More boredom: the real problems with health insurance, part I

I know, I know, this week-long vacation in Hartford, Connecticut is the least entertainment we have ever had here, and that's saying something. But it must be done. Maybe we can visit the Mark Twain house once we're done with the tour of the filing cabinets.

Now that we've figured out that health insurance isn't exactly insurance, how does moral hazard apply? Actually, it applies in a completely inverted way. If you are on so-called maintenance meds -- say for blood pressure, or cholesterol, or any other chronic condition -- have you ever wondered why your insurance company only lets you buy 30 days worth at a time (or possibly 90 days by mail order)? Wouldn't it be easier to let you get a big jar that lasts six months, so you don't have to keep hassling with refills? (Most meds don't expire for considerably longer than that.) In fact, most people stop taking their blood pressure pills after a few months, and that's one of the big reasons why -- it's a pain in the neck to have to keep going to the drug store every month, fork over a co-pay of $10 or more, and have to keep getting your doctor to give you refill prescriptions.

The reason insurance companies don't let you buy a long-term supply of meds is because you might lose or change your insurance at any time -- because you lose a job, or change jobs, or your employer changes plans. Then they would have bought you some pills for a period of a few months during which they weren't getting premiums for you. They would lose a few bucks. Of course, it might cost them a hell of a lot more if you have a heart attack or a stroke, but by the time that happens, chances are very high that you won't be on their plan. They have figured out that it's in their financial interest to make you refill your prescriptions every thirty days, even if that makes you more likely to have a stroke 10 years from now. Now that's moral hazard!

If you'll look at your co-pays, you may find that the co-pay for a colonoscopy is something like $150. That's enough to discourage a lot of people from getting one. Colonoscopies are fairly expensive to the insurer -- something like $800 or more -- but they pretty much can totally prevent colon cancer, which is far more expensive. However, once again, by the time you are diagnosed with colon cancer, 10 or 15 years after you should have gotten your screening colonoscopy at age 50, they figure you won't be on their plan any more. Now that's moral hazard!

You may have read about an experiment in New York in which people with diabetes received intensive disease management -- frequent examinations; lots of education and support to help them control their blood sugar through diet, exercise, and medications; education and support on foot care and other measures to prevent amputations. It really worked -- it was shown to be cost-effective in the long run, because an amputation costs $30,000 and up followed, of course, by disability and additional expenses. But the insurance companies wouldn't pay enough to make the programs sustainable, even though they are more than happy to pay the $30,000 for the amputations. Once again, they are betting that by the time you need the amputation, it will be somebody else's financial responsibility. Now that's moral hazard!

I could go on and on. There are tons more examples. Wow! This is really dumb! What's the answer?

Universal, comprehensive, single payer national health care. If everyone is in the same pool, and guaranteed to stay there, the financial incentive is clear: prevent disease, promote health. Spend money to save money, and to prevent suffering. What's wrong with that?

The rest of what health insurance is

Okay, so health insurance is partly sorta kinda like casualty insurance. However, 90% of the time that's not what it does for us. It's more like a maintenance contract. It pays for most of the routine and preventive medical services that people ordinarily use even when they haven't just been hit by a bus or collapsed with a squeezing pain in the chest.

Now, some percentage of that is basically predictable -- there are recommended intervals for mammograms, it's recommended that people have their blood pressure, cholesterol and blood sugar checked, etc. Most people get physical examinations every year or two. Then there's is a part of it that varies somewhat from person to person. If you are diagnosed with hypertension, your doctor may prescribed medications, for example. You may have acute diseases that aren't extremely serious but still result in treatment, such as an antibiotic prescription or minor surgery.

Health insurance smooths out the budget for those lesser expenses and also spreads it among individuals and families. There is some benefit in convenience and predictability, and a justice interest, although the justice issue is not as sharp as it is in the case of emergencies or life threatening disease.

However, an even more important reason why it makes sense for people to have this kind of insurance is that spending a little bit of money now can save a lot of money later. Vaccinations are an obvious example of a very inexpensive intervention that has a huge impact on later medical expenses and also prevents a great deal of disability. (You may be too young to remember the devastating effects rubella on fetuses, causing the birth of severely retarded infants; or deafness caused by measles; or paralytic polio.) But there are many other examples. Cervical cancer and colon cancer are almost entirely preventable by screening and early intervention. Control of hypertension and diabetes pay enormous dividends in prevention of disability and the need for very expensive medical procedures.

It has been shown by gold standard studies -- randomized controlled trials -- that when people have to pay out of pocket for such routine care, they often decide not to get these preventive services, or they delay seeking medical attention for symptoms until disease is more advanced and more expensive (if not impossible) to treat. Some people, of course, can't afford them at all; others just decide to do something else with the money. Are they irresponsible, or self-destructive, or crazy? No, they just aren't experts on primary care medicine. They are making decisions that seem right to them at the time, but which they might regret later.

