Map of life expectancy at birth from Global Education Project.

Monday, October 16, 2017

Death Panels

One of our medical students, Vishal Khetpal, has a column in Slate about the "R" word, that is "rationing" of health care. He says we need to do it.

If you've been viewing this space for many years, you know that I used to talk about this quite a lot. One of the most popular tropes of right-wing opponents of government-provided health care, whether we're talking single payer or kludgier methods, is that it will mean "rationing." The horror! The horror!

That was of course supposed to be the single most evilest thing about the Affordable Care Act, that it included death panels that would supposedly decide who would get the privilege of meeting Jesus in the sky. Obviously, it doesn't have any such provision. Nor does it have any rationing, however conceived or implemented. On the contrary, prior to the ACA most policies had lifetime dollar limits. But now they don't. To quote health benefits consultant Ryan Seimers:

On the eve of the ACA, most plans still had a lifetime dollar limit . . . often at $1 million or $2 million. The actual occurrence of a $1 million claimant was very rare. [But now] "No longer did hospitals have to "tap the brakes" as costly care approached $1 million. Specialty drug developers (and their investors) were provided a limitless runway to fund therapies . . . potentially costing $100,00s per year.
He cites surveys showing various insurers facing increases in claims above $1 million of three times or more. You might want to read the whole slideshow to understand the issue.

So there were all sorts of rationing before the ACA -- including annual and lifetime limits. And of course, denial of insurance entirely to people who would likely be expensive. And limited benefit packages -- no vision, no dental, no behavioral health, that sort of thing. There wasn't a group of people in black robes sitting around a table deciding that Pemberton P. Throckmorton of Nutley, New Jersey, must be denied medical treatment. But there were plenty of reasons why Pemberton might be shit out of luck.

The fact is, we condemn people to death in this country every day because they can't afford medical care. The difference now is that thanks to the ACA, we do it to fewer of them. And if we had universal, comprehensive single payer national health care, we'd do it to even fewer.

But -- and this is the part that people have trouble with -- it would be a bit more obvious when it did happen. And it would have to happen. Resources are finite. It is always possible to find ways to spend more money to give desperately sick people a small chance at extending their very unpleasant life by a few days. And there are other demands on society's resources, including investing in improving population health and reducing the prevalence of disease. Health care could easily devour the economy if we let it.

So no, we don't need any panels to rule specifically on the individual fate of Pemberton Throckmorton. But we do need to decide that there are some treatments that just aren't worth the cost. If you're as rich as the Koch brothers, you can still pay for them yourself if you want to, but as a taxpayer, you need to set limits. That's just the way the world works. But as long as we're doing it -- and we are, right now, today -- we should find ways of doing it more fairly and transparently.

Friday, October 13, 2017

The Base

There is a great deal I can say about the recent executive orders regarding health insurance, but let's start with this from David Anderson (formerly known as "Richard Mayhew" on Balloon Juice.)

The executive orders basically do three things:

  • Eliminate the cost sharing reduction payments to insurers, which subsidize premiums for low-income individuals
  • Allow people to buy insurance through "associations," which does not meet the minimum benefit standards of the ACA
  • Allow people to buy so-called "limited duration plans" for up to a full year. These also offer limited benefits and can exclude people with pre-existing conditions
There are two basic effects from this. First, it will enable people who are relatively young and healthy to evade buying insurance with the minimum benefit standards. Over time this will have the effect of segregating lower-cost and higher-cost people into separate risk pools. That, along with elimination of the cost-sharing subsidies, will drive up premiums on the ACA exchanges.

Funny thing though -- people with incomes below about $48,000, or families below $98,000, are eligible to receive subsidies for buying ACA policies on the exchanges, and the subsidies are based on cost. So their subsidies will go up along with the rising premiums, and their insurance will remain affordable. The subsidies, of course, come out of tax dollars and so this will increase the federal deficit. However, people with incomes above those amounts do not receive subsidies -- they will bear the full brunt of the premium increases.

By the way, contrary to conventional wisdom, that's where the Trump voters are. Funny thing about that.

The only reason for doing this, of course, is to try to wreck the ACA, since it was stubbornly refusing to wreck itself. In other words, the purpose is to screw people out of spite.

And you don't have to take it from me. Well known Communist Chuck Todd and friends say that these moves, along with other efforts to sabotage the exchanges:

[M]ake a strong case that the Trump administration is deliberately trying to break Obamacare. After all, if fewer people enroll in the marketplaces, premiums will go up and fewer insurers will participate.“Cutting health care subsidies will mean more uninsured in my district. @POTUS promised more access, affordable coverage. This does opposite,” Rep. Illeana Ros-Lehtinen, R-Fla., tweeted last night in response to the Trump administration’s subsidy announcement. Trump himself seemed to suggest that he was ending this subsidy to force Democrats to negotiate (which they’re ALREADY doing, given the ongoing negotiations between Sens. Patty Murray, D-Wash., and Lamar Alexander, R-Tenn.)
So even if you don't think the ACA is the greatest, why deliberately make things worse? Maybe because you're a psychopath.

Monday, October 09, 2017

Flat Earth Society

I'm at a conference in Baltimore, specifically the International Conference on Communication in Healthcare. I might have something to say about the conference at some point, but today I'm going to talk about, well, today.

I actually got here yesterday. I drove, because by the time I drive an hour to the airport and pay for parking there, and a cab from BWI to here, and the time and money involved, it was just easier. I made excellent time until I got off the highway and onto the Baltimore streets, after which it took me an hour to get to my hotel which was ordinarily only ten blocks away from the Interstate.

