You don't just have to take it from me . . .

Lots of good freebies in today's NEJM -- they're making more and more material of broad public interest open access, and so they're getting credit where it's due. Long-time readers know that I have castigated them unmercifully about this, so I guess it's the awesome influence of Stayin' Alive that's brought about the change.

Anyway, I commend your attention to J. Oberlander's essay on the prospects for health care reform. He largely agrees with me in seeing the political interests as stacked against major changes. The drug and insurance companies just aren't going to allow it if they can possibly help it. And if they won't give up any income, real cost containment isn't going to happen because Obama's talk about saving money through electronic medical records and enhanced preventive efforts is speculative at best and unlikely to yield major savings. But he sees a glimmer of hope in all the bad news -- if enough people lose their health care insurance in Great Depression II, and the federal deficit is already a gazillion dollars anyway, maybe providing some real form of universal, affordable coverage will become feasible. I don't know if it's something we ought to wish for, but maybe so.

Michael Sparer (who might be a guy I went to college with, I don't know for sure but it's not the world's most common name) thinks that the idea of expanding Medicare and allowing people to buy into it won't fly, largely because it will invoke a term he considers to be radioactive, to wit "single payer." So he recommends expanding and allowing buy-in to Medicaid, instead. That seems to me like a pretty feeble reason for preferring what, in my opinion, would be a highly inferior option. Michael, or Dr. Sparer, depending on whether I actually know him or not, sees advantages in the state-level administration of Medicaid, which allows the states to try different policies and thereby we can muddle through to whatever works best. However, as far as I'm concerned, Medicare already works, so what's the problem? And as for any stigma that may attach to the term single payer, I'd rather work to change the culture than surrender to idiocy.

Finally, they give rare free access to a research article, in this case an epidemiological study of the effect on life expectancy of reductions in general population exposure to fine particle pollution. This is important as we now have an administration that has pledged to make environmental policy based on scientific truth rather than the venal interest of polluters. The amount of healthy life we can buy by reducing air pollution are impressive indeed -- about 7 or 8 months for every 10 micrograms per cubic meter. Since fine particle concentrations in U.S. cities today are typically around 15 mcg/m^3, we still have room for improvement. (Near major highways, people are exposed to high levels of even smaller ultrafine particles, which are even more dangerous. But that's a story for another day.)

So, let's see if Congress tightens the standard for PM2.5 pollution, which means better controls on auto exhaust, power plants and industrial emissions. It might save your life.