And that brings us to the Ownership Society proposal for health care reform: have people buy really crappy health insurance that only insures against catastrophe, and save up money in tax advantaged accounts to pay for routine and preventive care. This is supposed to control medical costs because if we're spending our own money, we won't be subject to moral hazard. Yup, Chimpy and his friends apparently assume that people are gobbling hydrochlorothiazide, lovastatin, and erythromycin; having lumps in their breast biopsied and tubes stuck up their colons; having their appendices removed and their coronary arteries reamed out, not because they actually need any of these things, but because their insurance is paying for it so they might as be freeloaders.

This is so patently absurd that every human being with common sense should hold them in utter contempt. But Bill Frist and the Decider go around the country spouting this idiocy in front of college educated journalists and even audiences of physicians, and they are taken seriously. Of course, I'm not being fair and balanced, I'm relying on facts and logic.

Slacker Sunday: The Weirdness File

For some years, I have collected weird shit, to use the technical term. This is an inexhaustible, bottomless well of the inexplicably human -- much of it objectionable, much of it just totally nuts. Today, I'm going to offer a sampling of the nuts. No particular message or theme.

Here's a business card somebody handed me at a reception (name changed to protect the last true Rennaisance man):

Brokerage Business Centers/Management
Education Development Administration Offices of:
Dr. Eustace O. Atwanya

Expert: General Consulting Contracts, Assets Management, Real Estate Investments, Home Buying Services, Loans, Insurance, Travel Services, Social-Political Public Relations Liaison, Negotiation-Medication-Resolution, International Services & Cuisine Finder, Promoter, Advertiser, Caregivers, Research, Edu-Care Technologies, Fundraisers, Training, Recruiting, Financial Services, Career-Employment-Business Opportunities.
We bring the best in business and in human nature!

Solutions Reservoir Executive

Anyone requiring Dr. Atwanya's services should contact me for his number.

Then there was this news clipping from 1996. Perhaps you remember it?

By Reuters
The St. Louis Art Museum has filed a $2.5 million lawsuit against the Whitney Museum of American Art and its security services for a 1993 incident in which a guard drew a heart and wrote romantic messages on a Roy Lichtenstein painting.

"Curtains," a large Lichtenstein canvas, was on from the St. Louis museum to the Whitney when a security guard disfigured it. . . .Mr. Walker used a felt-tip marker to write "I love you, Tushee, Love, Buns" and to draw a heart inscribed "Reggie + Crystal 1/26/91" on the work.

Personally, I view this as an enhancement. Then there was the preacher who handed me this flyer:

READ WHAT GOD'S PROPHET SAYS
EmphasizesRepentance&ObediencetoTruth

PREACHING AGAINST: Adultery, divorce & remarriage, marriage annulment, fornication, common-law living, oral sex, lusting, homosexuality, lesbianism, pimps, pornography, mixed bathing, women wearing shorts, hatred, stealing, cheating, lying, deceiving, gambling, using God's name in vain, dope addiction, alcoholic beverages, tobacco use, smoking, pride, make-up, certain television programs etc., suicide, murder, rape, bribery, extortion, arson, mini skirts, revenge, burglary, rock music, and all the rest that Bible condemns!

Jesus said, you compass land and sea to make a prosylite and now he is ten times more a child of hell. In other words, you made him more wicked than he was before. Listen to what the prophet says and be ready for Jesus' coming. The blood of Jesus cleanses as you repent.

If you want to know what the Holy Ghost said concerning television sets, he said, "Move them out".

Love in Jesus name, "That Prophet"

Unfortunately, I only have an out-of-date Bible.

And now, a classic: Ruth Reichl's most famous restaurant review (edited to go straight to the good parts):

Any sane person would have given up after the asparagus-raisin sorbet.

Not me.

But then I already had a surreal history with Shin's. There was the first visit, when the waitress tok our order and went off, leaving us to sit, foodless, beneath the huge pink rhinoceros . . . ."I'm so sorry," said a pretty woman, coming up 45 minutes later to retake our order. "Your waitress quit." Was it something we had done? She shook her head. "She just didn't speak English." . . .

So here we are, three months later, seated at a corner table. The lights above us are blinking: they get very bright, then dim again, then suddenly blaze on. We want a drink, anything to get warm, but we can't get anyone's attention. "Can we please get a waiter?" we plead. Finally a man with a ponytail comes loping over. We point to the place in the menu that talks about an intriguing fresh sake "exclusive in the U.S. to Shin's." The ponytail nods. He comes back empty-handed. "We don't have that," he says.

