cost. I never got a single bill for anything.”

Rosenthal (pictured at right): “I actually had health insurance the day that I was diagnosed (with thyroid cancer). But when I called to get a second opinion, the nurse said, ‘I’m sorry. You don’t have any health insurance.’ And to me, hearing that I had no health insurance was way more startling than even hearing that I had cancer in the first place.

My employer had forgotten to submit my COBRA paperwork… I was leaving a job, and I had filled out all of the paperwork, and I submitted what I needed to submit, but they didn’t submit what they needed to submit. Now, my problem was, because I had been diagnosed with cancer just a week before, I now had a pre-existing condition, so I was not able to go out and obtain my own health insurance.

It was up to me to spend my time on the phone with the COBRA administration and with the privatized company that was administering the COBRA. That’s what I did for the first month after my diagnosis. I was on the phone Monday through Friday, nine to five, haggling with people. And I ended up sort of weasling my way into getting back on to COBRA.

The image that kept coming to mind over and over again is you hear these legends or myths about children who are trapped underneath a car and their moms are just suddenly empowered with this Herculean strength and they’re able to pick up this massive hunk of mental and get their child out from this trapped situation. And I kept thinking, I feel like the child and the mother at the same time and I am just trapped underneath this incredibly complex and suffocating system of health care and I’m trying to save myself, and I have to use my own energy to do it.

I was constantly on the phone, nine to five. I had to present a good case. But it was really exhausting. So when these phones shut down at nighttime, I was a wreck. I mean, I was hysterical. I was crying all of the time. People think that when you are diagnosed with cancer, it’s about healing, taking a bath, lighting candles. I was utterly exhausted, frustrated and completely freaked out that I might die because I don’t have access to health insurance.”

By the time Kairol Rosenthal won her battle with the bureaucrats, her thyroid cancer had spread to 30 lymph nodes. She’s never been in remission. Iva Skoch’s colon cancer is in remission.

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posted by Cynthia Craft | Permalink | 6:32 PM


The Promised Land if you're Chronically Ill

Tuesday, November 18, 2008
The Netherlands!

According to the latest Health Affairs web issue, a Commonwealth Fund study of seven industrialized nations reveals -- once again -- that the US is dead last when it comes to quality and cost, particularly as it relates to caring for people with chronic conditions: diabetes, heart disease, arthritis, depression, etc.

The US spends the most ($7k per capita versus about $3k), and in spite of that more than half (54%) of patients end up skipping drugs, doctors visits, etc. because it's too darned expensive. Patients in the US are least likely to have a regular doctor, among the least able to see a doctor the same day when sick, and more likely to report that recommended treatments were unhelpful or that medical care was poorly organized.

Meanwhile, other countries, like the Netherlands, Canada, the UK or France, place strong emphasis on medical homes and chronic disease maintenance and don't require any co-pays, co-insurance for the maintenance of these conditions. In Germany, coinsurance is limited to 1% to 2% of income.

While there's quicker access to specialists in the US, the same can be said of the Netherlands, where requests to see a specialist are usually met in fewer than four weeks.

Here's a NY Times editorial on it.

In the meantime, diabetes cost the US $217.5 billion in 2007, according to the National Diabetes Economic Barometer study, by the Lewin Group. Perhaps other models worth a view.

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posted by Hanh Kim Quach | Permalink | 1:34 PM


Rebuilding our muscle

Thursday, May 08, 2008
American manufacturers pay more than twice as much per hour for health benefits as the manufacturers in countries we regularly trade with, according to a new report by the New America Foundation that found for every $2.38 an hour paid for benefits by US manufacturers, others pay about $0.96. It's a losing proposition all around that:
  1. Makes our products more expensive -- read: less competitive. (ie. an American-made car costs $1,500 more due to health costs versus $900 more by foreign competitors.
  2. Results in American businesses trying to ratchet down what they pay in health care costs, and resulting in crappier coverage for their workers. (for more money, I might add)

  3. Results in jobs going overseas -- like Ford going to Canada as reported earlier this week.

The report runs through a litany of interesting stats, including:

  • In 1960, health benefits were only 1.2% of payroll. Now, it's more like 9.9% (averaged across all businesses, including those that *don't* provide coverage).

  • Since 2000, fewer employers are offering coverage (from 69% to 60%). But for workers that *do* get coverage on the job, it's costing more -- 102% more (from $135 to $273 monthly premium).

