Category Archives: Health Care

The Legislative Logic of Proton Therapy

Proton therapy delivers precise doses of radiation, resulting in fewer side effects and less damage to surrounding tissues.

Proton therapy delivers precise doses of radiation, resulting in fewer side effects and less damage to surrounding tissues.

I just love it when legislators tell insurance companies whose services they should insure. Lawmakers are obviously so much more qualified to judge the efficacy of different medical treatments — why shouldn’t we trust their judgment?

Pardon my snark. A bill has passed the House of Delegates and moved to the state Senate that would forbid insurance companies from holding proton therapy to a higher standard of clinical evidence than other radiation treatments.

Del. David Yancey, R-Newport News, submitted the bill on behalf of Hampton University (HU), which just happens to have a Proton Therapy Institute. HU complains that the procedure is still treated as experimental despite decades of research, explains Travis Fain with the Daily Press.

To tug at legislators’ heart strings, the bill’s supporters brought in Carolyn Lambert, wife of Benjamin Lambert, who served in the Senate more than 20 years and died in 2014. The Lamberts’ son is fighting prostate cancer now. Speaking in a halting voice, she said, the insurers “have abandoned him.”

Insurance lobbyists counter that they use blind studies to make coverage decisions, and that proton therapy makes the cut in some cases, such as pediatric and skull cancers, but not in others. “The bottom line is we don’t evaluate them differently,” said Doug Gray, executive director of the Virginia Association of Health Plans.

The Senate Commerce and Labor Committee passed the bill on what appeared to be a unanimous voice vote, reports Fain. Sen. John Cosgrove, R-Chesapeake, a motioned “as a cancer survivor” to send the bill to the floor.

Bacon’s bottom line: This illustrates the worst of everything about the way the General Assembly works. Anecdotal information and sentimentality demolish reason and empirical evidence. The legislature is well on its way to passing a law that could well nudge the cost of insurance policies higher. The prostate cancer of Sen. Lambert’s son is a tragedy. What we will never see is the tragedy of the “third man,” the invisible victim for whom the cost of medical insurance will be put just out of reach.

Nonprofit Hospitals, Market Power and Charity Care

Medical campus of VCU hospital, one of the largest providers of charity care in Virginia.

Medical campus of VCU hospital, one of the largest providers of charity care in Virginia.

A new study of California hospitals between 2001 and 2011 has found no evidence that nonprofit hospitals provide more charity care when they gain market power. Nationally, 58% of all non-federal, general hospitals are nonprofit. Nonprofits dominate the health care sector in Virginia as well.

“Economic theory indicates that a balancing of social benefits against harm from market power may be appropriate under the assumption that nonprofits will provider greater social benefits when they have greater market power,” write Cory Caps, Guy David, and Dennis W. Carlton in a study undertaken as part of the National Bureau of Economic Research’s health care initiative.

They conducted the study to see if the theory held up in practice. In the case of California, it didn’t.

The study, “Antitrust Treatment of Nonprofits: Should Hospitals Receive Special Care,” could have implications for the debate over the Certificate of Public Need (COPN) in Virginia. Under the COPN law, the state must give its approval for major capital outlays such as new buildings, expansions and purchases of expensive equipment. The law is widely acknowledged to reduce competition and bolster profits for hospitals, but is justified on the grounds that helping hospitals maintain market share enables them to spend money on uncompensated care.

California is not Virginia, and the authors were exploring the relationship between a hospital’s market power and uncompensated care in the context of antitrust laws, not COPN. So, the findings may not be replicated in the Old Dominion. But insofar as the authors developed a methodology for examining the relationship between market power and uncompensated care, it would be worth conducting the same exercise in Virginia.

Virginia nonprofits receive exemptions from state, local and federal taxes. If it turns out that they aren’t using their revenue “surplus” to provide charity care and cover bad debts any more than their for-profit peers are, Virginians might legitimately ask what public benefits they are using their “surplus” for.

Cost Cuts Coming in a Post-Obamacare Health System

he University of Virginia medical center will have to adapt to survive in a post-Obamacare world.

The University of Virginia medical center will have to adapt to survive in a post-Obamacare world.

The University of Virginia Health System will need to dramatically cut costs to adapt to a post-Obamacare world, Dr. Richard P. Shannon, UVa’s executive vice president for health affairs, said yesterday.

