Well Jesus H. Christ

today is International Blasphemy Day. I kind of see this as being like National Brotherhood Week -- you mean I can't blaspheme the other 364 days? My proposal is to combine it with Talk Like a Pirate Day -- imagine the possibilities.

Anyway, of more urgent concern is this finding that fewer than half of graduating medical students say they understand the system in which they are about to begin practicing. Tell me about it. I used to teach a course for med students called Patient, Doctor and Society, in which we tried to explain it all. They eliminated the course because the students complained they didn't have time for that shit, they had a licensing exam to pass.

And it was a whole lot of shit, to be sure. Just explaining Medicare was a week. I tried to create a diagram showing the organization and financing of health care in the U.S. and it ended up looking like a wiring diagram for a jet fighter. I couldn't get a readable version onto a legal-sized page. For each patient, the doctor has to figure out what is covered and what isn't -- including which drugs are in this person's formulary -- and how and where to send them for specialty services and how much the doctor is going to get paid and by whom and when. Here's the answer:

Universal, comprehensive, single payer national health care.

Very easy to understand. Everybody's covered for everything that's actually good for them. The doctor gets paid by the same payer, in the same way, for every patient. Everybody has the same formulary. No problem. Don't worry about it. Go ahead and study for the licensing exam.

Now that's blasphemy.

Methusaleh Planet

No doubt you are at least vaguely aware of the research -- some of it going on right here at our nutrition research institute -- that grows out of the observation that mice who are given a nutritionally well-balanced but calorically restricted diet have abnormally long life spans and are spared typical ravages of aging. Experiments are underway to try the same strategy in humans, but hardly anyone is able and willing to stay permanently hungry on a diet of broccoli and soybeans, for 50 years. So now scientists think they are getting a handle on why this works, and that they can reproduce the effect with drugs, even as you pig out.

If this ultimately works -- and I have to say it just might -- we will have some serious problems to wrestle with, which the folks in the linked article, not to mention reporter Nicholas Wade, seem not to be thinking about. For example -- and this is just the really, really obvious one -- you might have noticed that we're having a hard time keeping up with the human population we have now, as far as oh, sufficient arable land, potable water, breathable air, fish in the sea, minor details like that. Since those foolish young uns are still having babies, if people stop dying for 30 or 40 years it's going to get mighty crowded around here, "here" meaning the third rock from the sun.

Another problem is that if I'm still sitting here amidst heaps of file folders and stacks of paper and miscellaneous electronic equipment 40 years from now, that's at least one post-doc who will never get a job, at least until the age of 60 or so. Tough luck, that. On the other hand, if I decide I've had enough and go on the dole, said post-doc may have a job, but will have to spend half the salary supporting me. That may or may not be a good deal for me -- I may get tired of Matlock re-runs after a few decades and wish I'd already checked out -- but it won't be a good deal for the youth, who may start to campaign for youthenasia.

You can see where this is going. How will it play out in countries that already can't support their population? Presumably when Sirtris first comes out with the pills, they'll want their patent protection and their big bucks, so most of the world won't be able to afford them. Eventually their exclusive marketing rights will lapse, or India and Brazil and China will just violate them, and the pills will be cheap, but both phases are going to mean tremendous conflict -- intergenerational, obviously, but the international, regional and sectoral resource wars we can already look forward to are going to be grossly exacerbated. And what about prisoners serving life sentences? Presumably, if they have a right to health care, and this becomes the standard of care, they'll have a right to it, which means that Bernie Madoff's 150 year sentence may not seem so ridiculous after all.

We can go on and on with this, spin out your own scenarios. It might be worthwhile at least thinking about it.

Oh yeah, climate change

I haven't written much about the very important problem of anthropogenic global warming, essentially because I haven't felt that I had very much to add to the subject. I'm not particularly an expert on any central aspect of the issue. But then again, neither is Paul Krugman. His column today suggests implicitly that we probably all should do what we can to get the polity to pay more attention, so I'll chip in what I can.

Krugman points to two main reasons why political action to address AGW, indeed even widespread acknowledgment, is lacking. One is that powerful vested interests are threatened by the possibility of meaningful action, and the other is that the prevailing "free market" ideology cannot encompass reality. But there is of course a third reason, and that is our relationship to the future. This is a question I do happen to know something about, since it's central to public health and health policy. It's actually something that economists think about a lot too, in their own way, so I'm surprised Professor K doesn't mention it as well.

I discussed this earlier in the context of QALYs: people will say today that they would exchange some amount of life span to avoid some form of sickness, disability or pain; but that does not mean that once the ill health happens to us, we necessarily value our lives less. If you think about it, people actually make a similar bargain when they smoke tobacco or eat at McDonald's: they are exchanging not only life expectancy but future good health to avoid having to forgo something they find pleasurable or convenient today. It's just that the wager includes a negatively framed and immediate component -- giving something up today -- as opposed to a positively framed component in the intermediate future -- avoiding something unpleasant. Either way, we are valuing the present and near term more than we do the more distant future. It's the same reason why people live on the slopes of active volcanoes or on Galveston Island. (Well, come to think of it, hardly anybody lives on Galveston any more.)

Economists model this as the discount rate. The future just doesn't matter as much as the present because we expect to have more in the future; our investments will grow so we can buy our way out of trouble, is the basic idea. They actually treat this as a sort of law of nature and believe it is evidence of their "rationality." Is it? Certainly not, especially if what we perceive as growing wealth is actually just extraction and consumption of finite resources, such as the earth's atmosphere.

The point is, we blithely bargain away the future, but when it gets here, the indulgences of the past generally turn out to be no consolation. Alas, I fear the bargain has already been made. It's happening, ready or not.

Grand Outrageous Prevaricators

Driving to CT yesterday morning, I caught the news on National Pubic Radio. (Oh sorry, did I commit a typo?) Naturally, they mentioned Obama's weekly radio address, and that he said something about the Group of 20 meeting; then they played a long clip from Rep. Johnny Isakson's Republican response. He said (close paraphrase, I don't have the transcript), "Call it public option, trigger, or co-ops, it's all code for a government takeover of health care. Government run health care doesn't work in Canada, it doesn't work in England, and it won't work here."

Of course, there was no comment, context, or response to this offered by NPR "reporters" or by anyone else. I don't think I need to deconstruct this tissue of lies for my readers here. Consistently, without exception and with no redeeming social importance, our political discourse consists of one party that utters nothing but lies, which the corporate media simply transmit; and another party that at least includes a few politicians who generally tell the truth and try to make policy in the public interest, who the corporate media generally mock and deride.

That's it. We don't have debates over opposing analyses, value orientations, or goals. We have debates in which one side is lying, all the time. That's our "democracy."

Spare the rod . . .

please. I mention this subject only because it is really, really important. Murray Strauss was really the first person to gain prominence for academic investigation into family violence. Although we have always known that parents hit children and spouses hit each other, it was something that people used to take for granted and indeed, husbands hitting wives used to have strong endorsement from clergy -- as parents hitting children still does today among right-wing "Christians."