It also acknowledges that not all costs can be shifted to workers, either in higher premiums and out-of-pocket costs or lost wages, because it would affect a business' ability to be competitive in hiring good quality employees -- something all businesses must grapple with in order to stay competitive. And that the cost of health care can't depress wages -- particularly for those already making minimum wage ($5.85 or $8 in CA), or in cases where a labor contract acts as a backstop.

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posted by Hanh Kim Quach | Permalink | 2:24 PM


Look who's moving to Canada

Monday, May 05, 2008
The Associated Press reports that the Canadian Auto Workers have signed a three-year contract with Ford. Chrysler is next.

High health care costs have been a primary source of angst for automakers, who two years ago made headlines by appealing to Washington for some kind of help. Since 2005, though, automakers' health care costs have declined by $2.1 billion. The United Auto Workers agreed to some changes, that resulted in increases costs for retirees and workers.

Salaried workers have seen premiums increase as much as 30%, out-of-pocket maximums increase by 33% to $4,000, and a tripling deductibles from $500 to $1,500.

All this -- and automakers are *still* moving to Canada.

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posted by Hanh Kim Quach | Permalink | 6:01 AM


Oh, Canada!

Friday, February 08, 2008
Sara Robinson at the Campaign for America's Future blog has a much heralded post that provides a fair comparison of Canadian and American health care. It's fair, and not sugar coated one way or another, but is aggressive in its "myth busting" of some of the common misperceptions.

And there's a new edition of Health Wonk Review at Health Business Blog, with lots of links...

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posted by Anthony Wright | Permalink | 10:31 PM


Over there

Tuesday, January 29, 2008
Here's an interesting little video clip about how the Netherlands' new health system works.

Until a few years ago, the Dutch had a patchwork healthcare system, like ours, with a mix of public coverage (65%) and privately purchased (35%) coverage. Now, through an individual mandate everyone is in insured by a private insurer, but insurance companies are heavily regulated -- required to issue coverage to all, and rewarded (or given extra money) for taking good care of sicker patients.

Employers pay, government pays and citizens pay. Subsidies are available for lower-income residents. Lots of cost and quality control, through transparency, etc. (Sound familiar?). They implemented their reforms in spite of budget constraints.

In 2004, the Netherlands spent 9.2% of GDP on health care, versus the US' 15.3%.

The conversation to get there, however, took decades, including the implementation of primary and clinical care standards in the 1980s. So I guess all this is to say maybe we'll get there someday.


posted by Hanh Kim Quach | Permalink | 12:18 PM


Charmingly Third World

Wednesday, January 09, 2008
I know we have very talented smart, physicians, scientists and researchers in this country that make America's health care system the greatest. But it's a total waste to have an amazing arsenal of doctors if the people who need to see them can't.

A new article in Health Affairs this month says the US is dead last among industrialized nations in preventing deaths from amenable diseases (those illnesses that can resolved with good healthcare, such as whooping cough, tuberculosis, treatable cancers, diabetes, bacterial infections, etc.)

For a full list of what's considered an "amenable illness," click here. My personal favorite is euphemistic "misadventures to patients during surgical and medical care."

Some interesting stats:

  • In 1997, the US ranked 15th among OECD countries in amenable mortality, with a rate of 114.7 deaths out of 100,000
  • In 1997, the US fared better than Finland, Portugal, UK and Ireland.
  • In 2002-03, the US ranked last (19TH) among OECD countries in amenable mortality, though our rate improved to 109.7 deaths per 100,000
  • Other countries improved their rates by up to 20%, while US improved by only 4%

There are many reasons people die from diseases and illnesses that are treatable, but one of those reasons is lack of insurance -- people deferring or skipping care until it's too late and the cancer as spread, etc.

Perhaps most interesting is the number of preventable deaths annually. IF the US achieved the same mortality rate as other industrialized nations, between 75,000 and 101,000 Americans would survive annually. That's at least four times higher than the figure we often cite from the Institute of Medicine, which describes how 18,000 people die annually due to uninsurance.

Ironically, we also learned this week that the amount the US spends per capita has increased to $7,026 -- a collective $2 trillion plus annually -- more than any other industrialized nation.

So WHAT exactly are we getting with our money?

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posted by Hanh Kim Quach | Permalink | 5:00 PM


How others make it work....

Wednesday, November 28, 2007
The Commonwealth Fund has a this handy little compendium that describes how other countries insure their citizens.

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posted by Hanh Kim Quach | Permalink | 12:45 PM


Over There

Monday, July 16, 2007
I had the opportunity to attend a swanky event hosted by the California HealthCare Foundation with the German Minister of Health, Ulla Schmidt. Through a UN-like interpreter service, Ms. Schmidt described recent reforms that the country has taken to try and control skyrocketing costs.