As the Daily Progress reports, Shannon briefed members of the Medical Center Operating Board:

Republican plans, written to replace the Affordable Care Act, likely would favor a market-based approach that forces insurers into a price war. Though it may lower insurance costs for consumers, it would mean lower reimbursements to hospitals that could add up to hundreds of millions of dollars over several years, Shannon said.

“Take it all together and I think you can predict there will be enormous pressure on cost in the health care enterprise over the course of the next iteration of the Affordable Care Act,” he said. “The honest answer is we have to get more efficient and we have to get more productive.”

Shannon highlighted some of the tools the health system might use to drive down costs. Artificial intelligence might be used to diagnose some types of cancer. Big data can help doctors predict health problems before they arise. Telehealth can extend healthcare into outlying rural areas. Last year, UVa made 11,000 health visits; Shannon wants to increase that number to 60,000.

The UVa Health System will have to change, as market pressures wipe out hospitals that fail to adapt, he said. “You’re going to see hospitals disappear. The question is, who are the 50 percent who are going to survive?”

Bacon’s bottom line: I wouldn’t want to be a hospital in a post-Obamacare world, but as a health care consumer, I find Shannon’s analysis heartening. As a nation (and a state) we need to shift our focus from who pays for health care, invariably a win-lose proposition involving wealth transfers from one group to another, to a focus on productivity and innovation, which will drive down costs for everyone. If we want to make health care more affordable and accessible, we need to make it less expensive.

Shannon approaches the challenge from the perspective of what UVa can do to drive down costs. Virginia policy makers need to think about what the Virginia health system can do to drive down costs. And that might require thinking previously unthinkable things.

First, if emerging federal policy relies upon competition to drive down costs, state healthcare policy should do so as well. Not just competition between insurers but between all kinds of delivery platforms, from hospitals to independent, ambulatory surgery centers. If Congress passes the kind of legislation Shannon anticipates, it is imperative that Virginia repeal the Certificate of Public Need (COPN) regulations that protect hospitals from competition.

Second, we must come to peace with the prospect of some hospitals going out of business. Frankly, many rural hospitals may no longer make economic sense. In their place, we might well see more clinics, more nurse practitioners, more outpatient surgery centers, more telemedicine, and more travel to regional hospitals for complex procedures. If done properly, the result could be better and cheaper health care for rural Virginians.

Michael D. Williams, UVa’s Center for Health Policy, also told the medical center board that a big cost saver could be the sharing of medical information to avoid duplicate tests and scans. Reforms to patient-privacy laws and more effective data sharing could reduce redundancy. By necessity, some of those data-sharing reforms will come from the federal government, but Virginia should be looking at what can be done on a state level to foster the efficiencies.

Shannon has given the warning. Big change is coming. Will Virginia be prepared?

State Oversight of Physicians Needs Tightening

State officials are lax when it comes to disciplining doctors for infractions of the law.

State officials are lax when it comes to disciplining doctors for infractions of the law.

by Victoria Nicholls

State Sen. Diobhan S. Dunnavant, R-Henrico, a Henrico County physician, broke federal health privacy laws when she sent a political solicitation to her patients during her 2015 campaign, the Richmond Times-Dispatch reported two weeks ago. And what were the consequences? Nothing.

The first-term senator won’t face fines or penalties, according to a letter from the U.S. Department of Health and Human Services’ civil rights office. And that should concern every Virginian and American.

In the Times-Dispatch article, Dunnavant stated that her campaign solicitation letter was approved by a medical practice board and lawyers. Really? Did she chastise her lawyers for malpractice? Did any of her advisers suggest that she consult the Health Insurance Portability and Accountability Act (HIPAA) specialists first? No? Why not?

Patients should be alarmed that Dunnavant was willing to transfer their data to a political campaign without their permission. If a nurse or admin had done the same, would the public agree that it was of no consequence for them to mine patients’ info for volunteer help and votes? What if another doctor or nurse used patients’ data for political purposes? Would they get the same hand-spanking?

“For me, it’s really all about the fact that none of my patients were harmed,” said Dunnavant.

What does Dunnavant have to say about her patients’ loss of data? What about their loss of privacy, which she was obligated by law and public/social agreement to protect? What about the loss of trust in the system? What other “enterprises” do doctors conduct on the side that we, the patients, are sacrificing our privacy for?