Spanking and other corporal punishment, Strauss now finds, is actually associated with lower IQ in children. I'm not necessarily as worried about IQ -- it's kind of overrated if you ask me -- as I am about how it affects children's basic understanding of how the world works and how to get your way in it. People tend to think that we teach our children by telling them what's right and wrong and by rewarding and punishing them, but that's not really how it works. We teach them how to behave by the way we behave -- it's called Social Learning Theory. Here's one simple explanation:

Aggressive responses can also be acquired through social modeling or social referencing. Small children are likely to look to a familiar face to see how to react to a particular person or situation. By demonstrating aggression, one can unknowingly encourage aggression in suggestible children. One of the most popular current debates which centers around the idea that TV violence contributes to increased aggression in viewers exemplifies the idea that people are easily influenced by others' behavior. By modeling the behaviors of TV, movie or video game characters, acts of aggression become increasingly more frequent and violent. Researchers suggest that after aggressive behaviors are acquired, other factors serve to maintain their presence including self-reinforcement, in which the aggressive individual is proud of his or her harmful action.

Well, if just watching aggressive behavior on TV can make kids violent, what do you think happens when their own parents hit them? And if you're one of those materialist types who wants to see "hard" evidence, how about this from Tomoda et al in the journal Neuroimage (Aug. 2009, suppl):

OBJECTIVE: Harsh corporal punishment (HCP) during childhood is a chronic, developmental stressor associated with depression, aggression and addictive behaviors. Exposure to traumatic stressors, such as sexual abuse, is associated with alteration in brain structure, but nothing is known about the potential neurobiological consequences of HCP. The aim of this study was to investigate whether HCP was associated with discernible alterations in gray matter volume (GMV) using voxel-based morphometry (VBM). METHODS: 1455 young adults (18-25 years) were screened to identify 23 with exposure to HCP (minimum 3 years duration, 12 episodes per year, frequently involving objects) and 22 healthy controls. High-resolution T1-weighted MRI datasets were obtained using Siemens 3 T trio scanner. RESULTS: GMV was reduced by 19.1% in the right medial frontal gyrus (medial prefrontal cortex; MPFC, BA10) (P=0.037, corrected cluster level), by 14.5% in the left medial frontal gyrus (dorsolateral prefrontal cortex; DLPFC, BA9) (P=0.015, uncorrected cluster level) and by 16.9% in the right anterior cingulate gyrus (BA24) (P<0.001, uncorrected cluster level) of HCP subjects. There were significant correlations between GMV in these identified regions and performance IQ on the WAIS-III. CONCLUSIONS: Exposing children to harsh HCP may have detrimental effects on trajectories of brain development. However, it is also conceivable that differences in prefrontal cortical development may increase risk of exposure to HCP.

It is absolutely urgent to change cultural norms so that adults no longer hit children.

Special bonus multi-post

Yesterday I was kind of busy so this post will be enriched with extra vitamins.

First, NEJM today gives you a lot of freebies on health care policy and reform. Scroll down toward the bottom portion of the page to find it all. Arnold Relman is especially good and succinct as he explains the fundamental problem of Provider Induced Demand, which is one of the reasons why health care is not anything like the fictional "free market" they indoctrinate college kids with. We don't know any better, so doctors tell us what we need, and they are paid to do more stuff. A different approach to paying for health care is needed. I've hammered and harped on that a lot here, but Relman is a good explainer. Lots of other good stuff there, including Jacob Hacker on why "cooperatives" are no substitute for the so-called public option. It even has a poll, so go there and freep that poll!

Next, sorry to have to frost your pumpkin, but don't get too excited by the much-ballyhooed HIV vaccine "breakthrough." It's always unseemly when researchers run out and talk to the press before they've been through peer review, and under the circumstances I can't even judge the merits of the trial design. But, assuming it has no methodological flaws and the results mean what they seem to mean, they don't mean much.

The degree of efficacy shown -- reducing the incidence of infection by less than 1/3 -- is very far short of supporting actually using such a vaccine. Actually, just eyeballing it, it's probably marginally significant anyway. And the follow-up is only 3 years. The problem is, if you start giving such a vaccine to people, it will cause many of them to rationalize that they are protected so they can engage in unsafe behavior. It could even be counterproductive. Furthermore this targets strains specifically circulating in Thailand. It might not work on other strains, and even the Thai strains could evolve away from it. Whether this actually raises the likelihood of a truly useful vaccine anytime soon is unclear, but count me as doubtful.

Finally for now, another open door crashed through, this time by creeping socialism. The president of France hired Amartya Sen and Joseph Stiglitz to create a "provocative new study" finding that the widely used Gross Domestic Product is not actually a measure of economic well-being. Since Sen has spent the past 30 years saying that, it's not a big surprise that he said it again. So have a lot of other people, including everybody who isn't sitting on his or her own shoulders. I especially want to acknowledge Hazel Henderson, who gave me her book Creating Alternative Futures in 1978. She used to say that GDP stands for Gross Domestic Problem.

This is another issue I've harped and hammered on here but come on, it's obvious. GDP counts costs and ills as goods. When a hurricane wipes out south Florida, GDP goes up because people have to buy building supplies and hire carpenters. Their houses are gone, but GDP doesn't even notice that. When somebody buys cigarettes, that adds to GDP. When they get cancer, it adds even more because they pay doctors and hospitals and drug companies and ultimately morticians. When one person is paid $40 million in a year and another makes $5/hr., GDP per capita is $20 million, which sounds great, doesn't it? When you pump oil out of the ground, 100% of the price of the oil is added to GDP, but the oil is gone forever -- which GDP again doesn't notice. And on and on and on. Yet when GDP goes up, the corporate media say the economy is healthy. That has always been bullshit, always will be bullshit, and we have always known it. Repeating it doesn't seem to do any good, however. The culture gives it a nod and then forgets all about it.

If you have one or more little kids

(and I know some of you do) or you just care about them, you might be interested in live, online coverage of the Washington, D.C., conference on September 23-24 on the link between early childhood care and obesity later in life. Just passing it on.

The People's Republic . . .

of Massachusetts is once again in the glorious vanguard of the line of march toward the final victory of socialism. Specifically, I refer to a little-noticed element of our recent transportation reform legislation. Our revolution will put you in the driver's seat.

The reform act got a lot of attention because it abolishes the Massachusetts Turnpike Authority, an independent agency which has been a major irritant to successive governors, otherwise consolidates transportation agencies in a single department, and creates an umbrella office of transportation planning that covers all modes. That's supposed to save money and be efficient and all that, but the socialist part -- to the extent that roads, bridges and mass transit aren't socialist already, which according to the true patriots who protested something or other in Washington last week they evidently are not -- is the part that says transportation planning has to take into account the public interest.

The planning office has to make programs "sustainable," expand people's mobility, reduce congestion, save fuel, and improve air quality. Transportation policy must promote bicycling and walking, which means "equitable" bicycle and pedestrian access has to be designed into all transportation facilities. Best of all, the Department of Transportation has to form a working "compact" with the Executive Office of Health and Human Services, Energy and Environmental Affairs, and the Department of Public Health to develop a mechanism for conducting Health Impact Assessments in relation to all transportation policy and projects.

Whoa. Now that is a thing of beauty. With all the health care reform hoo hah going on lately, I've strayed a bit from our core mission here, which is in part to remind everyone that health is not, for the most part, about health care. We have a cultural proclivity in this country to conflate the two, and to assume that the answer to poor health and health inequity is more and better and more equitable doctoring and drugging and surgery. In fact, health care is mostly what happens after we've already screwed up.