I had no idea why the streets were blocked and the whole city gridlocked, until I saw the leading edge of what turned out to be a parade in honor of Columbus day. For this they must have paid a quarter million dollars in police overtime and probably more than that in lost business and truck idling time, to send a parade right down the main street in the heart of the city, blocking all the cross streets long the route as well, and by the way nobody, and I do mean nobody, was watching this stupid parade which consisted of old guys in medieval Italian attire carrying banners and a couple of high school bands.

In case you didn't already know, the story they told you in school was completely false. People in 1492 did not believe the earth was flat. Every sailor knew perfectly well that it was spherical. (Okay, it's only approximately spherical in reality but that's beside the point.) The ancient Greeks knew that and they also knew how big it is. The reason people didn't try to sail west from Europe to China is because they knew that if they tried it, they would run out of provisions and starve long before they got there. Columbus, however, believed that the earth was only 16,000 miles in circumference.

He was of course wrong, and he would indeed have starved to death had he not accidentally run into a continent Europeans didn't know about. (Actually the Scandinavians knew of the existence of what is now eastern Canada but they didn't know the extent of the land mass.)

What followed upon the fortunate blunder of luck fool Christopher Columbus was genocide, expropriation, and slavery. Making me sit in traffic for an hour to celebrate this evil idiot caused a big change in my opinion of Baltimore.

Thursday, October 05, 2017


People, including the Las Vegas sheriff and reporters are all obsessing over discovering Stephen Paddock's motive for mass murder. That's actually a very easy question.

He was fucking nuts.

In case you don't want to take my word for it here's neurobiologist David Eagleman explaining the possibilities. Just to summarize, Paddock wasn't schizophrenic -- that has onset typically before age 25, and he clearly was fully functional his whole life. And while it's conceivable he had some psychopathic tendencies, there isn't really any evidence of that. He wasn't the most sociable guy but he seemed generally well behaved. And even if he did have a lack of empathy that would not affirmatively motivate his actions.

The likely possibilities are a brain tumor - as Texas Tower sniper Charles Whitman was found to have on autopsy -- or frontotemporal dementia. Unlike Eagleman, I'm leaning against FTD, because Paddock didn't seem to have any noticeable impairment other than the selection of a highly abnormal purpose in life. Usually signs of FTD include such symptoms as aphasia or cognitive impairment along with personality changes. But a tumor would work.

The reason I bring this up is simply to clarify that this incident had nothing whatsoever to do with anything about the culture. It was not the result of the decline of morality, or community. It did not result from atheism or religion, liberalism or conservatism, the abandonment of traditional values, multiculturalism, or any other cause you happen to dislike. It happened because the human cerebral cortex, which we tend to take for granted because we all have one and in fact it is the very essence of what we are, is an awesomely capable machine that can also go haywire. Set it to work on the wrong objectives and you get Las Vegas, or the Holocaust.

Paddock's actions could not have been prevented by a better mental health system, because he was never ascertained as mentally ill and he never sought treatment. They would not have been prevented by him finding God, or joining a bowling league, or Making America Great Again. The only way to prevent this catastrophe would have been to make it much more difficult for him to obtain a massive arsenal of weapons of war, that have no conceivable purpose other than killing people. A registration system that alerted authorities to a guy acquiring 30 or more assault rifles, high capacity magazines, and thousands of rounds of ammunition might have been helpful. Outlawing the manufacture, import and sale of all that crap would have helped as well.

That's why this kind of thing only happens in America. By the way, owning guns does not make you more safe, it makes you less safe. Gun owners are more likely to be shot than non-gun owners, and much more likely to kill themselves. And the successful use of firearms by law abiding citizens in self-defense is vanishingly rare. You don't have to take it from me.

Monday, October 02, 2017


Here's the breakdown of mass shootings in the U.S. since 1982, by the race/ethnicity of the perpetrator. (I came across this in the discussion by Jen Hayden at Daily Kos, which also features tweets by Nelba Márquez-Greene whose daughter was murdered at Sandy Hook elementary school.)

So yes, the majority of mass shooters in the U.S. are white men, and very few of them are Middle Eastern terrorists. Many bloggers, such as Duncan Black, are complaining that it isn't called terrorism if white people do it. The justification you will get from the corporate media is that the word "terrorism" implies a political motive, and most of these rage killers don't have one. In other words it's not the race of the shooter, it's the reason.

Now, if you want to use the word that way, you can. As of now there is no evidence of a political motive behind the massacre in Las Vegas. This is looking like a brain tumor to me. That might change of course. But in the meantime the issue is that being worried about politically motivated terrorism, whether or not you think that includes right wing extremists and white supremacists as well as Muslims, while not being nearly as concerned about non-political violence, is irrational. People who commit mass murder of random people out of some ostensible political motive are just a particular kind of nut. They embody their rage and alienation in a political ideology but what difference does that make? The people in Las Vegas are equally dead and injured no matter what was going on in the shooter's head.

The reason why this happens in the U.S. and not so much in other places is that our country is full of firearms. In this case, clearly the shooter used an automatic rifle, probably the equivalent of an AK-47 or an M-16. It is legal to own these in the U.S. if they were first sold before 1986. They have to be registered and most of them are at specially licensed gun ranges, though private citizens can keep them in their houses. There are about 390,000 such legal weapons in the country. But it is actually very easy to convert a semi-automatic weapon to be fully automatic. So there are an unknown number of illegal automatic rifles in the U.S., and Stephen Paddock had at least one.

Update: As we all know by now, he had a dozen semi-automatic rifles that had been modified to shoot rapid-fire like an automatic rifle using a device which is perfectly legal. So it's even worse than I thought.

This could be fixed by legislation that outlaws semi-automatic assault rifles and large capacity magazines. (Based on the sound of the gunfire, which I heard on NPR, Paddock had 30-round magazines.) Instead, congress is getting ready to repeal the ban on gun silencers, because they are obviously essential to recreational shooting and self-defense.

We are insane.