Authorities said Dunnavant, when aware of the potential privacy violation, moved quickly to “mitigate the damage” by deleting the protected data from a campaign computer.”

I’d like to know who else might have that data now. Was it backed up? If so, where? Who had access to it? Who else saw it? Did they sign confidentiality agreements? Are they even bound by HIPAA laws? No they aren’t. This is what makes this a huge, huge issue. Most people do not realize how much their personal data is sold on the market.

The system in Virginia isn’t willing to hold physicians accountable. In July 2016, I SENT Virginia physician-legislators including Dunnavant and Del. John O’Bannon, R-Henrico, information that a convicted Tennessee pill-mill doctor was working in a hospital in Virginia. Federal law mandates that convicted drug traffickers be jailed pending sentencing. No response. I asked the Virginia Department of Health Professions how either (a) he got a license or (b) the State Medical Board missed the fact that he had no license.

Still no response.

Victoria Nicholls describes herself as a concerned Virginia citizen living in Chesapeake.

Virginia Hospital profits in 2015: $1.89 billion

Virginia hospital profits remained stable in 2015, down only a smidgeon from the previous year.

Virginia hospital profits remained stable in 2015, down only a smidgeon from the previous year.

The Virginia hospital industry remained highly profitable in fiscal 2015, according to a report issued yesterday by the Thomas Jefferson Institute for Public Policy (TJI). Although profit margins were not as juicy as the previous year, the absolute level of profits remained stable, declining a mere 0.6% to $1.89 billion.

Thanks to the reinvestment of profits, or “surplus” in the case of non-profit enterprises, the combined net worth of Virginia’s hospitals increased by $1.1 billion to a total of $17.8 billion.

“Last year our report showed a year-over-year profit of 8.6% for our hospitals statewide,” states Michael W. Thompson, author of the report. “This is on top of the 10.7% profit in the previous year. Not bad for an industry bemoaning its financial troubles.”

TJI has been publishing the hospital data, compiled from the Virginia Health Information website, for several years. Hospital profits are an especially contentious issue in the 2017 General Assembly session as legislators push to roll back the Certificate of Public Need (COPN) law, which requires state approval of major capital investments by hospitals and surgical centers.

Critics say the law restricts competition and preserves monopoly profits. Hospitals say they need COPN in order to continue providing charity care to hundreds of thousands of Virginians. The question inevitably arises: Are Virginia hospitals profitable enough that they could continue providing charity care even without COPN protections?

The Virginia Hospital and Healthcare Association (VHHA) objects to TJI’s methodology for tabulating profits, arguing that the fiscally conservative/free market think tank skews its numbers by counting surgical centers and non-hospital affiliates of hospital companies. Also, the association contends that average profits obscure differences between hospitals, some of which are very healthy and others of which earn  less than the 4% profit margin to maintain reserves, cover depreciation and invest in growth. Half the state’s rural hospitals operate at margins below that level, according to the VHHA’s own spin on the Virginia Health Information numbers.

However, TJI has found that the number of money-losing hospitals has declined in recent years — from 42 in 2012 to 27 in 2015. “Clearly, when the numbers are reviewed, the hospital industry is once again substantially healthier than it was a year previously,” says Thompson.

The hospital association responds that the current level of profitability may not last. Congressional threats to repeal Obamacare, or at least to roll it back, create enormous uncertainty. “Cuts related to the Affordable Care Act … are forecast to deprive Virginia’s local hospitals and health systems of roughly $1 billion annually by 2022,” stated a VHHA press release commenting upon the 2015 numbers.

Bacon’s bottom line: Everybody wants profitable hospitals, even if they are “non-profits.” The HCCA says 4% operating profit margins is a reasonable standard for hospitals to maintain their financial health while continuing to invest in their operations. While many hospitals fall short of that goal, several exceed it — by a wide margin.

The public needs to know the level of hospital profits. It also needs to know what hospitals are doing with those profits. I have reviewed the annual reports of the big health care systems — Inova, Sentara, Carilion — and find them uniformly unhelpful. All corporate annual reports are P.R. pieces, but those of Virginia’s health care systems have more fluff than a down pillow.