The transportation infrastructure is one of the most essential determinants of the structure of communities, cities, regions, the nation and the world. Transportation can connect, or it can divide. It can heal and it can sicken. It's not just air pollution, which certainly matters. Yes, poor and working class people are more likely to live near highways and bus yards and diesel trains and truck terminals and to breathe invisible, poisonous particles. But poor people in this country also very often can't get to decent grocery stores, to jobs, to educational opportunities, to cultural events and institutions. They live in food deserts, job deserts, cultural deserts, and affordable mass transit is the only way out.

Here in Massachusetts, back in the 60s, they bulldozed an interstate highway through Somerville. It cut East Somerville in half, destroying communities and isolating neighborhoods that used to be connected. Then they built low income housing projects right next to it, where the people breathe the fumes and listen to the roar all day and all night, but they don't own cars and they can't ride on that big ribbon of asphalt to go anywhere.

Then they tried to do the same thing to Jamaica Plain but the people stopped them. Instead we got a rail corridor with a subway that takes us right into town, right to Amtrak, right to the airport, right to work, right to two community colleges plus all of our universities, right to the Stop & Shop, everywhere in the world. On top of it is a beautiful linear park where every year we have a big wonderful festival. All the side streets are intact. Instead of splitting us apart, it brings us together. Instead of poisoning us, it detoxifies and purifies us.

Now that's revolutionary.

Utopia Now!

Thank you for the comments on my previous post, as usual the best part of doing this blogging thing for me.

So, here's more of what really matters about transforming health care in the U.S. As I have said many times, the debate we are having right now defines universal coverage as the issue, but in fact it is only the beginning. How we achieve universal coverage matters not only because of how the financial burden will be distributed and whether or not insurance company CEOs will continue to jet to Paris for Sunday brunch, as Jesus said God wants them to do. It also matters because of the prospects it offers for changing the way health care is delivered and the way we all relate to the health care institution.

The patient-centered medical home is the hot new ideal. The linked document is a bit dry, so let me tell you how I envision this from the patient's point of view.

Right now, people with more than minimally complicated medical problems negotiate a fragmented non-system that reflects the historic biological reductionism of medicine. If you have -- as too many people do -- say, diabetes, kidney disease, arthritis, and heart disease, you probably see at least four different doctors at least three of whom are specialists. They are likely to be in different places, have little or no contact with each other, and each of them is worried about a particular organ or metabolic system. Each of them is handing you two or three or four different prescriptions and telling you to do various, possibly contradictory things about diet, activity, and so forth.

You, however, are not a bag of kidney, pancreas, knee joints and heart, you are a person. You have a life, which is not well served by taking 12 different pills on eight different schedules, finding a way to haul your ass to five different places 8 times a month, telling the same story over and over again to six different people who don't listen anyway, and by the way, how did you end up with all those problems in the first place?

What you need is a doctor, your own doctor, the person who knows you and what-all is going on with you. And by the way, you don't necessarily need to see a doctor regularly, that "doctor" could actually be a nurse practitioner or a physician's assistant, although a primary care physician who really understands how to do patient care and care management might also be the best for you. Certainly a physician will supervise and work with the non-physician provider, and you will know that physician and have access to him or her when you want.

The specialty doctors get called in for the technical stuff but your personal doctor knows all about it, keeps track of it, and keeps the whole story in one place. Oh yeah -- as much as possible, all of these people are also in the same place, along with the pharmacy, counselors such as nutritionists, health educators, a nurse who you can call with routine questions, etc. Your doctor has an electronic medical record where all the information about you from all the different providers, including prescriptions, test results, physical exam results, notes about what you told them, is right there. Your doctor will talk with you, and listen to you, and help you make your own choices. And the entire team will work with you from cradle to grave to try to keep you healthy and prevent medical problems.

This requires a radical restructuring of how we pay for medical care, how doctors are trained, and how much different categories of doctors get paid, among other changes. The shortest path to such a new world goes through universal, comprehensive, single payer national health care, but it isn't absolutely essential. However, nothing remotely resembling this will ever be produced by the fictitious, impossible, "free market." Believe me.

One person's waste, fraud and abuse . . .

is another person's income. As Bix properly asks, how can we possibly get to anything close to a socially optimal health care financing system when there are such enormous vested interests in the insane mess we have now? The people who do medical underwriting, rescind your coverage as soon as you actually need it, charge a $250 co-pay for a colonoscopy because they figure you'll be on Medicare by the time your cancer is diagnosed anyway, cash their dividend checks in the Hamptons, etc. maybe parasites on society, but they have families to feed and bills to pay of their own.

If, by divine intervention, the health insurance industry was vaporized tomorrow and a government sponsored single payer system appeared in its place, only a small percentage of those people would find jobs in the far more efficient new administration. Now, it's fair to presume that in the long run, universal single payer national health care would be very good for the labor market. It would make employing people less expensive, which translates into more hiring. It would make it much easier for people to change jobs, meaning more workers would be better suited to their positions and happier, there would be more openings to fill, and the economy on the whole would be more productive and create more opportunities. Oh yeah, people would be healthier.

But, it's true, in the short run those health insurance workers would all be out on the sidewalk. The shareholders would also be wiped out, which means that in all fairness the government would have to buy out the entire industry; provide the workers with extended unemployment benefits and retraining, since they have no marketable or socially useful skills; and at the same time take on the enormous cost of transitioning the entire population and the entire health care industry into the new system.

So no, you can't just do it. The process of transition would have to take a long time. Setting up a public system and allowing it to gradually absorb the entire market -- which it could indeed do if allowed to exploit its cost advantages, in a regulatory environment which truly prohibited private insurers from medical underwriting -- would work. The insurance industry knows that, they know that many people do indeed have an ulterior motive for the "public option," which is indeed to destroy them. I won't lie to you.

But you know what? Industries come and go all the time. My office before I took this cool new job was furnished with stuff we bought at the Polaroid bankruptcy sale. And wasn't the Pony Express romantic and exciting? Lots of Americans are out of work right now because their jobs were automated or moved to China. Conservatives don't want to stop any of that, they call it progress.

If we're going to do this, we do need to take care of the people who will be hurt by it. But that's more than capitalism ever does.

Breaking news! Mass poisoning of children

You may not be reading it here first that a bunch of people with long strings of letters after their names -- specifically Kelly D. Brownell, Ph.D., Thomas Farley, M.D., M.P.H., Walter C. Willett, M.D., Dr.P.H., Barry M. Popkin, Ph.D., Frank J. Chaloupka, Ph.D., Joseph W. Thompson, M.D., M.P.H., and David S. Ludwig, M.D., Ph.D. -- have written an essay now posted on the NEJM website urging a tax on sugary beverages. They figure a tax of a penny an ounce -- applied not only to soda but also so-called "sports drinks" and beverages sold as fruit juice but aggressively sweetened with mutant high sugar grape juice -- would raise $14.9 billion for the federal government in the first year.

That would obviously help pay for universal health care (although I'm cynical enough to believe it would just get sucked up by the insurance industry with a little help from their best buddy Max), but more important, it would discourage people from consuming the stuff. It's not just that the empty calories make you fat, which they do. Oh no, it's worse than that. The best summary I know of is by David S. Ludwig, in JAMA, May 8 2002 (v. 287 p. 2414), but you aren't allowed to read it. So I'll tell you what it says.