We settle for ordinary sake and settle in with our menu. It urges us to order the chef's special omakase tasting dinner, a customized menu that changes every night. We ask the waiter to tell us about tonight's omakase menu. He looks puzzled, as if this is the most exotic possible request. But he dutifully flips out his pad and starts reciting.

Everything he mentions is on the menu.

When we point this out, the waiter has a ready answer. "You see," he explains, "the chef's don't speak English so they can't really tell us what the dishes are." [After a couple of edible appetizers] we are starting to be happy. At that precise moment the busboy picks up a plate and kocks a glass of ice water into my lap. As he tries to sop that up, he knocks over a bottle of sake. By now the tablecloth is a puddle and my clothes are soaked.

[Some dishes follow ranging from uninspiring to disgusting.] Those who have chosen not to experiment with the omakase menu are not doing much better. Chopsticks that break in the wrong place. Soggy tempura. Black cod with the unnerving texture of Cream of Wheat. . . For desert there is aparagus-raising sorbet. Don't want that? You have a choice of berry cottage cheese or banana sorbet. What do they taste like? It is impossible to tell: all three are suffering from freezer burn and all three taste like the refrigerator. Shin's is out of all other deserts.

Leaving, we are handed our coats and an umbrella that isn't ours. For a moment, we actually contemplate making off with it.

Unfortunately, you won't be able to eat at Shin's. For some reason it closed shortly after this review.

Finally, although I could go on for days, here is an advertisement from the Boston Globe. Somebody paid good money for this.

DEMON LAWYERS AND THIEVES

A dead realm ruled by golden radiation
Left haunted by wealth and power
Orange opposes the papal empire
Where true peace can never flower
A piece of red is answered on yellow
Revolving around the fire's glow
Blue lays out the proposed solution
Grey turns to dancing white tango.

Dedicated to my grandfather Chester Kime (Kime and Bonebrake, J.C. & E.K. photographers, Akron.) He broughthis wife Margaret "Peg" C. Marin, a high school classmate of John S. Knight of Knight Ridder, a Willys Knight (whose namesake W.J. Willy died with Joseph Patrick Kennedy, Jr. in 1944. (Joe Jr.'s sister Kick's husband William, Marquess of Hartington, also died that year. (Kick died in '48.))) He died of alcoholism in 1944 (2/2) leaving 3 children: Joseph, Janet and William (of DePere, WI) and saleman for Employer's Insurance of Wausau (dec'd '86.))
Also to C. Nelson Wright (born Nelson in Rittman, OH) who sold tools from the trunk of his car prior to founding Wright Tool & Forge Co. in 1927. He died Easter Sunday, 1972.
Please see my ads in the 3/16/90 Globe; 3/1/91 N.Y. Times (& Harvard Crimson); 3/14/91 S.F. Chronicle/Examiner. Always remember Alice Cooper's "Billion Dollar Babies" and watch out for spiders!

I have taken that advice to heart.

The Decider hears the voices

One thing they tell him, consistently, is that cutting taxes causes faster economic growth, because if the money stays in your pocket, you spend it, so companies can sell more stuff and they hire more people who in turn have more money to buy more stuff with and round and round it goes. "It's Economics 101!" he yells, channelling the voices.

Well, actually, no it isn't. When the government collects tax money, guess what it does? It spends the money! Yup, and when government spends money, it buys things from companies that hire people who . . . etc. And government hires people itself, who spend money that . . . etc. Or government puts money back in people's pockets -- social security beneficiaries and so forth -- who spend the money . . . etc.

In fact, government can spend money in ways that create economic growth, that the private sector will not and cannot do. Government spending, in fact, is absolutely essential to the very existence of a modern economy. Government builds and maintains roads and airports, educates children, pays for basic scientific and medical research on which industry depends for technological advancement, but which private industry would not fund because the company that spends the money cannot monopolize the benefits of the resulting discoveries.

A pre-eminent example is biomedical, public health and clinical research supported by the National Institutes of Health. Guess what? National "defense" spending (the vast majority of which has nothing whatever to do with defending the country) is now $1,600 per person, per year; while federal support for medical research is $97 per person per year. Most of "defense" spending is indeed squandered: it buys bombs and missiles that just blow themselves up along with buildings and people; airplanes that fly incredibly fast but don't transport anything or anyone to anywhere except for those bombs that destroy; tanks and "fighting vehicles" and gas guzzling armored trucks that carry guns around the countryside of Iraq and shoot and kill people and blow stuff up. The economic payoff for all that: negative. It's Economics 101.