We know that Virginia hospitals are plagued by hospital-acquired infections, which afflict one out of twenty-five patients entering a hospital nationally. How much money are Virginia’s big hospitals investing in controlling those infections? Hospital annual reports won’t tell you. By comparison, how many millions are hospitals pouring into prestige-building medical research programs like Inova’s center for personalized medicine that may be great for humanity but are being funded, at least in part, by profits derived from patients? The annual reports don’t tell us that either.

If you count only hospital profits over and above the VHHA’s recommended 4% margin, that still leaves about $1 billion sloshing around, mostly generated by non-profit hospitals. Where is that money going? What are hospitals doing to justify their non-profit status? Does anyone really know? Where’s the accountability?

Who’s Treating the Infectious Diseases?

Click for larger image. Graphic credit: Virginia Business

I apologize for being obsessive on the subject of hospital-acquired infections recently (see here and here) but I just heard a story today of someone who went into Duke University hospital for a routine colonoscopy and contracted a case of flesh-eating bacteria. This was Duke! Supposedly one of the top hospitals in the country!!

Virginia Business magazine has published data on the volume of infectious diseases treated at Virginia’s larger hospitals in 2015. The data comes from the Virginia Health Information Foundation.

Note: The data does not necessarily reflect infectious diseases acquired in the hospital. Here’s how VHIF describes the data set:

These diseases can be transmitted from human to human, from animal to human, by direct or indirect contact; e.g., fevers of unknown origin, sexually transmitted diseases (including HIV infection), herpes, central nervous system (CNS) infections, measles, rubella, mumps, hepatitis, rabies, and rickettsial infections (such as Rocky Mountain spotted fever). Bacterial infections such as streptococcal and chlamydial infections also fall under this classification, as well as those of spirochetal, protozoal, helminthic and mycotic causes.

The total is not quite 38,000. That strikes me as a remarkably low number for all infectious diseases. Perhaps most of these diseases are treated by primary care doctors. The million-dollar question: How many of these cases, if any, were contracted in a hospital setting?

More Data on Hospital-Acquired Infections, Please

Pneumonia is among the more common hospital-acquired infections.

Pneumonia is among the more common hospital-acquired infections. The public deserves more transparency.

Hospitals are dangerous places. Americans acquired 722,000 infections in a hospital setting in 2011, the most recent year cited by the Center for Disease Control and Prevention. About one out of twenty-five patients fell victim to preventable hospital-acquired infections.

In the interest of controlling infectious disease, health care officials have begun tracking the data more closely in recent years. In November the Virginia Department of Health published its Virginia-specific findings for 2015. Overall, hospitals in the Old Dominion compare fairly favorably with their peers nationally based on a methodology that adjusts for the acuity of patients and other relevant factors.

But that conclusion is tempered by (a) significant weak spots in Virginia hospital performance, and (b) the fact that the methodology compared only five categories of common infections, not all infections.

That said, here follow the statewide conclusions from the consumer version of the study based on 2015 data. Virginia hospitals exhibited:

  • Fewer bloodstream infections than predicted based on the national experience in 2006-2008.
  • Fewer urinary tract infections than predicted based on the national experience from 2009.
  • More infections following abdominal hysterectomies and about the same number following colon surgeries based on the national experience from 2006-2008.
  • Fewer methicillin-resistant Staphylococcus aureus bacteremia laboratory-identified events than predicted based on the national experience from 2010-2011.
  • About the same number of hospital-onset Clostridium difficile laboratory-identified events as predicted based on the national experience from 2010-2011.

Bacon’s bottom line: As I argued previously, Virginia consumers/patients should have full transparency into the risks they are taking when they enter a hospital. When I wrote previously, I was unaware that the Virginia Department of Health collected the data. The department deserves kudos for publishing its report in a form comprehensible to the public. But it should go further.

The report lists every hospital in the state and gives it a green star (better than expected compared to national norms) a red X (worse than expected), an equal sign or a “No Conclusion.” This really isn’t very helpful. Does the Depaul Medical Center, to pick a random example, outperform national norms for bloodstream infections by a razor-thin margin or a wide margin? Do Virginia Commonwealth University patients undergoing colon surgeries experience many more infections or just a few?

More to the point, why doesn’t the health department tell us the total of all hospital-acquired infections at each institution and how the numbers compare to national norms?