Some carbohydrates, among them refined sugars but also potatoes and white rice, among others, get converted to blood glucose very quickly. When you eat them, your blood sugar shoots up, an event called a glycemic spike, hence these foods are said to have a high glycemic index. That forces your pancreas to pump out a whole lot of insulin. Then, as the blood sugar declines, the insulin is still around, which means you get hungry again. Sugar consumed in beverages has little or no satiating effect; on the contrary, it actually makes you hungrier a couple of hours later. It has been found that kids who are given sugary soda with meals actually eat more later on than kids who are not.

Just as bad, if not worse, repeated insulin spikes over the years cause your cells to become insulin resistant and also wear out the pancreatic beta cells that make insulin, in other words you start to develop Type 2 diabetes. They also seem to have a direct effect on atherosclerosis, but the worst part is that diabetes puts you at risk for heart disease, kidney disease, blindness, loss of limbs -- it's one of the very worst things that can happen to you. Or, as Ludwig himself sums it up,

The rate of carbohydrate absorption after a meal, as quantified by glycemic index, has significant effects on postprandial hormonal and metabolic responses. High–glycemic index meals produce an initial period of high blood glucose and insulin levels, followed in many individuals by reactive hypoglycemia, counterregulatory hormone secretion, and elevated serum free fatty acid concentrations. These events may promote excessive food intake, beta cell dysfunction, dyslipidemia, and endothelial dysfunction. Thus, the habitual consumption of high–glycemic index foods may increase risk for obesity, type 2 diabetes, and heart disease, a hypothesis that derives considerable support from laboratory studies, clinical trials, and epidemiological analyses.

(The American Diabetes Association, by the way, having accepted millions of dollars from the sugar industry, works very hard to downplay this inconvenient truth. They even want to tell you that it's a "myth" that consuming sugar causes diabetes. It is not a myth, it is a fact. For shame.)

By the way, while potatoes and rice do have a high glycemic index, they are typically eaten as part of a complete meal. Consuming high glycemic index foods with a meal that also includes fiber and fat damps down the glycemic spike. So you don't have to give up potatoes but what you definitely don't want to do is eat french fries by themselves as a snack, or even worse, make a meal of fries and soda. Fruit, by the way, has a low glycemic index because it contains fiber. The GI for instant rice is 91; for an apple, 36. Beans, fruits, vegetables, whole grains -- that's the way to go. But you already knew that.

The excise tax would be imposed at the manufacturing stage, so it would be no problem to implement and manufacturers could simply lower their tax burden by lowering the sugar content of their beverages. It would be regressive in the sense that low income people consume more sugary drinks, but of course anyone can avoid the tax altogether by choosing other beverages. And by so doing, they will avoid the much greater price of a horrific, early death; and all of us will avoid the enormous cost of medical care for people with diabetes and its complications, including chronic kidney disease, heart disease, neuropathy, retinopathy . . .

There are enormously powerful forces arrayed against it, from Archer-Daniels-Midland to Coke and Pepsi and McDonald's, who will spend hundreds of millions to defend their God-given right to murder our children. Is there any possibility the people can be more powerful than them?

Insanity

One well-known definition is doing the same thing repeatedly and expecting a different result. The legislation emerging in the congress right now looks a whole lot like the Massachusetts health care reform legislation with which we now have two years worth of good experience. Reporteth the Boston Globe:

The state’s major health insurers plan to raise premiums by about 10 percent next year, prompting many employers to reduce benefits and shift additional costs to workers.

Increases will range from 7 to 12 percent, capping a decade of consecutive double-digit premium increases, according to a Globe survey of the state’s top health insurers. Actual rates for 2010 will depend on the size of the employer and the type of coverage, with small businesses and individuals expected to be hit hardest. Overall, premiums are more than twice as high as they were 10 years ago.

Oh yeah -- the state is broke so it remains to be seen what will happen to the subsidies that make insurance somewhat -- although often not really -- affordable for moderate income people, but simple arithmetic says it will get ugly. I also happen to be in possession of some secret knowledge about what has been happening to "universal coverage" but it's embargoed until tomorrow so I'll play by the rules on that.

“Health insurance is increasingly unaffordable for average working people and for employers, especially small employers,’’ said Drew Altman, president of the Kaiser Family Foundation, a nonprofit research group in Menlo Park, Calif. “It underscores the need to reach a consensus on how to reform health care and provide some help for low- and moderate-income people who can’t pay their insurance bills.’’

Well, the legislation we're looking at does essentially nothing to control costs. It will force people to buy insurance, no matter what it costs, which means the insurers will be free to gouge us all they want and will have essentially no incentive to try to rein in overuse; doctors and hospitals and other providers will still be paid more to do more; and we won't have any institutional mechanisms for sorting out effective and cost effective interventions from ones that are only effective at enriching doctors and drug companies.

Result: costs will keep going up, the cost to the treasury for Medicare and Medicaid and whatever new subsidies are introduced for moderate income people to buy insurance on the open market will just go up and up, and insurance will become less and less affordable and mandate or no, universal coverage will slip farther and farther away while the medical-industrial complex continues to bleed us dry.

Thanks Max.

We need universal, comprehensive, single payer national health care. That's it.

The Doctor is Out

Okay, now that we're all done baking our punctuation marks, it's time to get back to Medicare. In my view, the biggest flaw in Medicare is that it underpays for primary care and overpays for specialty care. An excellent overview of the history behind our current crisis in primary care is offered by Lewis Sandy and colleagues, but as usual, you can't read it because you are nothing but common scum.

In a nutshell, when health insurance first appeared on a substantial scale during the Depression, it paid for hospital care and surgeons; as it broadened to include Blue Shield plans that paid more broadly for physician services, it mostly covered specialty services; the availability of insurance, combined with the very narrow, biological view of medicine that was in vogue in those days, meant that fees for specialists grew to be much higher than fees for primary care. This discrepancy essentially got fossilized into the insurance system - at first the private system, and then, when Medicare came along, into the public system, through what are called Relative Value Units which set the reimbursement rates for various procedures, based essentially on historic norms.

Nowadays a bio-psycho-social view of medicine is widely accepted. It is neither effective nor cost-effective to treat people as piles of unconnected organ systems, ignore them until the kidneys or liver or metabolic regulation or whatever stops working and then send them to a kidney or liver or endocrine doctor for high tech biological tinkering. People need an ongoing relationship with an accessible primary care doctor who understands their full medical picture and also has some understanding of their life, circumstances and personality so they can work together to promote wellness, catch disease processes early, and if need be coordinate the various biological interventions that ultimately may be needed. But doctors who do this are paid much less than doctors who zap you with radiation or remodel your internal organs. They are also overworked and underappreciated. Hence there are not enough of them because who wants that when you can make millions working 9 to 5 and you don't even have to be on call?

Medicare also pays for a good chunk of graduate medical education -- residencies and fellowships -- and it also skews that funding toward the narrower specialties.

