Mammograms Revisited

Richard Thaler (coauthor of Nudge; I'll reference him often) wrote a piece for the NY Times about the current mammogram controversy. It's worth a read. He doesn't talk about "saving lives", he brings up the problems with prostate cancer treatment, and he provides some interesting numbers about the likelihood that breast cancer is not fatal and mammograms don't detect the types that are fatal, though not the expected life spans of women who are treated for breast cancer. I have a little commentary to add.

The stated false positive rate is 10% per test (which is huge for something with such serious consequences). For the math impaired, here's how that converts into the probability that women are likely to get a false positive over a decade. The simplest way to do this is to focus on the 90% chance that each test does not give a false positive. We use what is called the Multiplication Rule for Independent Events. For ten years, we multiply .9 (90%) by itself nine times: .9 * .9 * .9 * .9 * .9 * .9 * .9 * .9 * .9 * .9. This is more simply written as .9 ^ 10, and the product is about .35. So, there is a 35% over ten mammograms that a woman will not get a false positive, and a 65% chance that she will get a false positive. Of course, this assumes that there are no characteristics of a breast that would make it prone to false positives, which I imagine is unlikely. The 10% comes from aggregate data. I think it is more probable that women who produce false positives at age 40 are continuously more likely to do so each year than women who did not have false positives at age 40. Without the longitudinal data in front of me, I remain skeptical of the appropriateness of multiplying the false positive probabilities as though they are always independent events.

Thaler writes a little about the costs of all these mammograms in terms of unnecessary treatments that cause side effects, and the stress that women feel when diagnosed with breast cancer, but he avoids using dollar amounts to describe all the waste. What is missing is mention of opportunity costs. The cost of all the unnecessary procedures is not just the dollars exchanged for them, but also the other things we can not buy because our finite dollars were poorly allocated. I covered in my last post the idea that we could extend several times as many life years for Americans by taking the money spent on mammograms for women under 50 and spending on other endeavors, such as nutrition programs for children, or having nurses visit patients after operations to reduce treatment noncompliance complications. It is vital to consider opportunity costs. Mammograms for women under 50 don't just allocate $2 billion per year in exchange for a few thousand life years. They also cost us many thousands of other people's potential life years, and the unnecessary treatments and stress result in much lost work productivity. The practical net result, the way I see it, is that our system is effectively just killing other people early by insisting on giving mammograms to women under 50 who lack high risk indicators. Are women in their 40s more important than everyone else?

Many people have lost or almost lost loved ones to breast cancer. It is okay to feel empathy for them. If you are one of them, I feel empathy for you. That is not justification to ignore the data we have and allocate our limited resources on inferior practices. Emotions limit our perspectives and distract us from the ultimate goal of doing the most good we can with the resources we have. Please, let the cooler minds prevail and establish a system that gives America the greatest benefits it possibly can.

Autism Prevalence

A CDC report about autism has lead to some dramatic reactions. Here are some of my thoughts about this "1 in 100" "epidemic".

Summary, in case you want to skip the rest: Diagnosis got "better" for a while, but now I think we're overdiagnosing. There is really poor standardization in the medical field, and practically no oversight. Doctors refuse to let "bureaucrats" (epidemiologists, statisticians, and scientists, really) get in between them and their right to do whatever they feel like to their patients. New Jersey and Missouri have relatively high rates of ASD diagnoses because of nonstandard diagnosis practices. I expect the diagnosis rate to continue to increase, and that this is inefficient overall.

Firstly, remember that autism is not a disorder. There is a spectrum of severity of different features. To get an autism spectrum disorder (ASD) diagnosis, you don't need all the features, and they don't have to be severe. The primary feature involves impaired social interaction. Repetitive behaviors and sensory sensitivity are also common.

One big reason for the rise in the rate of autism diagnoses is that kids who would have otherwise been identified as mentally retarded are now being correctly classified. That is good because more helpful interventions can be assigned when diagnosis is accurate.

Unfortunately, another big reason for the rise is overdiagnosis. ASD is popular and famous. Neurotic parents whose kids aren't meeting expectations, who aren't the superstars the parents wanted, are looking for reasons and targets of blame and sources of hope. A lot of doctors just don't understand what they're doing, want to appease neurotic parents, practice defensive medicine, and benefit from making referrals to friends or businesses they have stakes in. The same nonsense that we see with ADHD and Bipolar diagnoses is happening with ASD. Little Billy likes to play by himself? ASD! Off to the occupational therapist! Little Billy has a slightly smaller vocabulary than his peers? ASD! Off to the speech therapist! Now, there are often cases in which some intervention would legitimately help a child, but interventions are expensive and different third-party payers have different diagnosis requirements for covering them. Well-meaning doctors commit a lot of insurance fraud, handing out inaccurate diagnoses in order to get a payer to pay for a useful intervention. This can be good for a client, but it is bad for our system. I generally see an enormous amount of money spent on small improvements.

The CDC report pertains to 8-year olds. There is generally a spike in diagnoses around age 8 because that is the transition to a developmental stage in which certain skills (reading and writing) are expected, as well as levels of self-regulation and interpersonal behavior. This is when school puts on more responsibility. Many learning disorders are suddenly noticed around this age. It makes sense for the CDC to use this age as it is likely to include cases caught late, though most autism should be recognized by age 3, when language is rapidly developing. A few teachers over the years increase the odds of recognizing problems.

What would be very interesting to look at is how many of these kids meet diagnostic criteria at age 12 or 18. There are a lot of reasons that kids develop skills and behaviors differently from each other, but a lot evens out the older they get. Many people carry around diagnoses like tattoos long after their natural developmental processes or interventions brought them into the normal range. All it takes is one doctor to use a label and a person who doesn't know better believes he's disabled for life, no matter what improvements are made. Anecdotally, I am familiar with a little girl who is almost three. She is quite a chatterbox now, but a doctor flagged her a year ago as having a low vocabulary. He offered the mother a referral to a therapist who would help the girl develop an average vocabulary for her age. Quite ridiculous and unnecessary and expensive. This was a doctor in New Jersey, by the way, which has the highest ASD rate in the country. Perhaps there is a medical culture in NJ that tends towards overdiagnosis. Perhaps their medical schools need to teach statistics better.

There is a lot of variance out there. People are different from each other. Every skill or characteristic of a person lies within a distribution. Half of people are below the average, and half above. There is a statistical term called "standard deviation" that describes how far from the average a person is relative to how widely people vary from each other in general. Most people are within 1 standard deviation of the average. There is precedent for saying that a person has a disorder when a characteristic of health or function is more than two standard deviations worse than average (a bit more than 2% of the population). Mental retardation is considered when a child's IQ is two standard deviations or more from the average. Many psychological tests flag problems when a person scores more than two standard deviations from the average on scales related to depression, anxiety, etc... But that alone should not be used to demark disorders or assign diagnoses. There has to be a convergence of information showing meaningful dysfunction.

Based on this precedent, we should not be surprised if the ASD diagnosis rate approaches 1 in 40. Kids who are socially awkward enough to rate as two standard deviations away from average on whatever metric someone makes up (there are a bunch of ASD symptom checklists out there, and they are not used well) would qualify for ASD. Asperger's and "high-functioning autism" are ballooning. We've gone past the point where formerly-mentally-retarded kids are being correctly identified with ASD, up to the point where formerly normal kids are being dragged into disorder land. They were probably called "weird" before, but is that something we need to fix? Is it really a problem?

I can't help but compare Asperger's to homosexuality. It was not long ago that homosexuality was considered a mental disorder. Now the legitimate medical community accepts homosexuals as healthy people who are just in a minority on a characteristic. We are surrounded by people who meet criteria for Asperger's, but they do well in academics, science, and technology. They are computer programmers and engineers and scientists and professors. Do we really need to say they are disordered because they're socially awkward and repetitive? Criteria C is redundant because criteria A necessarily involves social impairment. Are we really helping by imposing labels and interventions on these children?

