Docmomof3, do you happen to know where I can find the references about infant mortality rates, adjusted for all those factors? The only thing I've seen is in the article linked above, which said, "As Nicholas Eberstadt, a scholar at the American Enterprise Institute, points out, Norway, which has one of the lowest infant mortality rates, shows no better infant survival than the United States when you factor in weight at birth."

Re Massachusetts, the report below says that pay is one of the reasons for the physician shortage (see p 19 of the report), but it doesn't go into details about the actual plans:

http://www.massmed.org/Content/Navigatio...mmary_final.pdf

However, I did hear that that affordable plan is proposing to cap physician pay:

http://www.examiner.com/x-2823-Health-Care-Industry-Examiner~y2010m3d22-Massachusetts-Affordable-health-plan-analogy

It sounds like you are somewhat protected from these problems, hopefully by an enlightened employer who knows that retaining PCP's is important.

A couple of problems with the infant mortality statistics.

In many countries, a premature infant that doesn't survive can be characterized as a stillbirth or miscarriage...particularly in countries that don't practice the very aggressive preemie care that we practice here. Also, even higher income countries have more sporadic data collection practices which make evaluating these rates more difficult.

Pre-term births are rising in the US as well as other countries that do have problem-free access to prenatal care (ie Norway). According to the March of Dimes, this is due to: greater usage of assisted reproductive techniques which increase the rates of multiple gestations; a rise in the proportion of births to women over 35 years of age; and changes in clinical practice such as the early induction of labor or performance of Cesarean sections close to, but not at, full term.

https://www.marchofdimes.com/files/66423_MOD-Complete.pdf

Also, according to UPenn, 5 year survival rates for cancer are among the highest in the US...and our mortality rates above the age of 50 can be largely attributed to lifestyle choices and our higher murder rates... http://repository.upenn.edu/cgi/viewcontent.cgi?article=1012&context=psc_working_papers

I think every American has the right to access to health care and I don't know what the answer is...but I can tell you that many people I know want it all and want it for free. They think that other people should have to pay and that this is only fair. My 37 year old brother is a prime example. He earns 30kyear as a home inspector and his health insurance premium monthly is ~200$ through his employer (my dad). My brother absolutely refused to pay the money, so my dad simply signed him up and takes the money from his check monthly to cover it. My brother has complained bitterly about this. He has the money to go out and play pool at night, pay to play in big games of Texas Hold' Em and lose more than his insurance premium in a night if he's unlucky...oh..and he's a 2 pack a day smoker.

He recently bought a brand new truck...and...within the first week, opened the door to get in, banged himself on the head, knocked himself out cold and had to be taken to the hospital for stitches and monitoring for a head injury. Fortunately, he had health insurance. I pointed this out to him and asked what he would have done if he hadn't had health insurance. The answer "Not PAY! Why should I...those doctors are rich." End of story.

SAHMD-My mistake was in thinking the statistic in the 20's was the corrected statistic. Here is an article that attempts to correct for some of the discrepancies.

http://findarticles.com/p/articles/mi_m0795/is_n4_v13/ai_13359858/pg_15/?tag=content;col1

What is especially striking to me are the differences in outcomes within the US depending upon your socioeconomic status. I was on a very low birth weight task force in the city in MA that I used to practice in, and within the same medium sized city there were striking differences dependent on SE status and race. Obviously multifactorial, but still striking.

Re: MA docs not accepting the new insurance-I read the Physician Workforce report when it first came out. It is talking mostly about salaries, and physician shortages and job satisfaction, not about accepting the new insurances. It came out the same year we started universal coverage. One big mistake MA made was to mandate universal coverage without having adequate supplies of physicians in place to deal with the masses of people who suddenly wanted to see the doctor. There was also a huge upfront cost associated with this-imagine-you haven't had insurance for 15 plus years and all of a sudden you are forced to buy some-you obviously want to use it and have healthcare needs you want to have met, as well as things the doc may want for you, like cholesterol screening,pap smears, etc. Huge upfront costs which hopefully will pay off down the line if people end up being healthier b/c they had access to primary care. The trick is getting access for everyone.

I went to a Mass Med Society meeting last week where the president of the society presented on the new national health reform bill, and some MA stats about healthcare expenses that they have been collecting since we instituted health reform. It was interesting....it looked from one of his graphs that we are starting to catch up with the costs that we had at first-the system may be financially solvent by like 2015 or something, according to him-I can't find his presentation on the website or I would be more specific on that but I remember the graph b/c it went against what I have been told about how much money this is costing the state..

In terms of people not accepting the new insurance plans, I can only report what I see from personal experience as a primary care doctor. I was in practice pre and post universal coverage. I work mostly with the uninsured and underinsured. Prior to health reform, we had a system for the uninsured called 'freecare'. It was basically a Peter Pan thing where hospitals and I believe other healthcare organizations in areas that didn't have a lot of uninsured had to put money into a 'pool' that could be accessed by those hospitals and agencies that did have to serve the uninsured. If you had freecare, you could get emergency services and certain primary care things covered if you were seen at a community health center, or an academic center in the 'clinic', for example. Most specialists didn't accept freecare. If you needed specialist care you had to go to an academic center, or I as the PCP had to beg specialist colleagues to see my patients gratis or for very little reimbursement. It was very difficult as a PCP to get care for patients, especially when you added in language and education barriers as well as transportation issues.

Now, with universal coverage, everyone has insurance that is accepted by someone. It is so much easier to refer out if I have to. There may be a wait, but at least they can get an appointment. Personally I think the group that has benefited(sp?) the most are the self employed working class/working poor. They now have health coverage, many for the first time in years. I think people should be mandated to have some sort of health insurance, for the reasons mommd2b lists in her post above about her brother-even if you are relatively young and healthy, you never know when something will happen to you, and I believe you should have to pay into the system that is going to take care of you. By having our ER's not be able to turn patients away, we are basically saying that everyone has the right to healthcare. By mandating health insurance, we are making everyone have to pay for it, at least in some way.

Docmomof3, thank you for the excellent article. I stayed up late reading the whole thing. I agree with you about the socioeconomic factors, which can affect infant mortality (and health in general) in so many ways.

As for correcting for the factors, it seems that individual studies have been done to correct for one factor at a time, but not for all the factors at once. Our infant mortality rate improved significantly when controlling for reported distribution of birth weights. The simulation reported in the article said that birth-weight distribution accounted for 75% of the difference between the infant mortality rates of the U.S. and Japan. It would have been nice to know how much of the birth-weight distribution was due to low-birth-weight babies being counted as "stillbirths" in Japan and "live births" in the U.S., although they touched on that in a different section.

The section about our much higher rate of teenage pregnancies showed how that was an important factor as well, for many reasons, although it was not as important as birth-weight distribution.

Thanks for the information about MA. It will be interesting to see if your state is really catching up financially or not. A lot can change between now and 2015, as people learn how to game the system and as the system adjusts in return.

Also from the article:

"Notably, in the birth weight categories under 2,500 grams, the U.S. [perinatal death] rates were actually lower than those of the two other countries [Norway and Japan]."

Our healthcare system is very good at saving premature babies. I would not want to have a baby anywhere else in the world.