Lots of people know this is wrong and are trying to change it, but the medical specialty societies up until now have proven to be too powerful. As a result, we face a crisis. Specialists today typically make 2 1/2 times as much as primary care physicians, whose real income has actually fallen by 10% from 1995 to 2003. If Medicare fixes this ridiculous situation, private insurers will follow. American College of Radiology, get out of the way. You already have your yachts and horse farms. ¡Basta! Okay, I'm dreaming. But it has to be done. Sandy et al want 50% of the clinician work force to be in primary care. That will require redirecting training funds and drastically revising reimbursement policies, among other steps. We can crank up the primary care clinician workforce relatively quickly by training more nurse practitioners and physicians' assistants, who are much easier and cheaper to create than new doctors, but we need physicians too.

We can also reorganize primary care to make it work better for patients and be more rewarding for clinicians. That's another story, for another day.

Breaking News!

Baking Contest Highlights 6th Annual National Punctuation Day®

PINOLE, CA — The first National Punctuation Day® Baking Contest will highlight the celebration of the 6th National Punctuation Day (NPD) on September 24, 2009.

RULES FOR THE NATIONAL PUNCTUATION DAY BAKING CONTEST

1. Entrants must send a recipe and a sample of their cookie, cake, pastry, doughnut, or bread baked in the shape of a punctuation mark to National Punctuation Day, 1517 Buckeye Court, Pinole, CA 94564.

2. Entrants must send two print photos—one putting the item in an oven before baking and the other taking it out when it’s done. Make sure we can see the baked goods clearly.

3. First-, second-, and third-place winners will receive a box of non-edible NPD goodies, and all entrants’ photos and recipes will be published on the National Punctuation Day website.

4. All entries must be received by September 30, 2009

I think I may be in some trouble for overuse of the dash -- this thing [--] -- but it works for me.

Medicare -- can't live with it, can't live without it

Back when I was an impecunious graduate student I was a teaching assistant for a health care policy 101 type course. As I recall, it took us two weeks -- that's four lectures and two discussion sections, with the attendant reading -- to pound the basic info about how Medicare works into the heads of our bright and eager students. Like every product of our largely dysfunctional political system, it's a lot more complicated than it ought to be and it has a lot of absurd self-defeating elements that were put there basically to sabotage it by people who don't like it. Yes, it can be described as a "single payer" program except that a) thanks to the introduction of Part C it isn't really and b)it's not clear that it made sense to call it a single payer system in the first place because there are other payers active in the economy, which seems to conflict with the very definition of "single payer." But it still manages to be better than typical private insurance in a few important ways:

1) They can never take it away from you. It is an entitlement.
2) They can't refuse you in the first place, either. Once you turn 65, you are in. (People younger than 65, who qualify on the basis of disability, may have to wrangle.) So none of that jive.
3) It's much more efficient -- no profits, no marketing costs, no money spent figuring out how to exclude people from the plan or deny them coverage or kick them out.

But, there's also a lot of bad and ugly. Before we get to that, however, a lot of people don't even know the basic structure of the program. I don't want to bore my readers or insult anybody's intelligence, but I still feel it's best to begin at the beginning and make sure we all have the fundamentals in our minds before I get into the details. A good, accessible source of information is the Center for Medicare Advocacy, and I recommend that anyone who wants to get more in-depth knowledge of the program go there. Clicking on "information by topic" I find gives you the easiest way to find what you are looking for.

Medicare Part A pays for hospital care. It is funded by a 2.9% payroll tax. This finances the Medicare trust fund we hear so much about -- the one that is projected to run dry in (gulp) 8 years. That doesn't mean Medicare Part A will cease operations -- it will still have the income from the payroll tax, it just won't have a cushion to pay the gap between income and expenses. So the government will either start borrowing the money, or kicking in something from other revenue sources, or find a way to cut spending to match income, or something. Whatever happens, I expect it to be ugly.

You are enrolled automatically in Part A when you turn 65, and you don't have to pay any premiums. There are, however, immediate co-pays, and periodic and lifetime limits on benefits. The biggest problem from the consumer's point of view is that it will not pay for long-term care (beyond six months), or for so-called "custodial" care, which means feeding and bathing and dressing people who can't care for themselves. This is what bankrupts lots of elderly people and drives them on to Medicaid, where the government ends up paying for it anyway.

Part B pays for outpatient care. It is funded in part by premiums, but it is heavily subsidized out of general tax revenues. Since it is an entitlement, it sucks up money in the annual federal budget before Congress even acts -- an amount which is steadily increasing. There is a small deductible, less small copayments, and a lot of restrictions and exclusions, which I will get to later. Still, it's better than a poke in the eye with a sharp stick. When you turn 65, you have to sign up and start paying the premium. If you don't sign up right away, you will face a lifetime penalty premium increase, unless you are still working. Once you finally do retire, however, it's play or pay. Just about everybody does sign up, because it's subsidized and hence a good deal.

Part C is what happened when Congress decided back in -- 1997, IIRC? -- that all that socialist single payer stuff was just too offensive to Real Americans. The basic idea is, the government bundles the amount of money they expect to pay for the average beneficiary and gives it to an insurance company to provide coverage. The theory was that by "managing" your care they could save some money and pass part of the savings on to you, the beneficiary, in the form of lower co-pays and/or expanded services. It kind of works for people who can figure it out and pick the best plan for their own situation out of the welter of competing offers, but you can also kind of get screwed if your health situation changes and you find yourself in the wrong plan after all. And the government definitely gets screwed because the insurance companies are actually spending more per beneficiary than straight-up Medicare.

Part D is the prescription drug benefit, which GW Bush rammed through using false actuarial assumptions (real lies, in this case, since the Medicare actuary who computed the correct numbers was gagged). Part A pays for drugs given in the hospital, and Part B for drugs actually administered in a doctor's office -- meaning mostly cancer chemotherapy -- but most people take drugs at home, and those weren't covered before. It's good that people now have some outpatient pharmaceutical coverage, but again, the government intentionally screwed itself for the benefit of drug companies, which are the biggest winners here, while still leaving a lot of seniors with drug costs they can't pay for. Part D is also financed out of general tax revenues.

So that's the framework. In future episodes, I'll run it through the Critic-O-Meter.

While we're sitting around waiting . . .

. . . for the U.S. to establish its own communazifascist grandma killing institute to tell us WTF works and what doesn't in medical care, thanks to the miracle of the Internet it is actually possible for Americans to expose themselves to the evil bureaucrats of the United Kingdom. Experience the shock and horror of reading actual, credible information that might even help you make your own choices without the benign, Christian guidance of drug company marketing campaigns, if you dare, by clicking on this link. (Warning: Not safe for the willfully ignorant.)

Yes, that's the National Institute for Health and Clinical Excellence, known to its friends and fellow evildoers as NICE. There's a little search box there about halfway down on the right. Has your doctor told you that you have a particular disease, be it osteoporosis or type 2 diabetes? Have you been told to consider a particular treatment? Type the word in the box and see what happens.

You may want to be careful about who might happen to walk in on you as you do it, and you may want to clear your Internet cache and history once you are done, because you are now an enemy of capitalism and freedom. Don't tell anybody where you got that link. It's just between us.

I'm not a real doctor . . .

I'm a doctor of philosophy. Nevertheless I am a member of IAPAC. Here's a press release I can be proud of:

WASHINGTON, DC (September 10, 2009) - In response to President Barak Obama's address last night before a joint session of Congress, the International Association of Physicians in AIDS Care (IAPAC) today lauded his commitment to extending health insurance coverage to millions of Americans, as well as his call for eliminating barriers to health insurance coverage, including pre-existing condition exclusions.