Unlike some of their European counterparts that have universal healthcare system controlled by a central government entity, Germany’s system is based on coverage through private non-profits that arose out of sickness funds created in the late 1800s, that compensated workers in certain professions (who were required to pay into the system) from losing income when they got sick. Still, with this decentralized (and privatized) healthcare system, the country manages to cover 90 percent of its citizens.

As a result, Germany is struggling with many of the same issues of a private health care system that we are here – including the balance between regulation and encouraging free-market competition.

Perhaps we can borrow from lessons Ms. Schmidt has learned:
“Whoever calls for more competition in health services will usually not want that principle applied to themselves.’’

The system is now a patchwork of 292 sickness funds (down from 1,200 a decade ago) and workers can choose to move between the funds. The funds are required to contract with any applicant (guaranteed issue!). The result has been that younger, healthier and wealthier have fled to “sickness funds’’ that are cheaper (sound familiar?).

The way they’ve chosen to deal with this, Schmidt said, is that just this year, the federal government is starting to pool together all the contributions and distributing to the sickness funds based on the make-up of each funds subscriber base. So if one sickness fund has sicker people, then they’ll get enough money to assure that those people get proper preventive and maintenance care. This, Schmidt hoped, would take away the incentive for sickeness funds to design plans that attracted healthier people – AND reward efficient funds.

Funds that could take care of their members well – keep them healthy with existing dollars – would be rewarded. If they really used their money wisely, then they’d be able to refund subscribers

On the other side, inefficient funds that ran out of money would have to ask their subscribers for additional money. Those subscribers would then become disgruntled and be free to move to another plan.

Additionally laws in Germany require coverage and contribution based on income, mandate a very high level of benefits, and protect consumers from having to pay too much out of pocket already. We don’t have that here. But Schmidt said that’s the role that government plays – to assure those rules are followed.

In a sense, that’s what we’re trying to do this year: create more rules.

It was encouraging to hear from Schmidt, who presented ideas we might be able to borrow from.

Germany, however, has a very strong sense of solidarity among its citizens, that I’m not sure exists in all parts here, that could be more of a barrier for us. “Everybody has to contribute from their income to the health care system. That’s the principle. The healthy pay for the sick. The young pay for the old. The people with no kids pay for people with kids. That is the system.”

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posted by Hanh Kim Quach | Permalink | 2:43 PM


From small changes to BIG changes...

Wednesday, July 04, 2007
Wednesday, July 4, 2007

* Organizations line up to support SB840; Partisan debate over merits
* Other health bills on children's coverage & drug trials are voted on in Assembly committees

New on the Health Access WeBlog: More on High Deductible Health Plans; Polling on Health Reform; Paris Hilton Update; International Comparisons; Border Health; San Francisco Starts Enrolling; Bush Opposes SCHIP Expansion; Tom Tomorrow Cartoon; Statehouse Reporters

Tuesday was the last day for Senate health-related bills (aimed to be passed in 2007) to be heard in Assembly Health Committee. The Committee heard testimony into the evening.

SB840: First among the bills considered was SB840, Sen. Shiela Kuehl’s universal, single-payer health reform measure. “If you don’t have single payer, someone is going to get left behind,’’ said Kuehl, in calling on lawmakers to support her legislation.

IN SUPPORT: The Assembly Health Committee approved SB840, but not before the regular stampede of dozens of organizations showed up to support the bill.

Of the many organizations that mentioned their support for SB840 were: California Nurses Association, Western Center on Law and Poverty, Health Access California, California School Employees Association, California Physicians Alliance, City of Berkeley, California Catholic Conference, California Labor Federation, Congress of California Seniors, Gray Panthers, Service Employees International Union, California Faculty Association, Planned Parenthood, Consumer Federation of California, California Federation of Teachers, California Association of Retired Americans, California Professional Firefighters, Health Care for All, California Primary Care Association, United Nurses – AFSCME, Consumers Union, California Senior Legislature, Friends Committee on Legislation, Senior Action Network, United Food and Commercial Worker retirees, Breast Cancer Action, American Association of University Women, California Foundation for Independent Living Centers, Richmond Commission on Aging, City of Berkeley, Wellstone Democratic Club, League of Women Voters, California Teachers Association, Latino Coalition for a Healthy California, California Commission on the Status of Women, CalPIRG, American Medical Students Association, Green Party, and consumers who said they were victims of “insurance company malfeasance.’'

One poignant testimony came from a cancer patient who was about to have her short-term policy run out, and was being denied renewal of that policy, given her condition.