Maybe. I don't know. I hope someone is recording a lot of data, and that there are enough "natural experiments" going on to eventually give us the answers. We definitely do need better standardization of diagnosis practices.

Prescription Information Availability

I got a little excited when I read that Congress might limit Big Pharma's ability to use doctors' prescription behaviors for their marketing. Of course, the proposed idea was quickly eliminated.

Pharmaceutical companies spend incredible amounts of money on marketing. Besides outright bribes to doctors with free food and paid speaking opportunities (averaging $3900 per targeted doctor), the marketers use information on which doctors are prescribing what and how often to custom-tailor their pitches. They can tell which of their sales techniques are most effective by looking at the spikes in prescriptions after each sales pitch. They know if a doctor was a waste of bribes, and they can focus their efforts on the ones who respond well to incentives.

The companies will claim that their behavior is to help keep doctors up to date on what works, but that is an outright lie. The marketers push the new, still under patent, expensive drugs over the cheaper drugs regardless of effects. Expensive drugs that do not work better are touted. There is no good reason that doctors should listen to the obviously biased salesmen of a drug instead of looking at peer-reviewed research articles in selective journals. There are problems even with those articles, but they are better.

I have attended drug rep presentations at medical facilities. They use anecdotes about outlier cases to hype up the drug, and lay out some lunch and branded office supplies. The MDs in the room didn't look at the fine print, which revealed to me the variance in the drugs effects (40% of participants for one drug got worse, and those who got "better" were still severely ill, so why use this expensive drug with lots of side effects?). A medical degree is no guarantee that a person is going to be careful or attentive, or even understands statistics, or keeps up to date with research. There is practically zero oversight of doctors in most settings because they run the show and they only listen to each other. Doctors are fallible and subject to manipulation. Smart hospitals have banned drug reps.

I am all for accurate and complete information about drugs being disseminated to prescribers. It should be done by unbiased parties, and be presented in a way that doctors can understand, comparing the risks and benefits of the drugs, and I would also include the costs. The PDR is obviously inadequate, and tends to just collect dust on a shelf. No drug marketing should be allowed, ever. Until that happens, let's keep prescription information from the marketers so they are less able to target unethical and mentally weak doctors.

Consumer Reports, an independent organization, may be a good resource. They have a free website about drugs. For example, recent 60-study analysis showed that $10/month Doxazosin is as effective as $246/month Flomax. Flomax is heavily advertised because it is new and expensive, not because it is more helpful.

Rationing is Ethical

This is what I'm talking about. Allocate our finite resources in such a way that they bring our whole country the greatest benefits. It is completely detrimental and unsustainable to keep spending huge amounts of our resources at the end of life. I want my tax dollars and insurance premiums to result in the greatest possible increase in quality-adjusted life-years, though I understand the inherent subjectivity in determining how to measure or weigh "quality". Even ignoring quality and focusing on life-years would be a vast improvement over our current system. $80,000 of Avastin for a few more months of life? That money could lead to dozens or scores of extra life-years if spent elsewhere. If we, as a country, invested more in childhood nutrition, health education, and smoking cessation instead of pharmaceutical and biotech companies, we would have greater national health and longer, happier lives.

Small Businesses

I want to start a small business. I'll start out with a few employees, and try to grow. How is my business affected by the various plans proposed for health insurance in America?

Status Quo (most states): Since I'm small, I don't have to give my employees an insurance plan. They pay for their insurance out of pocket, if at all. Some will likely not get insurance so they can spend their money on other things, like bigger houses. Those with insurance will overpay for their coverage because they can't negotiate, and will probably be underinsured. I may have to pay slightly higher salaries to make up for the lack of benefits in order to attract good workers, but since people generally don't understand the values of employer insurance packages, I won't have to pay much more. My costs are kept low, and I am better able to function as a small business. Republicans and Libertarians like this arrangement because it helps small business development and entrepreneurship, even though it exploits workers a bit and sets up people for hardship and bankruptcy if they develop health problems. Half of US bankruptcies, largely the cause of our economic collapse, are due to inability to pay medical bills.

Individual Mandate: My employees will be required by law to buy their own insurance. They are likely to buy catastrophic coverage with the lowest premium and least coverage. They will probably be underinsured. The minimum wage is the same, and my competition could consider ending employer-provided insurance, so I won't have to worry about paying much more in salaries, if any more at all, to make up for my employees' health insurance costs. Insurance companies love this arrangement because the government is forcing people to give these companies money, and the government will probably pitch in for people who need help paying. Free money for insurance companies, cheaper labor for businesses. Real Republicans and Libertarians don't like the government interference (most Rs are bought off by insurance lobbyists and have no values), and liberals don't like the poor quality of insurance and the burden on the working poor who may not qualify for enough subsidies.

Employer Mandate: This is my nightmare. The government would force me to pay for my employees' insurance. Since I have a small business, I don't have leverage to negotiate a good price. There are some small business collectives, though, that can negotiate together, depending on my state. I sure wish there was a national insurance market so the collectives could negotiate more freely. I have to deal with the local insurance monopoly. Combined with minimum wage laws and competition with larger businesses that can negotiate better, paying for health insurance plans for my employees may inhibit my small business's growth, or even make it unsustainable. My business may not last long, or even get started. It's a shame because consumers would really benefit from my business's existence, but not enough to justify paying the prices I would have to charge to stay in business if I have to pay for health plans. This plan also leaves unemployed people in the lurch, and when my business fails my employees will have nothing. Maybe my business can survive if I fire some people and work the others harder. Big businesses like the employer mandate because they already give their employees well-negotiated health plans, and this would make it harder for new competition to sprout up.

Public Plan: Ah, I could relax. Everyone has basic health coverage. They can buy fancier private plans if they want, but the basics are covered, and are better than the old private catastrophic plans. I am more likely to be able to pay competitive salaries or reinvest profits. My employees are secure. Real Liberals (not the bought-off ones), unions, health economists, and the poor favor this idea because it provides security and needed health care to all Americans, and improves the stability of our nation's economy while setting a stage that fosters small business innovation. Republicans and Libertarians hate the plan because it is government control (they blindly hold on to a belief and a value despite all the harm their decisions cause), and insurance companies hate it because they love the profits they get from our current horrible system.

Mammograms

The current mammogram controversy is yet another example of ignorant, unthinking people going crazy about something they don't understand. Most critics of the new U.S. Preventive Services Task Force guideline do not understand that our system has finite resources. They also don't understand that there is no such thing as saving a life. There is only delaying death. Also not mentioned in any of the articles I am reading is that breast cancer mortality rates are usually only measured for five years.

The new guideline says that the recommendation for mammograms should be once every two years starting at age 50. This replaces the recommendation for annual mammograms starting at 40. They found that only 1 in 1900 mammograms for women in their 40s delayed death. This may save $2 billion per year and result in maybe 600 undelayed deaths. That means the old guideline resulted in spending about $3.3 million dollars per delayed death. I don't know the life expectancy of breast cancer survivors, but for the sake of more math, let's say that all of these deaths were delayed by 40 years. That's over $83,000 dollars per year of life, just spent on mammograms! Keep in mind that these women will continue to incur more health care costs over those 40 hypothetical years, too, and I am not considering quality of life.

The British system refuses to pay for drugs that cost more than $45,000 per quality-adjusted life year (QALY). Medicare limits hospice spending to about $22,000 per year (if I read that right). These measures are necessary to protect the whole system from going bankrupt, as our system is destined to by 2017 unless we make drastic changes. These measures also help ensure that the system's finite resources are being used where they can do the most good.

Think about how much good could be done with that $2 billion per year. I guarantee that we could save far more than the breast cancer's 24,000 (my certainly too-high hypothetical estimation) life-years by spending it somewhere else. I bet that $2 billion could be easily spent to save 100,000 life-years or more. Critics of the new guidelines are selfish and short-sighted, and would rather hang on to their anecdotes of women whose deaths were delayed while sentencing thousands of other people to a lack of care due to insufficient resources. These costs also keep insurance premiums high, pricing working poor out of comprehensive insurance.

