Map of life expectancy at birth from Global Education Project.

Thursday, August 23, 2007

Pragmatism

Lots of stuff in the new NEJM. I'm sure you've heard about that study about all the old folks having sex, so I won't discuss it. (How can I get in on some of that?) But I will draw your attention to Jacob Hacker's riff on Sicko, which the multi-millionaires at NEJM have graciously made available to you free of charge. Hacker endorses Moore's critique of the morally repugnant health care regime under which we currently perdure, but he thinks it's feckless to be talking about single payer national health care, essentially because the current Gordian Knot of a non-system has too many vested and hidden interests to unravel, and there's no-one who wields the mighty sword that can cut it.

Hacker recommends the approach of letting people under 65 buy into Medicare, and requiring or strongly incentivizing employers to either buy into Medicare for their employees or give them private insurance. He figures Medicare will be the better deal and it will eventually become the Blob that Ate Health Insurance, and there we'll be.

Maybe, but there's a lot that can go wrong with that, including the current limitations on Medicare. It theoretically pays only for treatment of disease, and has limited benefits for screening and preventive services. If it's extended to people under 65, the benefits will have to be enhanced in order for it to be appropriate. It also has a limited pharmacy benefit, as we know, and does pay for long term care, which means that young people with disabilities will still be on Medicaid. And, of course, we'll still have an affordability problem for people with moderate incomes, so there would need to be a sliding scale subsidy to make this really work, which means raising the payroll tax . . . In other words, we're still going to have to untie that Gordian Knot, even if we do this.

In the same issue, two studies find that bariatric surgery for severely obese people yields a substantial survival benefit over 10 years. One of them focuses specifically on gastric bypass, the other includes gastric banding. Both studies find that people who don't get the surgery rarely achieve substantial weight loss.

It certainly goes against the grain with me to concede that there are probably millions of people whose best bet is to have their stomachs reduced to the size of walnuts. There are complications of the surgery, people do regain some of the weight over the years, and they are likely to be somewhat nutritionally compromised. And of course surgery is expensive. It would be so much better if we could prevent this problem in the first place. I fear that if stomach reduction surgery becomes as common as haircuts, the pressure will be off to change the food environment and encourage physical activity. Society will be far, far better off if we stop getting kids hooked on sugar water and fried starch; stapling their stomachs after they get fat is the wrong answer.

But it seems to be the right answer for a lot of individuals. And there you have the fundamental conflict between medicine and public health, and that's why the URL of this blog is healthvsmedicine. Health versus medicine, get it?

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