It also would be helpful to get a sense of what’s happening to hospital-acquired infections over time. To pick an example, it’s nice to know that Virginians incurred fewer bloodstream infections in 2015 compared to the national baseline of 8- to 10-years previously. But that’s a long period of time. How much progress has been made? How rapid has the progress been — have Virginia hospitals made big gains, or are they doing only marginally better than a decade previously?

The cost of health care poses one of the greatest challenges to 21st-century American society. Eliminating hospital-acquired infections should be low-hanging fruit for controlling costs and improving medical outcomes. While Congress argues over Obamacare and the zero-sum question of who subsidizes whom, Virginia needs to take the lead in driving down costs and improving medical outcomes to the benefit of all. Greater transparency can help by making hospitals more attentive to patients’ concerns and by shining a spotlight on under-performers. If  hospital managements fear looking bad in the eyes of the public and its board of directors, they will make the control of infections a top priority.

Budget Shortfalls Will Dog States for Decades

Projected state/local budget shortfalls as percentage of GDP absent policy changes.

Projected state/local budget shortfalls as percentage of GDP absent policy changes.

Over the next 44 years, state and local governments face chronic budget shortfalls driven by Medicaid spending, government employee health care costs, and underfunded pensions, warns the U.S. Government Accountability Office (GAO) in a report issued earlier this month.

“Absent any intervention or policy changes, state and local governments are facing, and will continue to face, a gap between receipts and expenditures in coming years,” states the report. Closing that gap would require cutting spending by 3.3%, increasing revenues by a like amount, or implementing some combination of the two, stated the report.

Budgets eventually will come back into balance around 2060 when the demographic bulge of the Baby Boomer population passes from the scene, reducing pressure on Medicaid and pensions. However, fiscal pressures could become acute long before then.

The increase in health care expenditures will be relentless, drip-drip-drip year after year, driven not only by the cost of delivering care but the cost of providing care to an aging poor population. Unfunded pension liabilities are easier to sweep under the rug in the short-term but could become a crisis as pension funds burn through their accumulated assets.

States the GAO report:

While most state and local government pension plans have assets sufficient to cover benefit payments to retirees for a decade or more, plans have experienced a growing gap between assets and liabilities over the longer term. Our simulations suggest that state and local governments will need to increase their pension contributions, absent any changes to benefits or employee contributions in the future. Alternatively, state and local governments may need to take steps to manage their pension obligations by reducing benefits or increasing employees’ contributions.

Bacon’s bottom line: Analyzing the state/local government sector as a whole, the GAO report did not differentiate between the states. Clearly, some states will experience more severe budget shortfalls than others. My impression is that Virginia is better off than the average but that we still face a reckoning.

Virginia’s exposure to higher Medicaid costs should be less than the national average because Republican legislators blocked Governor Terry McAuliffe’s bid to expand the program as encouraged by the Affordable Care Act. Long-term, Virginia would have been responsible for funding 10% of the expansion. There is a trade-off, of course. The Old Dominion is foregoing an injection of federal dollars to fund medical coverage for the near-poor.

Also, Virginia did reform its state/local government pension plans under the McDonnell administration, keeping the old “defined benefit” plan for older state employees but implementing a hybrid defined benefit/defined contribution plan for new employees. State funding to the Virginia Retirement System also assumes a 7% annual return on VRS’s investment portfolio, less than the 7.5% assumed by other states. The actual return likely will be lower, I have argued, requiring everyone to pony up more cash than expected. Regardless, Virginia’s adjustment to economic reality will be less traumatic than that of many other states.

Meanwhile, House Speaker William J. Howell, R-Stafford, has been exploring a second round of reform at VRS. The state could save millions of dollars a year by paying less to outside money managers. Also, Howell has backed a 401(k)-like defined contribution plan for new employees, which shifts the risk of under-performing stock and bond indices from the state to employees.

Press reports have suggested that Howell is having difficulty getting traction. Perhaps Virginia should emulate the Social Security and Medicare Trust Fund trustees who annually publish projections of how long the Social Security and Medicare trust funds will last before the money runs out. It would be useful to know (1) how long the money in the Virginia Retirement System will last before the coffers run dry, (2) how much it will cost the state at that point to restore benefits to promised levels. Such knowledge might focus Virginians’ attention on the need to act sooner rather than later.

(Hat tip: Tim Wise.)

Too Many Deaths from Surgical Complications at UVa

Feds penalize UVa hospital for too many surgical complications.

