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.