"We applaud the President for defending a public health insurance option in his address to the nation. Our US clinician-membership supports a public health insurance option because it would redress disparities in access to health care services for millions of currently underinsured Americans, while creating a competitive environment that would force private insurers to place public health above profits," said José M. Zuniga, President/CEO of IAPAC, a professional medical association which represents approximately 4,000 HIV-treating clinicians in the United States [and a total of 13,000 in over 100 countries].

"We were also very pleased to see both Democrats and Republicans stand to applaud the President's call to end health care discrimination based on pre-existing conditions. The elimination of pre-existing condition exclusions is needed to protect Americans with chronic illnesses from coverage exclusions when they are most in need of medical care and the insurance that makes it affordable.The use of pre-existing condition exclusions is, at least partially, why 30 million Americans, including an estimated 500,000 Americans living with HIV/AIDS, are underinsured."


A recent IAPAC survey (July 2009) shows that 73% of its US members support the public health insurance option. A majority (82%) also support the elimination of pre-existing condition exclusions. Of the 400 survey respondents, 70% were physicians, 23% were nurses, 5% were pharmacists, and 2% were physician-assistants.

As negotiations around what shape health care reform legislation ultimately will take, IAPAC urged Congress to reflect on the life-or-death nature of such legislation and the urgency with which it is needed.

"We ask that Congress side with the American people on this vital issue, pass health care reform legislation that includes a public health insurance option and protections for individuals with chronic illnesses, including HIV, and thus defeat the special interests that are at the heart of seeding dissent," Zuniga said.

Multi-tasking

With all the brouhaha over one thing and another, we have largely forgotten that the FDA lacks adequate capacity to inspect food processing facilities, enforce safety standards, and assure the safety of the food you buy. A coalition of good groups is trying to make sure congress passes legislation to fix this problem. Check out their web site and let your persons of congressness know that this legislation is a priority for you.

Distinction with a difference

And now, an important clarification: the QALY concept as applied considers only the net effects of treatments. It does not generally consider the baseline status of any particular individual who may receive the treatment, except perhaps insofar as this is relevant to the effectiveness of the treatment under particular circumstances. (For example, you would want to avoid adverse drug interactions, or people who are at higher risk for adverse outcomes of a treatment.)

In other words, NICE does not view medical care for Stephen Hawking less favorably because he has crippling ALS. Whatever people in surveys may have said about how much they don't want to be paralyzed, the issue is not Prof. Hawking's current disability but how much people in general can be expected to benefit from the medical care he receives. His life is not worth less. Indeed, if an effective treatment could be found for ALS, it would score very highly on any health utility scale and the National Health Service would be willing to pay a lot for it.

That is also why former governor WinkyWinky Starburst is wrong about baby Trig (whoever's son he may be). That he has Down Syndrome is irrelevant to the valuation of any medical care he may receive. And indeed, were the baby a subject of Her Majesty Elizabeth II, WinkyWinky would never have to worry about his medical care, unlike the situation here in which people with income-limiting disabilities are at the mercy of state Medicaid programs which are often not very good.

However, NICE does take into account people's age because that has a strong influence on their current life expectancy. It is not true that older people cannot get joint replacements, for example, but it requires special analysis. Indeed, it is unfortunate that my father had his knees replaced as he was entering the middle stages of dementia, because he never did the rehabilitation work he needed to benefit from it, and in fact he suffered post-surgical delirium which probably hastened his deterioration. Under a more judicious system, the surgery would have been discouraged, to everyone's benefit.

Nevertheless, the recognition that expensive interventions yield progressively less benefit as people grow older seems to be very difficult for Americans. It is sometimes unsettling for the Brits as well and there are occasional controversies over specific cases. That is inevitable, and in my view a good thing. These problems ought to be processed publicly and openly and where people come to conflicting ethical conclusions they should debate. Without, however, hurling invective.

disQALYfying

Okay, since nobody cares to comment on the whole QALY concept, I guess if I want anything done around here I have to do it myself.

Obviously any evaluation of QALYs has to depend on how they are used. Just asking people questions, however strange the questions may be, and writing down the answers, can't in itself be wrong, although there might be better uses for your time. That almost everyone is willing to answer the Standard Gamble and Time Trade Off questions with death on one side of the equation proves that life is not, after all, infinitely precious, and that we are willing to take some chances with it or sell some of it out for particular benefits. That makes these thought experiments qualitatively useful, if nothing else.

However, the original point of the exercise, in every case, is quantification. Health economists and clinical researchers want to have standard units that they can use to compare the effectiveness of various treatments, and to allocate scarce resources. As I have pointed out before, these are two very different kinds of problem. They have been conflated in recent political debates and the result is great confusion and error.

A comparative effectiveness study would end up concluding something like "Treatment A yields, on average, 6 years of additional life with a quality score of .6 = 3.6 QALYs, and treatment B gives you 5 years with a quality score of .8 = 4 QALYs." That's kind of silly though, because if you are contemplating a treatment for yourself you don't give a FFOARD what the average response of 100 people to the hypothetical may have been. You only care about your own preferences. Furthermore, these predictions don't apply to you anyway -- you already have a certain baseline state of health, a certain age, possibly specific risk factors that interact with the treatment and with your disease. So you will still want to make your own decision. You want to know the information about the alternatives, but you the relevant QALY scores will be your own, not the result of a survey.

Where the fecal bolus hits the ventilator is when we want to use QALY information to allocate scarce resources. To do that, we have to calculate Cost-Utility Ratios. That's the cost of a treatment divided by the QALYs that it buys. And, in order to make use of the calculated CURs, we have to decide that there is a finite price we are willing to pay for a QALY. While there can be no doubt that there must, indeed, be a limit, it gets very ugly very fast when you start actually trying to apply one.

Most people, when they think about this, immediately see a serious ethical objection: the concept devalues the lives of people with chronic diseases and disabilities. When asked hypothetically to make a Standard Gamble, I may be perfectly comfortable doing so. But when I find myself actually disabled in some way, do I then decide that my life is worth less and I don't mind getting out of the way and letting somebody else use my health care dollars? Or do I feel that way about people I care about? At the extreme, maybe, if I already have Dr. Kevorkian on the speed dial. But most people find that they can cope with their problems and they may well have just as much they want to do with their lives, if not more, than before they acquired the disability.

So this is actually a very difficult problem that has no "scientific" solution. People involved in this field keep prescribing "further research" to clarify these issues but it isn't a matter of "research" to be conducted by brainiacs speaking incomprehensible jargon inside locked laboratories. It's a matter for public engagement and democratic process.

Unfortunately, we are completely unable to have that discussion right now because it immediately attracts hordes of screaming lunatics who inhabit an alternate reality in which death is just a work of the devil that righteous people will defeat. Unless we can get them to sit down and shut up long enough to make a reasonable presentation of the problem and have a respectful discussion about issues we all agree are difficult, we will never reach a manageable accommodation. That's the best we can hope for, but it is also the least that we must have.

Give mois a break

It's the first day of dental school, and Johnson & Johnson has a table set up in the hallway handing out bags of Johnson & Johnson products to the incoming first year students.

You can't make this stuff up.