IN OPPOSITION: The usual bevy of insurers and business groups opposed SB840 using some very familiar arguments.

Michael Shaw from the National Federation of Independent Business, a faithful opponent of SB840, said that a single-payer system would mean “government rationing of care’’ and that doctors and hospitals “would not be paid for the services (they) are giving.’’

Shaw’s assertion did not acknowledge the issue of nonpayment in the current system – by health insurance companies. Providers spend about $10 billion a year (nationally) on lawyers trying to recoup costs for services they’ve provided, but health insurance companies have denied. Insurers spend an additional $10 billion on lawyers trying to keep providers from getting their money.

Steve Lindsey from the California Association of Health Underwriters also opposed SB840, making arguments that elicited derision from the audience. “One of the ways single-payer controls costs is by denying care,’’ said Lindsey. Coincidentally on Tuesday, the Los Angeles Times had another article detailing how the Department of Insurance had found that Blue Cross mishandled more than half of the cases in which the company unilaterally cancelled policies on consumers who paid them premiums and expected health coverage.

Lindsey was put on the spot by Assembly Health Committee Chair Mervyn Dymally, who asked him, “Of the top 8 countries, can you name the ones that don’t have a comprehensive health system?” He was forced to response that “America does not have one.’’ “Right,’’ said Assemblyman Dymally, succinctly.

DISCUSSION BY LEGISLATORS: Republicans legislators Nakanishi, Gaines, Huff, and Strickland went through the usual litany of reasons that they do not support a universal, single-payer health care reform: They argued that the US has the best health care in the world, allowing for research and innovation, and any change would harm the good elements of our current system. They said that under such a system, the health care industry will have little incentive to invent new technologies, and countries with single-payer have long lines and care is rationed. They claimed that people from other countries come to the US for care, and that businesses will leave the state. Nakanishi reminded Kuehl that the state has a budget deficit. Huff asked, do you really want the people in charge of DMV or CalTrans running health care?

Assemblywoman Audra Strickland, R-Moorpark, attempted to blame the uninsured for not having coverage, naming undocumented immigrants and those between jobs. Strickland also said that some uninsured “make well over the poverty level’’ and “choose not to buy health insurance.’’

Poverty level is $17,170 for a family of three. While it’s unclear what Strickland meant by “well-over,’’ three times the poverty level is a family of three earning more than $51,510. According to the California Health Interview Survey, only 3.6 percent of individuals earning three times poverty actively decline coverage when it’s offered to them. For the remainder of the 96.4 percent of uninsured, they’re ineligible, not offered, or can’t afford coverage.

A calm Kuehl, in closing, rebutted arguments.

* On the U.S. being the best health care in the world: “We don’t have the health care in the world. It’s ranked 37th by the World Health Organization.’’
* On how single-payer would lead to rationing: “That’s what we’ve got here is rationing.’’
* On long waits: “We have long waits here. I can’t get an MRI tomorrow. I’m told I can get it in four weeks. The waits that people go through are expected. Of course you don’t get into surgery the next day.’’
* On the cost and increased taxes and innovation: “Stop wasting 30% of health care dollars on administration (which insurers use to try and deny care), that money is not going toward innovation. SB840 actually has a much better shot at encouraging innovation because it’s built into the budget.’’

In closing, Kuehl acknowledged that all lawmakers were trying to do something to improve the health care system we have currently. “Let’s talk about humanity. This state and this country is struggling to do what’s right. The reason I think this is the best is because it actually takes into account what people need.’’


Other bills of note to health and consumer advocates were considered in various committees, including Assembly Health Committee, Assembly Judiciary Committee, and Assembly Insurance Committee. They included:
* SB350 (Runner) PASSED. Makes technical amendments to last year’s AB774, which bans hospital overcharging.
* SB32 (Steinberg) PASSED. Would extend Medi-Cal and Healthy Families coverage to all children under 300% of poverty. Support.
* SB474 (Kuehl) PASSED. Technical bill that allows hospitals that receive federal funding for uninsured patients to continue receiving it. Support
* SB606 (Scott) PASSED. Requires drug companies selling products in California to make clinical trial results publicly available. With amendments, this got bipartisan support. Support.
* SB972 (McClintock) FAILED. Would have allowed small employers to create health insurance co-operatives that would have little state oversight, and could have ignored state consumer protections. Oppose.


Wednesday, July 11 will be the last chance for Assembly bills to be heard in the Senate Health Committee. Health Access will provide a full update of the outcome of AB8 (Nunez/Perata) the Democratic leadership’s health reform bill.