The UVa medical center has focused in recent years in bringing down the rate of deaths from surgical complications.

Here’s the good news: 75 fewer people have died from surgical complications at the University of Virginia Medical Center so far this year than last year.

Here’s the bad news: The public doesn’t know how many people did die from surgical complications.

UVa assuredly knows, but the figure did not appear in a Daily Progress article on the subject, presumably because hospital administrators did not care to share it.

Whatever the number, it was high enough to warrant recognition of the federal government. The hospital had higher-than-average death rates from surgical complications from 2013 to 2015, according to Centers for Medicare and Medicaid Services (CMS) data. The UVa hospital has been punished for the third consecutive year for high rates of hospital-acquired infections and other medical complications. As a result, the facility will receive an estimated $1.8 million less in Medicaid reimbursements this fiscal year.

UVa officials said that the hospital has launched a turn-around effort and that their data show big improvements, even if gains are not reflected yet in government data. “We are three years into a major transformation,” said Dr. Tracey Hoke, chief of quality and performance improvement at UVa. “It takes time for these efforts to be borne out in the national benchmarking services.”

Bacon’s bottom line: I’m not singling out UVa for special attention. I focus on UVa only because the Daily Progress happened to write about it. But it strikes me that the number of fatalities due to “surgical complications” is critical data that the public has a right to know. That data should be reported by every hospital in Virginia.

The fact is, hospitals are dangerous places. You don’t want to go into one unless you’re really sick. According to the Centers for Disease Control and Prevention, on any given day, about one in 25 hospital patients acquires at least one healthcare-associated infection. In 2011, the most recent data reported, there were 722,000 hospital-acquired  infections (HAIs); 75,000 patients with HAIs died during their hospitalization.

(The Daily Press refers to “surgical complications.” Could that also include medical malpractice? Between 2005 and 2015 there were roughly 450,000 medical malpractice payments and adverse actions taken nationally against health care providers, according to the National Practitioner Database.)

The idea of reporting mortality rates generally for hospitals is controversial because some institutions — UVa is probably among them — get handed the hardest of the hard cases. It wouldn’t be fair to judge them based on mortality without adjusting for the acuity of the patients, which is exceedingly difficult to do in a manner that everyone agrees upon. But that logic doesn’t apply to hospital-acquired infections. That indicator reflects the quality of hospital management and medical practice. Before submitting to surgery at any given hospital, patients should know the odds of contracting a debilitating infection there.

Transparency is sorely lacking in the health-care sector, and Virginia’s hospital industry is no exception. Patients cannot function as effective consumers of health care services without this information. Hospitals already have the data, so it’s not as if government would impose some onerous and expensive new obligation to require them to gather it. Virginians should insist that data on hospital-acquired infections be made readily available to the media and the public.

Update: The UVa medical center isn’t the only institution with a problem. From today’s Roanoke Times: “The federal government will again dock Carilion Roanoke Memorial Hospital millions of dollars for having too many readmissions and hospital-acquired infections despite progress in lowering both rates.”

A New Toy for Wonks: Interactive Death Map

Virginia death map

Mortality rates, all causes, 2014. Source: U.S. Health Map.

Virginia has mortality rates roughly in line with the national average, although there are wide variations within the state, as can be seen in part in this image captured from the U.S. Health Map published by the Institute for Health Metrics and Evaluation. Not surprisingly, the highest mortality rates are found in the impoverished Southwest and Southside regions.

The very highest mortality rates within the Old Dominion are located in the far Southwest. Excepting a handful of localities in the Dakotas (which I suspect are home to Indian reservations) the highest mortality rates in the country are in the Central Appalachia. This is coal mining country, and it should come as no surprise that the population there has the nation’s highest rate of respiratory-related fatalities, no doubt reflecting the prevalence of black lung disease.

Virginia’s coal-mining counties share many economic and cultural attributes with their super high-mortality neighbors across the border in Kentucky and West Virginia. I’m not sure why the mortality rates on the Virginia side of the border are notably lower (though still high by comparison with the rest of the state). The rate of chronic respiratory disease is just as high in  Virginia’s coal-mining counties. Mental and substance abuse disorders are almost as high.

But mortality from cardiovascular disease is measurably lower. Why would that be? Is poverty is less endemic? Is there a better (or less bad) health care system? Whatever the reason, it bears analysis.