Women considered high risk due would still be recommended for mammograms before 50. There is some talk about how black women would be disadvantaged by the new guideline because they tend to have earlier and more aggressive cancers, and of course that would be taken into account by informed doctors making recommendations. The task force guideline is based on aggregate information for the national population.

Mammograms have been oversold, and our country as a whole would be better off following the new guidelines. We need to make our entire system more efficient and cost effective (not the same as cutting the total cost, just demanding better results for our money) for it to be sustainable and good for the people of our country.

Stupak Inconsistency

I recognize that my ideas on health care, coming from my educational and work background, would have been far more interesting and useful to readers two years ago. Now we are deluged with health care information, and Congress is churning out thousands of pages of bills and amendments, which is too much for me to process and evaluate. There are great resources out there, such as Ezra Klein's blog, NPR, and so forth. I am trying to find my utility.

Anyhow, for today, a hot topic is that the Republicans just realized that they've been paying premiums to Cigna for 18 years that cover abortions, and they're going to stop. They say that abortion is evil. Enough Americans agree with that that some Democrats jumped on board and we got the Stupak amendment. Here's a quote from the site I linked to above:

"The Stupak amendment, named for sponsor Bart Stupak (D-Mich.), was adopted by the House before it passed the health care bill on Saturday night. It prohibits a government-backed health care plan from offering abortion services and bans the use of federal subsidies for individuals to buy into health care plans that provide abortion coverage. "

The ridiculousness of this, as was pointed out by Ezra Klein (I don't know that I would have caught this), is that the government heavily subsidizes health insurance plans that cover abortions. It does this by not taxing employer-provided insurance. People who get insurance from work are getting cheap insurance in part because of the government's decision not to tax the insurance costs as income (and also because of negotiating leverage depending on the employer's size).

I pay for my insurance individually. This means that I pay taxes on my income, then spend my income on insurance. I can still afford insurance because I have a very basic plan and I am not "poor". Many people who do not get insurance from work are poor and need more comprehensive insurance plans. Many of these people need government subsidies in order to have insurance. We already know that it is important to insure everyone to keep costs down because the uninsured get expensive ER care instead of cheaper basic care and prevention. The Stupak amendment is only hurting poor people's ability to choose insurance plans that cover abortion. This group is easily the most important group to provide that choice to.

Obviously, deontologists who think abortion is evil will try to make abortions impossible, even though unwanted pregnancies lead to all kinds of personal and societal problems such as child abuse, neglect, mental illness, delinquency, and crime, which all cost the people involved and our whole country billions of dollars, happiness, and function. So why aren't these same Stupak supporters clamoring to end the tax exemption on employer-provided insurance that covers abortions?

Uwe Reinhardt Highlights

NPR interviewed Princeton health economist Uwe Reinhardt. Reinhardt does a good job clearly and concisely explaining concepts. There is a lot more than gets covered in the interview, but this is good. Here is a summary:

* People are generally individually selfish, and need active leadership to coordinate for the good of the group.

* The current health system hides too much information (costs and quality), so we can't make good decisions about what care to get or how much to pay for it, which leads to high prices for mediocre outcomes.

* Prices are different for people based on what can be negotiated, not costs or benefit.

* Government-imposed standardized prices work well in Maryland and Europe.

* Care providers are paid way too much for giving treatment and tests. This is a huge incentive to perform unnecessary procedures and prescribe unnecessary drugs. They are generally not paid based on outcomes (hidden from consumers).

* A public health insurance option would be able to negotiate good prices.

* The free market screws over poor people by relocating care providers (in addition to pricing out insurance for those who don't qualify for Medicaid).

* The private insurance system requires a ridiculous amount of nonstandardized paperwork that raises costs and takes resources away from treating patients.

So, what are some ways we can use this information to make our system better? I think it's clear that we need a way to track outcomes by doctor and clinic, and make costs transparent. Outcomes can easily be tracked if we had a unified system (single payer), which would lead to paying providers for outcomes instead of for giving unnecessary treatments. A single payer would also negotiate good prices that make the system more sustainable, and vastly reduce costs and wasted time due to paperwork. Government intervention is necessary in order to make care accessible to the poor, since the free market only provides incentives to abandon them. Unselfish, compassionate changes that are good for the whole country will have to be made by the government because individual actors are selfish.

Insurance Monopolies/Oligopolies

I feel sometimes that I fell asleep and woke up in an alternate universe. The Republicans are trying to protect Medicare Advantage, which is wasteful of taxpayers' money. The Republicans are blocking efforts to establish a public health insurance marketplace that would foster free competition. It is the Democrats that are trying to facilitate free market competition by de-exempting insurance companies from anti-trust laws.

The Republicans violently oppose a public health insurance option on the grounds that it would unfairly compete with private companies. If they care so much about fair competition, will they follow the Democrats' lead and fight the unfair private insurance monopolies? I doubt it. The Republicans have abandoned their values and all reason, and act now only to cripple the current administration and regain power. They don't care about the citizens or economy of this country. They care about themselves.

Competition among insurance providers will reduce the prices of insurance. Let us see that competition. Start by stripping insurance companies of protection from anti-trust laws. A public marketplace would be another great step towards increasing competition and providing the American citizens more insurance options at lower prices.

Unsustainable Resource Allocation

Yesterday I wrote that our elderly are getting 2-4 times the money out of social services as they put in, as hard working taxpayers and their children are deprived of valuable services that would strengthen our country now and for the future. This recent MSNBC interview with crazy Betsy McCaughey gives the CBO citation and shows how the approximately 3:1 ratio was found.

There are two valid drivers for how we allocate money. The more deontological driver is to spend money to give people what they deserve. Benefits to soldiers, for example, or temporary unemployment benefits, or funds to support poor children. People who have a raw deal through no fault of their own, or who made sacrifices for the rest of us, deserve care. The more utilitarian driver is spend money on whatever will net the greatest good. What sets us up to have the best future? Military benefits are driven by this, also, as they are often calculated incentives to attract needed recruits so that we can even have a military. Public works projects that improve our infrastructure so we can continue trade and growth. Investing in research. Paying such vast amounts of money on social services to the elderly is more than they deserve and is not an investment in the future. At least McCaughey wants to raise the Medicare age to 70, even if she opposes making the system more efficient.

The major invalid driver of money allocation is greed. Special interests want their money. Politicians want votes and campaign contributions. Politicians make allocations (corn subsidies, no-bid contracts, F-22s, bridges to nowhere, etc...) that will get them votes and contributions, even though it hurts most people. Old people vote. Old people vote more often than young people. Politicians make policies that benefit old people at everyone else's (and the country's overall) expense. We are in a death spiral of increasing social security and Medicare expenses because politicians pacify the elderly now for votes instead of looking at the big picture and our country's needs for the future.

The interview also helpfully shows that a public option, or the public marketplace option that Obama talked about, would greatly reduce health care costs by eliminating the widespread occurance of localized insurance monopolies. I have two real choices for insurance provision in my area, and that is not competition that benefits consumers. When did Republicans start hating competition? Was it when insurance lobbyists handed them goodies, or are they just stubbornly trying to shoot down at any cost everything Obama tries to do?

Also, tort reform, which I've strongly advocated, seems to be a very low priority as far as cost controls go. It's still a good idea, and the special interest most opposed is the lawyers who take half the money, but it can go on the back burner.

Prevention - Is It Worth It?