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posted by Anthony Wright | Permalink | 2:05 AM


Building a fence at the border for whom...

Monday, July 02, 2007
Crossing the border into Mexico and Canada isn't just a prank that activists and Michael Moore stage to make a point about the expensive U.S. health system. And Americans aren't just buying drugs abroad anymore.

The LA Times today has an interesting story on how growing numbers of Americans (about half a million) are heading across the border -- even to developing countries such as Thailand and India -- to get medical procedures done at a fraction of the cost and often under far more luxurious conditions.

Of course, even though the cost for these procedures is about half what would be paid in the US, it still takes money to do this. It's probably unlikely that many of the 47 million uninsured and living on the edge are taking vacations to Singapore to have surgery.

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posted by Hanh Kim Quach | Permalink | 12:08 PM


International House of Health Care

Sunday, July 01, 2007
My wife and I split up many responsibilities, including newsreading. I handle domestic issues; she follows the international beat. ("Honey, how's the war going?") But she did point me to a fascinating discussion on her favorite website, that of the BBC.

In light of the opening of SiCKO, which favorably compares the health system of Britain and other countries to that of America, the BBC asked what its readers thought of their health systems. Perhaps uniquely, they got hundreds of comments, from not just the U.S. and Great Britain but all over the Europe and the world. Lots of opinions, from all parts of the political spectrum, from a truly international readership.

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posted by Anthony Wright | Permalink | 11:35 PM


Not suprised....

Wednesday, May 16, 2007
We already knew that the U.S. ranks 21st in life expectancy and 23rd in infant mortality, in spite of spending more than any other industrialized nation on health care, according to OECD stats.

The Commonwealth Fund yesterday just released a report reaffirming that notion.

It's not a surprising revelation for those of us working in health care, but hopefully, it will provide a jolt to those who insist that America has the best health care in the world.

That's not to say the other systems (in Australia, Canada, Germany, NZ and the UK) are perfect -- but they spend about half as much money -- per person -- being imperfect than we do.

Key findings of the report are that the U.S.:
  • Is the most inefficient -- costing the most while providing the least.
  • Is the most inequitable, leaving low- and middle-income citizens with no health coverage.
  • Does poorly on chronic disease management.
  • Is behind in adopting information technology to help manage chronic illnesses and see exactly what other treatments any given patient is on before prescribing care.
  • Has horrible access because it lacks universal healht coverage.

The only measure that the U.S. does well on is preventive care. But, really, what good is preventive care (discovering you have diabetes) when you can't get your chronic disease managed?

Hopefully, such a report will help convince proud Americans who are convinced that we have the best health care in the world, that while America is great on many things -- it's not really on health care.

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posted by Hanh Kim Quach | Permalink | 2:28 PM


We don't even have socialized medicine....

Monday, March 12, 2007
The Wall Street Journal (subscription required) this weekend had a story about the United Network for Organ Sharing is revising its kidney transplant policies -- favoring young patients over old, rather than the length of time on a waiting list.

This change in how kidneys are currently rationed, naturally, has stirred up the age-old debate over whose life should hold more value; who deserves to live and who will die waiting for care?

What's interesting to me, is that without this suggested policy change, there has been virtually no furor over medical rationing in the U.S. Fear of rationing occurs in discussions over "socialized systems'' such as those in Canada or the U.K. that will result in lines and rationing.

But we DO have medical rationing in the U.S. And people die at the rate of 18,000 a year because health care is rationed, according to the Institute of Medicine, making uninsurance the sixth leading cause of death in the United States.

The United States' method of rationing, however, is largely invisible to the middle and upper classes, because they have insurance.

The U.S. medical system current rations care based on who can afford to pay. If you can afford to pay, you see a doctor. If you can't afford to pay, you wait, you get sicker. You might see a doctor -- at an exhorbitant price -- and you are 25 percent more likely to die because of the lack of care you receive.

That's not to say other systems are perfect. In the U.K, for instance, waiting times for elective procedures (such as hip replacements) can be long. On the flip side, waits to see a primary care physician can be shorter than the waits in the U.S., according to an analysis of four countries' health systems.

The United Network for Organ Sharing is heading into a ideological and emotional storm and all new policies must be approved by the U.S. Department of Health and Human Services. These are difficult decisions to make and one could argue that none of us is qualified to judge who is deserving of life or not.

But let's not kid ourselves, just because our policies don't explicitly make those judgements, that rationing is happening today, and it's happening in the U.S.

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posted by Hanh Kim Quach | Permalink | 10:58 AM


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