Follow me deep into the wonkish weeds . . .

but wear protective gear. Here be serpents.

Before heading off to the Land That Time Forgot, I started to talk about probability theory and how most people's response to gambling propositions -- including the risks we take in daily life -- doesn't correspond very well to the way mathematicians and economists and weird people like that think about them. In addition, there is the vexed question of how we value possible outcomes. We know that ten bucks is ten times one buck, but how much more valuable -- if at all -- is ten years without arthritis in the left knee compared with ten years with arthritis? And would you be willing to give up some actual life -- say, die a couple of months earlier -- in order to avoid the arthritis?

That may sounds like a stupid or pointless question, but health economists ask it of people all the time. It's called the Time Trade-Off approach to measuring health utilities. Another, if anything even more popular approach drags the issue of probability right into the middle of the ring. It's called the Standard Gamble. What if there were a treatment that might cure your osteoarthritis, but it involved some risk of death? (Indeed there is such a treatment -- joint replacement surgery, like any surgery, involves a small but non-zero probability of killing you.) The Standard Gamble asks at what probability of death vs. certain cure you would be indifferent to the surgery. Another commonly used method is the Rating Scale, commonly presented as a so-called Visual Analogue Scale. If life in perfect health is a 10, what number is life with osteoarthritis of the knee? The VAS version of this has a horizontal bar and you point at the location on the bar, so you don't have to think in terms of numbers, which are yucky. The bar might even have a smiley face on one end and progressively less smiley faces as you move along until you get to a total yuck face.

Often, these questions are not asked about specific conditions such as osteoarthritis of the knee, but refer to vague, general states such as pain, mobility, mental acuity, etc. You can ask these questions of people who actually have a disease or symptoms of interest, or you can ask them of the general public in an even more hypothetical way.

Once you have this information from a sufficient number of people -- and how you define sufficient is an interesting question in itself -- you use it to calculate something called a Quality Adjusted Life Year, a QALY, usually pronounced "kwolly." Treatment A, let's say, that on average gets you 10 extra years of life but at 70% value based on the side effects of chemotherapy and the lack of a left lung, can then be compared either with another treatment -- say you skip the chemo in which case you can expect to live 8 years but at 90%, which is worth 7.2 QALYs and hence slightly better than the 7.0 you supposedly get from adding the chemo -- or to it its cost -- e.g. surgery + chemo costs $250,000 so you're spending about $35,700 per QALY.

It all sounds very scientific, no? Can you (or Betsy McCaughey) find anything wrong with this picture?

Back to civilization

Being as it's a holiday and all, I'm not going to actually work on this post, so all you get is a brain dump.

I did a lot of heavy lifting this weekend. In addition to loading and hauling some very heavy objects, I sectioned and split a chord of wood, loaded half of it and took it to my mother and my aunt's houses, where I unloaded and stacked it; then went back and got the rest and brought it here to Boston, where it now resides in the garage. I'll still need at least another chord to get through the winter, and that's assuming I've already got enough at the country estate to meet my needs there.

Good for me, I can still do that, but two or three hours a day of really hard physical labor is plenty. To make a living, I get to sit on my ass all day and think thoughts, deep or otherwise, but most people aren't so lucky. Physical labor isn't necessarily drudgery -- carpenters and masons and many other kinds of craftspeople need to be highly skilled, and they are often creative and take real satisfaction in their work. Other work -- plastering, hotel housekeeping or the loading dock -- is not so satisfying, but at least it puts a few cans of corn in the larder. Either way though, you just can't keep doing it for 40 or 50 years. The back gives out, there are only so many ladder cycles in the knees, you blow a biceps tendon or you just wear out. And then what? From age 50 to social security is a long desert to cross.

As a starving grad student, I taught at a community college for a while, and out of 60 students in a semester I had three or four who I knew about who had been manual workers who'd had injuries that put them permanently out of work. One of my students was a 40 year old former carpenter whose family was in dire straits since he'd injured his back. He'd managed to get into a state-funded retraining program that was paying most of his tuition, but this guy's chances of starting over as some form of clerk didn't look good to me. The factory jobs that used to offer a decent standard of living to a big chunk of the working class are melting away like the snows of March. The jobs that are left for people without high level technical skills are more and more soul-destroying drudgery that pays a pittance.

On top of this long-term structural change in the labor market, right now we have more people who are long-term unemployed than we've had since we started keeping records. These are people whose unemployment benefits are running out, whose homes and savings are gone, whose health is deteriorating, and guess what? For most of them, their old jobs are never coming back. And now, if Max Baucus and Ben Nelson have their way, they will never have health care until they finally stagger across the age 65 barrier.

These - the people, the ordinary folks, the real America -- are in deep trouble. And they have been convinced to view the prospect of a national community that might actually come together through its elected government -- to do something about their circumstances and build a decent and livable society out of our great though unjustly distributed wealth, as a threat, a plot to -- to do what? Steal the freedom and prosperity they do not have? Do they truly believe that it's all an elaborate scheme to murder their parents and establish a totalitarian anti-Christian communist state? Why do they listen to this insanity? What brain worm has gotten into our water supply? It's a deep mystery.

A thought for today

I expect to be disconnected from Your Intertubes for the next couple of days while I head out to The Land That Time Forgot. So I'll pick up on the whole probability and evaluation of outcomes thing when I get back.

Meanwhile, not that I haven't been cynical about politics previously, but the utter dysfunction and corruption of our political culture is just awesome to behold. The corporate media are at the heart of the problem, but the amoral politicians who collaborate with them on behalf of their parasitic corporate masters are equally culpable. Should I despair of our republic, or can this nation-state be saved?

If it can be saved, how?

Take a chance

I bought a lottery ticket, just to change my luck.
I thought I wouldn't mind alosin', cause it only cost a buck.
I won an electric toaster, and a baritone sax,
But I had to pawn my guitar, just to pay off the tax.
How come I always lose?
You got to suffer if you wanna sing the blues.

Like David Bromberg, people tend to perceive patterns in events. Sometimes they are really there, so it's a useful faculty. The tubers form in this place at this time every year; the lion wakes from mid-morning to mid-afternoon. But if we can't discern a real pattern, our minds will invent one. Does David always lose in order that he can sing the blues? Was Big Mama born under a bad sign?

Superstitions help us make sense of the world, but when scientists don't know how to make exact predictions, they depend on probability and statistics instead. Probability theory is philosophically vexed. The philosophy of science in its simplest expression depends on the principle of verifiability and repeatability, but are probabilistic statements consistent with these principles? If I say the chance of throwing a 6 on one roll of the die is 1 in 6, is that verifiable?

In fact, if I roll the die 6 times, it is unlikely that I will get exactly one 6. And if I repeat the experiment, I will get many different results -- to be precise, there are 6^6 possible results considering the order of the rolls, each of which is equally probable. Results that yield exactly one 6 are more numerous than results yielding other numbers of 6's, but that does not mean they will necessarily be the most numerous in any given set of trials.

Nevertheless, gamblers who know the odds and play by them will almost always come out ahead in the long run if they are playing against others who do not. They will not buy lottery tickets or play slot machines or roulette, because they know the odds are against them. Yet many people do play these games. Why? Often, they believe that there is some influence or determinant of the results, that they can take advantage of to tip the odds, be it prayer, the interpretation of dreams, runs of good or bad luck, or the results of previous trials -- that is, 6 hasn't hit for a while, so it's due.