I've already mentioned my skepticism of the cost-effectiveness of prostate cancer tests as a preventative measure, since they have notoriously high false positive rates and lead to much unnecessary cancer treatment that results in many side-effects and iatrogenic consequences. I have a vague memory of an issue in California a while back in which gonorrhea tests or treatments were mandatory at birth because gonorrhea can lead to blindness, but the processes were very expensive and only found such a tiny incidence that the requirement was not worth while. Remember, we have finite resources, and they have to be used where they do the most good. If we had infinite resources, we could test and treat everyone for everything.

Many preventative measures are easily worth their costs. Vaccines, obviously. How much has the US had to spend on polio over the last few decades? This CBO letter describes a few other good preventions, but points out that about 20% are not worth doing. Again, very obviously, don't smoke and don't be fat. Get even a modest amount of exercise.

There are some issues with how cost-effectiveness is evaluated. Different projective models come up with different results. (The Health Affairs article linked to by that blog costs money)

One of the most controversial issues in determining the cost-effectiveness of preventative measures is that they can result in increasing people's life spans so that they end up using more health care than they would have if they died earlier. There is also the argument that the elderly worked hard to pay into the system during their lives and deserve to be kept alive as long as technologically possible. Well, they're actually sucking out 2-4 times as much money from social security and Medicare as they ever put in, so that argument is junk. They should definitely get what they deserve, but not more than that at everyone else's expense. This is the reason those social services are unsustainable and threatening to bankrupt our country in less than ten years. We spend great amounts of money to keep people alive past the point of function. To state that we should reduce what we spend on that outcome incites revolt from hillbillies who throw around accusations of trying to kill their grandmothers. Remember, we have finite resources. Keeping someone alive in a bed at great cost takes away money that could help children and workers be more productive and contribute to our whole system. It is not heartless of me to deprive an aged person of expensive care. It is selfish to demand that expensive care at everyone else's expense. The utilitarian ethic is the most compassionate. England realizes this. If we stop spending great amounts of resources on end-of-life care, we change the models that calculate the cost-effectiveness of preventative measures, making more preventative measures worth using that will increase the overall health and productivity of the population of the United States. It is good for the whole country.

Health care is an investment. We pay up front so that we have better outcomes for the future. Make sure that we get the best outcomes we can for our investment. Pay to maximize function for us overall. This will help the system grow strong and be sustainable.

No Public Option

The Senate Finance Committee excludes a public option. This really is no surprise. We know that Baucus is in the pockets of insurance companies instead of his constituents, as are many other politicians. It is also blatently apparent that the entire Republican party is united to prevent the Obama administration from accomplishing anything good for America. The Republicans want the Obama administration to fail at improving our country and serving its citizens, just so the Republicans can cite the failure while campaigning for the next elections.

What can we do?
Well, we obviously need some campaign finance reform, for starters. There is an organization working to accomplish this goal. Change-Congress.org, organized by the illustrious Lawrence Lessig, fights against the sway that special interest groups (insurance companies) have over our government. When there is more of an incentive for politicians to work for their constituents, and less of an incentive for them to pander to money-grubbing companies, we will see policy decisions that are better for this country.

Did we need a public option?
Well, the CBO says that various plans proposed would cut the US deficit by tens of billions of dollars over the next ten years, while providing health care to tens of millions of American citizens who currently have no insurance. I've seen other organizations estimate that the deficit would drop by even more, since the CBO did not look at every related variable. There are different plans, though, and different ideas of what the public option would look like. So, there are proposals that include public options that would help many Americans and save our country money, which are both outcomes we need. There are other ways to get these outcomes, such as a single-payer system (HR676, Medicare for All, has hardly been mentioned) or extremely tight regulation on insurance companies, but a public option was the most likely to make it through congress. It just isn't likely enough.

I am confident saying that any politician currently opposing/stalling efforts to increase the government's involvement in health care, either through a public option, marketplace, expanding Medicare, or more strictly controlling private insurance companies, is motivated only by the drive for personal power. These politicians enjoy their campaign contributions and visits from lobbyists, and the Republicans know that sticking with the party line ensures they will keep getting support in future elections. The politicians who are fighting for the health of our citizens are the ones who care about their constituents.

Listen to the Experts

It is terrible that so many politicians make policy decisions to pacify ignorant and misled mobs instead of using the accurate information available to make the best decisions for our country. I cringe when I catch what passes for television news these days, a bunch of polls and tweets from random people presented as if they should be used to guide our government's policies. Those people don't know what they're talking about!

Here's a neat table comparing the opinions of the informed to those of the random. The average person is selfish and ignorant, and wants unlimited care for herself, not understanding the costs, consequences, or relative quality. They care about anecdotes instead of real data on the quality of a doctor or treatment. They don't understand what variance is, let alone its relevance in health care. They trust their heavily biased and marginally informed doctors.

It is hard to explain the details of health care economics to the average person. It is hard to explain why we should have fewer treatments and more tracking of patients and doctors. It is hard to explain why hospitals should have fewer high-tech machines. It is easier to explain why drug companies are evil and doctors shouldn't be so free to refer patients to clinics the doctors own stake in. Overall, the complexity and scope of health care is overwhelming and confusing to the average person who just wants some security.

The convergence of the expert opinions is good for the country. Trust the experts (in aggregate, not just the few who talk on Fox News). We want everyone to have security, just like you want for yourself. We want costs to be low, and quality to be high. We don't want people bankrupted by an illness. We don't want patients exploited. We don't want the nation's deficit to grow. Not only do we have these goals, we have the knowledge and skills to see how to achieve them. We just need everyone else to stop holding us back.

Obama's Marketplace Plan

Even the famous Ewe Reinhardt agrees with me. Obama's proposed marketplace, where private insurers would compete with a public plan to provide customer-friendly health insurance, is going to be costly. If you're going to give so much care to people, ban rescission, allow pre-existing conditions, and put a low cap on out-of-pocket expenses, then you're going to have an expensive insurance plan.

To keep costs practical, one thing you have to be aggressive about is the chronic diseases that make up the bulk of costs. Encourage and demand more personal responsibility, and be able to cut people off from expensive care caused by their irresponsibility. For example: diabetes is widespread and totally manageable. It is far cheaper to help diabetics follow their treatment regimen than to pay for all the ER visits resulting from improper self-management. Many hospitals offer services that help slower diabetics keep track of their medication, plan their diets, get regular check-ups, and so forth. Not everyone uses those services, though. Some people insist on doing whatever they feel like, and make six trips to the ER each year. That hurts the rest of us. When New York City began a program to call every diabetic regularly to remind them to get check-ups, there was a big outcry about violating their privacy. Well, they violate everyone else each time they avoidably use expensive health care resources. Should everyone pay for a smoker's expensive lung cancer treatment? For a head injury of a motorcyclist who refused to wear a helmet?

We are all part of a system. If a person is going to renounce their responsibility to the system, their responsibility to take care of themselves so costs to the rest of us are manageable, then they renounce their membership in the system. The system should help those who make good faith efforts to support the system in return, but should not be obligated to help those who selfishly and irresponsibly hurt the system. An arrangement like England's that refuses to pay more than a set amount to keep a person alive for a short time would also be appropriate. We have finite resources to be spread out among everyone in the system. If we focus on an individual at the expense of the group, we cause far more damage that we prevent. In health care matters, we need a teleological utilitarian ethic. Even some modern deontologists allow for a 'Principle of Permissible Harm'. Spend our finite resources first where they will cause the greatest increase in quality-adjusted life-years working. That will make the system much stronger and sustainable for the future. Our current system is not sustainable, and is killing more future life-years than it saves now.

Obama's Health Care Reform Speech

I'll just try to comment on his speech briefly.

It is a bit overreaching for Obama to be determined to be the last president to try to reform health care. We have no idea what the needs of America will be in fifty years. We will need constant monitoring, evaluation, and reform in order to adapt to future needs.

Over half of US personal bankruptcies are due to medical bills. Employer-provided health insurance (subsidized by the government) has been and is a bad idea. It is hard for US companies to compete internationally, and good American citizens get screwed if they are laid off or self-employed. Small businesses are over-burdened if forced to provide insurance, and the employees suffer either way. Trying to buy insurance individually strips away negotiating leverage and further hurts people.

America takes less care of its citizens than any other major nation. Not only has the government dropped the ball on taking care of everyone, but it lets insurance companies use techniques like rescission to exploit citizens. Obama is calling out our nation, an arrogant nation that likes to believe it is the best, on its cruelty and heartlessness towards its own members.

Obama correctly points out that we all pay more when the uninsured and underinsured end up in the emergency rooms for trivial problems, or major problems that could have been prevented by cheaper basic care. We pay more money as a country for pathetic health outcomes. What he doesn't go into are the details about that: our high payments for cancer treatments and whatnot to extend people's lives just a little instead of focusing on paying for basic and preventative care that would extend more people's lives by a lot. That would raise more "grandma-killing" nonsense, but it really is a great waste that hurts our whole nation. Is baby-killing better? Or worker-killing? Medicare and Medicaid costs are so bad because we provide expensive treatments to people who are going to die anyway, and we enable people with chronic illnesses like diabetes to not minimize their problems. When we can accept the fact of death for the elderly (the private insurance companies actually do have Death Panels, and they're effective at denying care to anyone), and get people to take the barest responsibility for themselves, costs will drastically drop. We also need to cut down on drugs as a whole culture. Pharmaceutical pill-pushing is costly, damaging, and out of control.

Single-payer systems are great, but not the only good solution. Making individuals buy private insurance is a terrible idea. The insurance companies would love that windfall.

The Republican party is united. That is their great strength. Unfortunately, they unite behind terrible ideas. The Democrats, instead of being blind sheep and puppets, like to think for themselves. This strength allows for creativity and progress. This unfortunately leads to many different ideas, such that even when these ideas are good, they split the votes and lead to conflicts that ultimately allow the Party of No to succeed.

THE PLAN
Finally, the meat and potatoes.
1) Enrollment in the public plan is optional if you have other insurance.
This is good. It will be healthy for private insurers to have to compete. Right now they have virtual monopolies in most of the country. People get to choose what they like (this is not always good because insurance plans can be hard to understand, and people are manipulated by advertisements). It is great to make health insurance mandatory. This will reduce waste due to ER visits, and reduce financial hardships for those who have sudden medical needs but didn't have insurance. Unfortunately, there is a hardship waiver for people who still can't afford the premiums. This is where the feds should just pay the premium, but later Obama says that he won't allow that. Hopefully Medicaid will take up anyone who can't afford the public plan premium.

2) Rescission is illegal for everyone.
This is good. People can have more security.

3) Federally mandated cap on out-of-pocket expenses.
This is interesting. I assume that the cap will depend on a person's income, and not be the same for everyone. This will raise premiums for everyone.

4) Federally mandated coverage for routine check-ups and preventative care.
This is probably very good. He mentions tests for cancer, and that worries me. Some cancer tests are very expensive and/or have high false-positive rates, leading to much dangerous, expensive, and unnecessary treatment. I'm especially thinking of prostate cancer. Overall, though, it will be good to regularly tell more people that they need to lose weight, eat better, stop smoking, etc... I hope this doesn't just give doctors more opportunities to prescribe unnecessary drugs.

5) Public plan for anyone.
This is great, if it is affordable. COBRA is absurdly expensive, especially since it's offered to people who just became unemployed! This will definitely help small businesses and self-employed persons, too. No one can be denied for existing conditions.

6) Here Obama talks about an insurance marketplace. It seems like items 2-4 above would only apply to insurance companies who want to participate in the marketplace. Earlier, it sounded like those rules would apply to everyone, but now it seems like they only apply to private insurers who compete for the customers in the public plan pool. That's good incentive for working people to quit their company plan and join the public plan, but maybe only if company plans lose their tax breaks so the true costs are apparent.

7) No coverage for illegal immigrants.
If you want American services, become an American.

8) No federal money for abortions.
Someone said to me that the public plan can still cover abortions because it will be fully funded by premiums, and not federal money. I am not sure about that. It still sounds like the government would pay 900 billion dollars over a decade for the plan, but expects to get that money back from premiums. Obama didn't say he wouldn't spend federal money on the plan. He only said it wouldn't increase the deficit. It is important for the plan to not spend federal money on abortions because the plan would get shot down.

9) Conscience laws still apply.
These are terrible laws that protect health professionals who refuse to do their jobs.

It is not clear to me what incentive insurance companies have to participate in the exchange. This plan says it will have low premiums, but also provide far more services to a group of people likely to have more health problems. Though there is a lot of waste and inefficiency and advertising in other insurance companies, I still do not see how this plan will work. What is offers is going to be expensive. New customers would only be profitable if they pay in more than they cost, and I am skeptical.

If it really would work, I'll sign up. I would love to have the health plan Obama describes. If I felt a need for additional coverage, I am sure a private insurer will have options available to supplement me.

Obama also proposes experimenting (hooray!) in several areas to see if malpractice reform would be helpful. This is something that I already think would be helpful, for the same reasons that Obama wants to try it, and the experimentation would help prove whether it is or not. I am very happy about that.

So, there are some good ideas there, and I am excited about some of them, but I am also skeptical that it will work out as described. We definitely do need reform. Our current system is terrible. Almost any implementation of this plan would be an improvement over what we have, but I think it is likely that it will not meet expectations, and that failure will be used in the future to oppose more needed reform, and against good politicians.

The Best Plan for America - Part 3

When we've reformed campaign financing, letting us end corn subsidies, we can get to the task of reforming tort laws and malpractice resolution processes.

3) Stop frivolous lawsuits against hospitals and doctors.
Why can suing doctors and hospitals be bad? It leads to doctors running unnecessary tests and performing unnecessary procedures and prescribing unnecessary drugs so that they can't be accused of not trying everything. These unnecessary tests and treatments can cause problems for a patient (side-effects, infections), and increase health costs. When costs go up, people with less money are rationed out of health care. Also, over use of these services creates delays, making people who need them wait, perhaps too long. Where lawsuits are common (Pennsylvania), malpractice insurance rates go up, which also increases the cost of proving care, and drives doctors away, which reduces the availability of good care. Hospitals need to hold larger amounts of money in reserve in case they get sued, which is money that could otherwise be used to improve care for patients.

But what if something bad happens because of a doctor's decision? Well, that's not exactly what malpractice is. We live in a very complex system, and have complex bodies with complex problems. There are hardly any treatments that work 100%, and sometimes bad things happen even when all the correct decisions were made given the available information. Doctors and hospitals should absolutely be protected from lawsuits if they can demonstrate that they followed known best practices. Rogue doctors who make decisions based on their feelings or personal experience instead of the collected empirical data of their fields can go hang.

Even when a doctor does do something wrong, the money involved should be more reasonable. Payouts are sometimes so ridiculously large (which hurts the entire system, remember, and not just the one doctor) that malpractice insurance companies often choose to settle for smaller amounts instead of going to court. This happens even when the doctor is innocent. So, we end up with a bunch of doctors being denied the opportunities to prove their innocence because an insurance company doesn't want to risk a big payout. These settlements are strikes against innocent doctors, and affect their abilities to get jobs, and can even result in licensure problems. If payouts were limited to reasonable amounts, the system would be more conducive to actually determining whether a doctor did something wrong, instead of settling with opportunists who sue at the drop of a hat.

By making it more difficult and less profitable to sue, we improve the entire system. Treatment becomes more accessible to those who need it, costs go down, overall outcomes improve, we can more often actually learn which doctors did something wrong and which were frivolously accused, and we encourage evidence-based medicine instead of defensive medicine. The only people who would really suffer are lawyers.

The Best Plan for America - Part 2

So, the first step was campaign finance reform, taking away some of the incentive for politicians to pander to big companies instead of the health of our nation. Once that's out of the way, we can target another big systemic issue.