But there is another feature of risk, or chance, when applied to real world situations, that scientific attempts to make policy have difficulty with, and that is the valuation of outcomes. The high probability of losing a dollar, for David Bromberg, seemed inconsequential compared with the much smaller probability of winning the greater prize of a toaster and a saxophone. Of course, it turned out he was mistaken, but given that he forgot about the taxes, was his initial decision actually "irrational"? That's hard to say. But it also mattered what the toaster and the saxophone were worth to him in the first place. I already happen to own more than one of both items, so I would not be interested in entering a lottery to win them. But there are other prizes that might tempt me to part with a small sum.

So, when it comes to weighing the "appropriateness" of medical interventions, as I touched on yesterday, we have a problem. The question never has a "scientific" answer. Information about probabilities can inform our choices, but it can never determine them. In fact, while on the margin health care payers always restrict choices -- in the United States as much as in the United Kingdom, by the way -- most of the information about costs and risks and potential benefits is treated as support for making personal choices, not as a restriction of choice. Unfortunately, few of us as patients and potential consumers of medical services are well equipped to understand or apply this information.

I suspect that's a major reason why a lot of people don't want to have it -- they're afraid of having knowledge that will only confuse and distress them. Psychologists have found that there is a point beyond which most people want fewer choices, not more.

Anyway, having set up some of the framework for this discussion, I will pursue it further in coming days.

Dream On

Reading medical journals and our mainstream political discourse is to inhabit alternate universes. Case in point, the new JAMA, which you, as a mere citizen, are not allowed to read. So, I will do my usual service and tell you some of what's in it.

First, another one bites the dust. Another widely performed operation, that is. A few weeks back we learned that vertebroplasty, a widely used procedure, is worthless. Now it turns out that a procedure called Laparoscopic Uterosacral Nerve Ablation, used to treat chronic pelvic pain, is equally useless. The data are clear in fact -- it does absolutely nothing. Chronic pelvic pain is a big problem -- it affects a lot of women, usually has no identifiable cause, and can really bring you down. So surgeons would cut some of the nerves thought to transmit pain signals from the affected area. Sounds logical, doesn't work, according to a very well designed and carefully analyzed randomized controlled trial using sham surgery as a comparison, done by Jane Daniels and a multitude.

Okay then, we ought to do a lot more of this kind of research, right? That's what the president wants to do and that's what's got profound policy analysts from George Will to Sarah Palin screaming that he wants to murder you.

Not only should we do the research, we actually ought to, you know, use it, according to Dr. Robert H. Brook. The RAND Corporation, which brought you the <sarcasm>highly successful counterinsurgency tactics used in the Vietnam War</sarcasm> has also done some reasonably commendable work. One totally brilliant idea they came up with, which I could not possibly have thought of, is to classify medical procedures as:

necessary (the care produces substantially more health benefit than harm and is preferred over other available options), appropriate (produces more good than harm by a sufficiently wide margin to justify use of the procedure), equivocal (potential health benefits and harms are about equal), or inappropriate (health risks are likely to exceed health benefits).

Absolutely brilliant. Only a think tank with megamillions in government funding could have come up with that. Anyway, Brook proposes setting up expert panels within non-profit organizations to review the available evidence and come up with clinical scenarios in which various procedures are and are not appropriate; then set up a web based application so that doctors and patients can enter information about the patient's situation and get an appropriateness rating on a particular procedure to help them decide if it's worth it. In other words, according to Senator Grassley, Dr. Brook wants to murder you.

Finally, Victor Fuchs reviews the reasons why we pay 2 to 3 times as much for health care as the civilized nations do, and have nothing but grief and pain to show for it. It's the same stuff I've told you about here, with mind-numbing repetition, but Victor Fuchs is famous and stuff and I'm not so I'll just repeat it all with the benefit of his immense gravitas:

1. Higher administrative costs: Hundreds of insurance companies (sucking up profits and executive salaries, which Fuchs is too kind to mention), millions of employers buying insurance, 50 states administering rules, clinicians having to bill separately for every individual service -- you get the picture.


2. Too many specialists, not enough primary care docs: In Canada, half of physicians are in primary care; in the U.S., even with generous counting, it's less than 1/3. Right now, in many parts of the country, it's literally impossible to get an appointment with a primary care physician.


3. Too many expensive machines: Hospitals compete with each other by buying MRI scanners and whatnot. "On average, each Canadian . . . scanner accounts for 48% more scans than each U.S. machine."


4. Open ended funding: No overall budget to assure value for the dollar.


5. More malpractice claims: This is a complicated issue which I won't go into here but some proposals for malpractice reform would be a good thing. Won't have much effect on overall costs, however. Sorry Victor.


6. Less social support for the poor: Now you're talking. If we actually try to do something about the extreme inequality in this country, we'll save money on medical interventions for socially caused disease. Among other benefits.


7. Higher drug prices: "The United States has been subsidizing the rest of the world by allowing the drug companies to practice price discrimination by charging higher prices in the United States than in other countries for the same drug." Victor, you f'ing commie.


8. Higher physician incomes: Okay, here they have to borrow a quarter million dollars for tuition, which in the civilized world they don't. Still, we could ameliorate a big part of this problem by not overpaying those overabundant specialists.

Now you can probably figure out for yourself where the title of this post comes from.

We need universal, comprehensive, single payer national health care. Everything else is idiotic blather designed only to confuse and mislead you.

Darwin Award nominee

I've been to Baja California, and met some of the campesinos as well as checking out one of those fancy resorts as well as a less fancy surfer bum resort. It was fascinating and I should probably write about my sociological observations some day. Baja is of course high desert and outside of the tourist towns the social classes -- or rather castes -- are defined by water rights as much as anything else. The town I visited, San Quintin, was dying of thirst. However, there were skeletons of cattle half buried in the dunes and incongruous objects up in the hills. The folks told me there had been a storm a few years back. These occasional storms are the only way the aquifers get charged, otherwise there is only occasional morning fog off the ocean and at most a bit of drizzle to moisten the soil.

Anyway, here comes another storm, and it's monstrous. My old friends appear to be a bit north and west of where the worst of it will be, but there are plenty of moronic Yanquis down in Cabo San Lucas:

Although city officials shut down the port, lifeguard Roman Dominguez with the Cabo San Lucas Fire Department said there's no feasible way to close a beach. "We struggle a lot with surfers," he said. "They're looking for waves." Lifeguards perched in a tower looked on Monday as two women, one with her boogie board, another on a surf board, paddled into pounding surf under cloudy skies.

Clay Hurst, 52, a fencing contractor from Malibu, California, and Ben Saltzman, 28, an emergency medical technician from Pacific Palisades, California, emerged from a swim in the 10-to-12-foot waves and pounding surf. "We are waiting anxiously, wanting to be right in the middle of it," said Hurst, who said he has never seen a hurricane as powerful as Jimena. "We were advised to leave, but we want to be here," he said. "I've always wanted to be in one ... a real bad one."

Saltzman echoed his friend's enthusiasm: "It's an adrenaline rush," he said.

Winds are currently at 155 mph. That'll be a rush alright. At least it won't matter if they have health insurance.