2) Stop subsidizing corn.
A big reason that America has such bad health outcomes compared to all those other industrialized countries that pay less for health care is that Americans are fat. Fat, lazy Americans eating lots of meat and drinking soda get those really expensive chronic illnesses like diabetes and hypertension. This raises costs for everyone, since we're in this system together. A major reason that so many people eat meat and sweets is that those foods are so cheap. An apple costs more than a candy bar. Juice costs more than soda (juice is also high in calories, but fructose is easier on your pancreas than dextrose). Also, impulsive and ignorant people would rather get fast food or some other form of processed junk than take half an hour to cook. Cooking healthy food can actually be very inexpensive, but it takes a little time, and most Americans would rather do something else.

So, how would ending corn subsidies lead to healthier eating? American corn is produced in far greater quantities than needed because the feds pay the big farm conglomerates to do it. There is so much unnecessary corn that the price is very low to buy it. Since it's so cheap, it gets fed to chickens, pigs, and cows to get them big and fat at a low cost. It also gets turned into corn syrup to keep our sodas and candy cheap (the price of sugar is artificially increased in America by federal tariffs on sugar imports, keeping down competition with corn). So, heavily because of this one crop subsidy, meat and sweets are very cheap and plentiful in the US.

There are other consequences. Since so many fields get devoted to corn (which does not require crop rotation like some other crops), less of other crops are grown that are not subsidized. More corn for animals and sweets (and fuel) results in fewer carrots and spinach and peas for humans. A smaller supply of those healthy foods for people means that they cost more.

So, ending the corn subsidy would make meat and sweets more expensive, and probably other healthy foods cheaper and more prevalent. There would be an economic incentive for people to eat food that is better for them, and restaurants would serve smaller portions of meat to keep costs low. Diabetes and heart disease rates, etc..., would fall, and life spans would increase again.

Animals might get switched to a different food, which would then be taken from humans, but I don't know what that would be. There would be other effects of the change, as well.

If the price of corn went up to the same level as that of other countries that do not subsidize (Mexico), those countries would stop importing the poor-tasting, standardized, potentially dangerous American corn that is wiping out their indigenous corn strains and making them slaves to the entirely unethical Monsanto. More expensive American corn would lead to more preservation of genetically diverse corn, which would protect our global supply from disease or insect. It would also let "heirloom" corn strains compete, which taste better and are safer to eat.

The Best Plan for America - Part 1

When I walk down the street, people often ask me, "Hey, old man, why aren't you wearing any pants?" Only slightly less often than that, they ask me what the best health care plan would be for America. The best plan is complicated, but not as complicated as many people think. Unfortunately, the best plan requires many changes to other aspects of our government and culture. Over time, I will gradually explain what would be the best health care plan for our country, and what it would take to get it.

1) Campaign Finance Reform
The necessary first step would be campaign finance reform. What does campaign finance reform have to do with health care? Very simply, the current system lets big companies control our nation's policies via legalized bribes to congressmen. The average citizen is practically unable to voice his or her needs to representatives. Our voices are drowned out by the sound of money getting transferred from corporations to politicians' campaign chests.

As we can see right now, it is nearly impossible to get enough politicians to serve the interests of the country instead of the interests of their financiers. If politicians could no longer be bought by corporations, we could have a government that serves the people. Instead of looking out for the interests of only Aetna's and Pfizer's shareholders, congress would look out for the other 300,000,000 of us.

Grab Bag 1

Here's just a bunch of topics I've pulled aside and not gotten around to posting.

Teen pregnancy and STD rates got worse under G.W.Bush's watch, especially in the South. No surprises, there. When you take money away from programs that work and give it to programs that don't work, the outcomes suffer. When you have a culture that uses evidence-based practices, you see returns on your investments.

Putting stents in arteries may be unnecessarily done 240,000 times per year. Dr. Teirstein is an obvious example of the big problem with many doctors. He is biased towards something he has experience with and makes a fortune from, which leads him to discount real research. He doesn't care what really works best for people. He doesn't want to be told what to do. He wants to do what he likes and effectively defraud insurers. Fee for service is a terrible way to pay doctors. We need fee for outcomes. They need to be accountable.

Stupid Americans will not vote for politicians who would actually make the best decisions for our country. Rationing is not bad. Every health system has rationing. In fact, every system that involves money or resources has rationing. It's a fact of life. Get over it. Right now, insurance companies ration the Hell out of people's health care, and the uninsured get nothing at all. The British system is brilliant. The British try to make sure they get the most pop for the pound. With finite resources, they try to do the most good that they can for everyone. Only complete idiots would take the American route and deprive children and workers from basic care while spending the bulk of resources on people who are going to die soon. Also in this article is the idea that we should find out what treatments work best in which situations, then NOT require doctors to use that information. I sure as Hell want my doctors to do what's been shown most effective instead of whatever else they feel like.

Corporal Punishment for Kids

We've had conclusive proof for the last half-century that striking kids is counterproductive. Corporal punishment makes kids more violent, angry, and likely to break rules when you're not around instead of incorporating rules into their personal values. It's one of the more stupid things an adult can do. Corporal punishment is especially counterproductive as a response to children's behaviors related to mental illnesses or developmental disabilities, as those behaviors are generally a result of anxiety, disregulation, and an inability to understand situations. Punishment increases the anxiety and disregulation, and makes further behavior problems more likely. Punishment of any kind is a terrible way to reduce unwanted behavior, especially for kids with disabilities. Teachers and school administrators should know this.

The American Civil Liberties Union just reported on a study of corporal punishment in schools. The report is unfortunately diluted with emotional anecdotes by people who clearly do not understand clinical diagnoses (not that they should, just keep the junk out of a report). It does have some interesting data in it, though.

Who is doing all this counterproductive nonsense?
It's our good friends in the South. The states that do the most are (in decreasing order): Texas, Mississippi, Alabama, Arkansas, Georgia, Tennessee, Oklahoma, Louisiana, Florida, and Missouri. We recall that these are also the states with the lowest education, most crime, lowest life expectancy, highest teen pregnancy, highest infant mortality, lowest incomes, etc... New England, the west coast, and the north central states have outright banned corporal punishment in schools.

What does this have to do with health care?
For starters, kids with disabilities are more frequently targeted for corporal punishment, which exacerbates their problems rather than treating them. I think this is also yet another symptom of the Southern culture. This is a culture that does not value human dignity, civil rights, or evidence-based interventions. This is a culture that relies more on invalid beliefs and tradition in making policy decisions. This is evident in their overall health care practices, as well as the educational system and so forth. Everyone needs to make decisions based on empiricism. Physically punishing (nearly any punishing, really) kids today is going to create greater ongoing mental health care needs, and the problems are more likely to get passed down generationally. Stop the cycle now.

More Truth about Proposed Plans

Since there are so many lies being propagated by those who oppose improving our health insurance system, the White House has had to create this site to help citizens understand what is really going on. Unfortunately, I expect that the people least likely to automatically recognize that death panels and so forth are lies are also the people least likely to go to the website.

Truth-o-meter

St. Petersburg Times' Truth-o-Meter is a good resource. There is so much misinformation getting propagated, especially by Republicans and other free market ideologists who want insurance companies to stay rich at the expense of America's health and productivity, and Obama shows up on the site very often. Both sides are represented, and it is interesting to see so many comments and sources evaluated side by side. Some statements are true, and some are qualified. The site does a good job going into detailed explanations of its ratings for each statement.

Conservatives for Patients' Rights - Fearmongering Liars

I'm really busy this month with a big project, but I will take a minute to remark on the commercials being run by CPR. They've been on CNN during pieces about health care reform. These commercials use scare tactics to raise a fervor against a public health insurance plan. These commercials are misleading.

The one that comes to mind warns people that a public plan would put government bureaucrats between them and their doctors.
A) So what? That's better than having insurance company bureaucrats between people and their doctors. Insurance company bureaucrats do what they can to deny treatments. The government is proposing a public plan to increase the availability of care.
B) Good! As I've discussed before, doctors don't always follow best practices, and too often make uninformed, biased, ignorant decisions that could be prevented by informed oversight.
C) 47,000,000 Americans don't even get to see doctors right now, and the public plan would fix that. What stands between these people and their doctor is the absence of government involvement.
D) NO ONE IS FORCING ANYONE TO SIGN UP FOR THE PROPOSED PUBLIC PLAN. IT IS VOLUNTARY. IF YOU DON'T WANT IT, DON'T JOIN IT. There is no reason to oppose its creation.

The commercials also claim that the government would be financially wasteful, and cites other examples of government waste. This completely ignores the fact that the government-run health payers we already have (Medicare and Medicaid) are the least wasteful health payers, and are extremely efficient. In fact, many other corporate stoog... I mean Republicans are opposing a public insurance plan on the grounds that it would be so financially efficient that people would flock to it and private insurance companies would lose too much business. You can't have it both ways, conservatives. Stop with the obvious lies and misleading claims. Stop trying to convince the public to oppose what's good for the whole country just so you can keep collecting contributions from the insurance companies. Stop blindly believing that capitalism will make everything good, and start looking at the real world.

Insurance Industry Buys Politicians - Probably

FiveThirtyEight.com has a great post with a pretty graph about the likely effects of the amounts of money the insurance industry spends on politicians. The largest receiver of bri... contributions is Baucus, the guy leading the health care reform decisions, and who is opposed to a public insurance option.

FiveThirtyEight continues to be clear and responsible, pointing out that it did not take into account counter-lobbying from unions and other pro-public-option factions, and also that it is hard to tell if "perhaps senators receive a lot of money from the insurance industry because they hold conservative positions on health care, rather than the other way around. Although I believe that accounting for ideology should correct for most of this".

HR 676 - The Good and the Bad - Part 5

Continued from Part 1, Part 2, Part 3, and Part 4.

"Non-profit health maintenance organizations that actually deliver care in their own facilities and employ clinicians on a salaried basis may participate in the program and receive global budgets or capitation payments as specified in section 202."
"Other health maintenance organizations, including those which principally contract to pay for services delivered by non-employees, shall be classified as insurance plans. Such organizations shall not be participating providers, and are subject to the regulations promulgated by reason of section 104(a) (relating to prohibition against duplicating coverage)."

Ugly
So, these sections serve to clarify how different HMOs will be treated. Non-profit HMOs that provide care will be treated as service providers that can qualify for reimbursement by the federal plan. Other HMOs will be treated as insurance plans.

This probably has to do with cost containment and standardization, making it easier to prevent outsourced and possibly for-profit doctors or clinics from indirectly charging the federal plan for services that would be harder to efficiently monitor. We're still on section 103, and have not gotten to the later sections that explain payment more thoroughly. On the face of it, this seems potentially unnecessarily restrictive, and may strong-arm doctors to become salaried or capitated employees of non-profits. I admit to an incomplete understanding of HR676's rationale for requiring salaried or capitated providers. I will explore different payment types and their consequences in the future.

"Patients shall have free choice of participating physicians and other clinicians, hospitals, and inpatient care facilities."

Good
Most hospitals will be participants from the beginning. Many more will make the transition. Most people who already have health insurance are already familiar with "in-network" versus "out-of-network" providers, so this idea will not be confusing. The difference will be that "in-network" with HR676 means most facilities throughout the whole country.

Freedom of choice will also put pressure on facilities to be more competitive with regard to quality. Since services will be free to people under HR676, service differentiation (covered services) will involve quality instead of price. Low quality providers will be less able to rope in clients by cutting deals with third-party payers.

Bad
I am at a loss.

National Center for Complementary and Alternative Medicine

USA Today had an article on the progress of the NCCAM over the last ten years. The federal agency funds research into the effectiveness of complementary and alternative medicines. The conclusion: $2.5 billion of research shows us that almost none of that stuff works better than placebo.

The tone of the article suggests that NCCAM is bad for spending so much of our money studying stuff that doesn't work. Really, it is only partly bad, and that is due to the agency's implementation. It is important to know what works and what does not work. If no one else is going to do the research (because there is no incentive, because CAM is underregulated), then it is good that NCCAM is picking up the slack.

Where NCCAM falls short is in telling us all that these things do not work. With a board loaded with CAM supporters, the conflicts of interests are apparently too strong to allow the agency to work the way it was intended. It is not spreading the message that bogus "supplements" and "remedies" are bunk, and there is no regulatory authority to ban these misleading products and treatments that take advantage of the ignorant.

It also falls short in that it continues to research absolutely ridiculous things, such as distance healing and energy fields. It wasn't good when the military looked into psychic detection of enemy submarines, and it's not good to waste money on this complete malarky now. Until someone gets James Randi's prize, the feds should stop wasting tax money in these directions. There are a lot of things we already know don't work.

Double-blind, placebo-controlled, randomized study is the standard when possible. Never trust someone who is trying to sell you something. Our country would be better off if our government protected people who just don't know better from snake-oil salesmen.

Health Care Related Bankruptcy

A report on NPR about a Harvard study relays some very interesting information.

"In 2007, 62 percent of all personal bankruptcies were linked to medical bills. That's nearly 20 percent more than reported in 2001. And in most cases, those who sought bankruptcy protection had middle-class earnings; nearly 80 percent were covered by health insurance."

Making methodological adjustments, the researchers give alternatives for the 2007 proportion of bankruptcies caused by medical problems: 44% or 69%.

This highlights the problem of underinsurance. Having some of the health insurance plans currently available does not guarantee financial security during an medical problem. Making insurance mandatory will not fix these problems. Only by dictating higher minimum standards of affordable insurance can people be protected. But the insurance companies don't want that, and free-market ideologues don't want that. They would rather have rich shareholders and deregulation than a healthy and productive society that won't fall apart when some people get sick or injured.

I can't help but wonder how much of our current economic crisis could have been prevented or mitigated by a government-provided health insurance plan comparable to other industrialized nations, since it would have prevented a huge number of loan defaults. Maybe it just would have delayed or dragged out a recession of the same severity, or maybe it would have given us more time to analyze and respond to a smaller version of what we got.

Infant Mortality Revisited

Continuing from before. An article on the ABC news website discusses factors related to infant mortality in Memphis, TN, which has the highest infant mortality rate among US cities. The article also reminds us that the US has the highest infant mortality among the 23 richest countries in the world.

"Premature birth is the primary medical cause of infant mortality." American doctors try really hard to turn premature births into living babies, spending massive resources on NICU treatment, then sending them home to still die at high rates compared to other wealthy countries. I used to challenge international infant mortality comparisons on the basis that other countries didn't include deaths of babies born after less than, say, 30 weeks gestation, while the US counted anything over maybe 24-27, depending on who's reporting. Lately, though, the comparisons have been careful to use the same gestation criteria across countries, I think with five hold-outs. What I do not know is the proportions of births by country that are premature. If America has higher rates of premature births, that could explain much of the higher infant mortality rate.



I believe that race washes out as a factor when the model includes SES, parenting, education, religion, and geography. Children develop into healthier, smarter, better-thinking people when they have affectionate, stable parents. Girls who grow up without dads, or without affectionate parents, make bad decisions about relationships, and are more likely to get pregnant early by another poorly raised teen or an exploitative adult. Remember to look at this model pangenerationally. The young people having kids that survive are the bad parents of the next generation of young parents; with poor brain development, making bad decisions, working poor jobs if at all, poorly educated, stressed out because they are incapable of managing effective lives. Religion contributes to ineffective education about birth control, and to preventing abortions. It is notoriously difficult for teens to get abortions in some areas of the US (like the South), so many babies are born to parents who do not want them and/or are completely unable to properly raise them. A recent TIME magazine chart showed that the South and Southwest have vastly higher teen pregnancy rates compared to other regions (New England has the lowest), and the chart was nearly identical to the earlier chart on infant mortality. Despite the media frenzy about the Massachusetts "pregnancy pact", the teen pregnancy rate in that area is very low for the US. Interestingly, mortality is only higher for the first-born of teens.

What can we do?
Obviously, a good start would be to get the areas with the worst problems to do more of what the areas with the best outcomes do. It blows my mind that the South wallows in problems while trash-talking New England. It also blows my mind that America wallows in problems while trash-talking Europe. Stop being blindly arrogant. Look at the outcomes. Apply best practices. Stop abstinence-only sex-ed. Promote safe sex. Provide social services that work. Make welfare-recipients buy vegetables (make them accessible, too) instead of chips and cigarettes. Make abortions and condoms accessible to teens. Provide drug rehabilitation instead of throwing addicts in jail. Provide incentives for the populations of people who can't make good decisions and resist being told what to do, so that they are more subtly influenced to do what is good for them. Not only would these things reduce infant mortality, but also reduce teen pregnancy, crime, and poverty, increasing national productivity and overall quality of life for the citizens of our country.

Elisabeth Edwards Interview with Jon Stewart

It's on Hulu, and it's a bit funny. Skip past the second commercial point; the interview is towards the end of the show. Edwards is hocking her book Resilience, which is mostly about her husband cheating on her, but the interview manages to focus on health care in America.

Mandatory Private Insurance - Why It's Stupid

The Washington Post has a very flattering article about Senator Baucus today. I am going to just focus on one sentence, though.

"Baucus is committed to delivering universal coverage and getting more and better care from health dollars, and he is seriously considering an individual mandate -- requiring adults to have health insurance -- and taxing employer-provided health insurance."

If he's considering an individual mandate, he is clearly not committed to getting more and better care from health dollars. This is very similar to McCain's proposal. Let's start with the setting. We have now about 50,000,000 people with no insurance, almost entirely because it is too expensive. We have tens of millions more people with inadequate insurance, who still go bankrupt if a major health complication occurs. We have companies offering less and less in the way of health benefits because prices are rising so much.

* Making health insurance mandatory for people who can't really afford it is going to require spending federal money on subsidies. It is flat out less efficient to give this federal money to private insurance companies with their high overhead than to just expand Medicare or Medicaid. This is just Congress's way of unnecessarily giving our tax dollars to insurance company stakeholders as a "thank you" for all the campaign contributions.

* Individual insurance customers have no negotiating leverage. Large employers get discounts on insurance prices because they can pool risk and threaten to take their big group contract to a competing insurer. Individuals can't negotiate to reduce insurer's profits, so they get gouged. Unless the government is going to really meddle with private insurance rates and practices, making private insurance mandatory is going to lead to an even higher percentage of health dollars going to profits instead of care. Depending on how the subsidies are worked out, this will either unnecessarily hurt the lower class, unnecessarily rip off taxpayers, or both.

* We will still have huge problems with underinsurance. Even with subsidies, even when it's mandatory, consumers with lower incomes are going to get the insurance plans with the lowest premiums. These plans may have high copays, high deductables, and poor coverage. We are still going to see bankruptcies due to medical costs. Unless the government meddles extensively with what insurance plans are offered, but that doesn't seem to be on the table.

* Regarding taxing health insurance from employers, that will result in a further reduction of coverage by employers, higher costs to individuals, poorer coverage overall, and further weakening of our ability to compete in the global market. What would eliminate all of these problems is a public, single-payer option, which would reduce everyone's costs, increase coverage, and let our industries be more competitive.

HR 676 - The Good and the Bad - Part 4

Continued from Part 1, Part 2, and Part 3.

Health care delivery facilities must meet regional and State quality and licensing guidelines as a condition of participation under such program, including guidelines regarding safe staffing and quality of care.

Good
This is a measure to appease people who oppose federal involvement in state affairs.

Bad
Some states insist on having unnecessarily low standards. "Best Practices" is the idea that everyone should do what has been shown to lead to the best outcomes. We are constantly measuring health care outcomes related to different policies, and it blows my mind that there are factions out there who refuse to do what is best for the people in their care. Mississippi's quidelines for quality of care are not the same as Connecticut's, and Mississippi has significantly worse health care outcomes. A single-payer has a great opportunity to use its leverage to require uniformly high standards instead of allowing states to choose whether or not they will slack off. Residents of Mississippi are still Americans, and the American government has a responsibility to them.

Participating clinicians must be licensed in their State of practice and meet the quality standards for their area of care. No clinician whose license is under suspension or who is under disciplinary action in any State may be a participating provider.

Good
Pretty standard.

Bad
Same as above about variance in state standards, but with an added gripe. It is a pain in the tuchas for clinicians to move from one state to another because licensure requirements are all different. Clinicians who live near a border are either stuck working in one direction, or have to go through multiple licensure procedures. I don't know if this constitutes an undue burden on interstate-commerce or what, but it is ridiculous. There should be at least the option of satisfying a single, high standard that would allow clinicians to move without getting a new license. There is a similar situation with gun laws, and many states accept a Florida license because it is more difficult to get than their own. Some states are easier to move to than others.

The complaints in this post are about our current system, and not about HR 676 in particular. It is just that HR 676 is accepting of these problems, and they are included in the bill. Causing as little turmoil as possible will help the bill's progress, though our system really does need some improvements.

Health Insurance Reform - Conflicts of Interest

It's been in the news for a week now that Senator Baucus's Finance Committee hearings are a total sham. With 59% of Americans asking for a single-payer system, it is absurd that the Senate would only meet with representatives from the industries that profit from the existing, inefficient private system. How could Baucus overlook representatives from single-payer supporting groups? The unfortunate and obvious answer is money.

Baucus has received "... from the insurance industry, $1,170,313; from health professionals, $1,016,276; pharmaceuticals/health-products industry, $734,605; hospitals/nursing homes, $541,891; health services/HMOs, $439,700" over his career.

"According to the report, Senator Baucus received $183,750 from health insurance companies and $229,020 from drug companies in the last two election cycles."

Insurance companies and drug companies have lots of money to spend on lobbying and campaign contributions (legal bribes). People who cannot afford health insurance also cannot afford lobbying or campaign contributions. The only way to get representation in government decision-making processes is to pay the people who get to make the decisions.

But wait... where did those figures come from? Some searching on news.google.com has only given me more blogs and op/ed pieces that cite DemocracyNow! or the 13 protesters who were arrested, heavily biased sources of information. Where can I find something more legitimate? A few seconds with Google gives me OpenSecrets.org. Let's look up our friend Max Baucus.

Three of his top 5 contributing industries and their contributions since 2005:
Insurance - $545,225
Pharmaceuticals/Health Products - $493,313
Health Professionals - $492,641

Individual contributers include Aetna, Amgen, Blue Cross, and Kindred Healthcare. For the billions of dollars these companies have riding on Baucus's actions, they are getting a pretty sweet deal. Baucus isn't alone, though. These companies donate to pretty much everybody to make sure their interests are taken into account more than the citizens of this country who do not make large financial contributions.

Something else that is interesting is that pharmaceutical companies gave 2-3 times as much money to Republicans as to Democrats until 2008. This may just reflect that we had a Republican majority in Congress until recently, but also that the Republican party values big corporate profits more than social welfare, relative to the Democratic party. Big Pharma would want to finance Republican campaigns in closer elections, but resort to just getting some leverage with Democrats in a year in which more Democrats were going to win anyway. I would like to hear other ideas.

I am glad that organizations such as OpenSecrets help give us transparency, but why isn't this information in the mainstream media? When CNN runs a story with politicians giving their policy views, it could easily and briefly mention each politician's conflicts of interest. Most people just don't know what's out there unless it's given to them, and it is the media's responsibility in a democracy to give the public relevant information.