Unfortunately, the corporate media doesn't know that. They take it as axiomatic that lower taxes mean higher growth rates. It just is not true, and international comparisons prove it. Overall levels of taxation are far higher in other wealthy countries, but they are not correlated with growth rates. That's just being reality based.

If we raise taxes, eliminate this insane spending on the military, and invest the money in true national defense -- energy conservation; mass transit; renewable energy; universal, comprehensive, single payer national health care; quality public education including universal access to higher education without regard to family wealth; scientific research including medical and public health research; public health infrastructure; early intervention for children with special needs; development of the arts; and whatever you want to add to the list -- we'll be far richer than we are now and more important, we'll stay that way, because right now, we're headed for the worst crack up since Easter Island.

And another new link

I've also added the Church of Reality to the sidebar. Res ipsa loquitur.

What is health insurance, really?

In our previous episodes, we discussed actual insurance, such as fire insurance and life insurance. Purveyors of these products must confront the problems of adverse selection and moral hazard, and the quandary that the better they do at reducing these problems, the less desirable their product becomes. If they could perfectly match the price of a policy to the individual buyer's risk, their product would be worthless, and nobody would buy it. They survive because the world is still fairly unpredictable, and they are helped by regulation which stops them from competing themselves out of existence in a process called the death spiral.

Is health insurance like casualty insurance? Partly, sorta kinda. It is true that part of the value of health insurance is that it pays for extraordinary expenses associated with catastrophic events, such as severe injuries from a car crash or a fire, or diagnosis with a serious disease, expenses that the policyholder probably could not afford to pay out of pocket. In that respect it is like casualty insurance.

We'll discuss what I'll call the non-casualty dimensions of health insurance in a later post. So keeping in mind for now that health insurance includes very important components that are nothing like casualty insurance, let's just consider the casualty part. Even that part of it is very different from other kinds of casualty insurance from the societal point of view. There are at least three very important differences.

The first is that when people experience severe suffering, or their lives are threatened by illness or injury, the ethical principle called the Rule of Rescue creates a social imperative to save them if possible. We do not feel compelled, as a society, to rebuild the home or business of someone who doesn't have fire insurance, or to restore the income of a widow who loses her business executive husband. (We do provide modest social security survivor benefits, and homeless families may get emergency shelter, but the value of these social insurance benefits is far less than the loss, and they are available only to the destitute.) However, we do not tolerate having people expire on the sidewalk outside of the hospital for lack of financial resources, even if their treatment would cost tens of thousands of dollars. We end up paying for it somehow.

Here's an excerpt from an e-mail I received yesterday:

Hi Joaquin,

I'm in desperate need of help. I am working at the University Hospital in Cincinnati, and I have this 25 year old patient who is an undocumented worker. On Sunday, he was involved in a motor vehicle accident that left him a quadraplegic with very minimal movement of both his arms. Because he is undocumented, has no family here that can take care of him full-time, and no health insurance, one can see the imminent danger once he leaves this hospital in a week. Hamilton county cannot provide him full services as an uninsured patient because he does not have documentation that he has been living in Hamilton County for longer than a month before the accident. He has an aunt and uncle that live close, but both have to work full-time and cannot take care of him. His only family is his mom living near Cancun who may not be able to take care of him, either. What we're trying to come up with is a solution to provide him with the equipment, rehab, nursing care, and prescriptions needed once he leaves this hospital.

Whatever may happen to this young man in the future, the hospital has already spent tens of thousands of dollars on his care. Furthermore, they cannot simply push him out the door and let him die. In this particular case, he may be deported to Mexico, but if he were a U.S. citizen, Medicaid would pay for his care, for life.

So the Rule of Rescue creates a kind of ethical externality -- both related and unrelated people would suffer from torments of conscience if we did not provide catastrophic medical care. But there are additional positive externalities. For example, people who are of working age who suffer curable or controllable conditions -- be it life threatening trauma or chronic disease -- can be returned to or maintained in the labor force, contributing to the support of their families and the common wealth; or providing care to their children, keeping a home, etc. Retired people may have important social roles as grandparents, repositories of wisdom, etc. That is a second difference from other kinds of casualty insurance.

Third, there is very little moral hazard involved in catastrophic medical insurance. While it is conceivable that having such insurance might make some people less diligent about practicing good health habits, there is no evidence for it. Getting lung cancer is sufficiently unpleasant, even if you have insurance, that it is unlikely that health insurance makes people decide not to quit smoking after all. There are much more powerful explanations for our bad habits. And nobody is going to check into the hospital for a heart transplant who doesn't actually need one, just because they have insurance to pay for it.

And that brings us to a final, essential point. The catastrophic part of health insurance is ultimately about social justice. The misfortunes that befall people, which can be ameliorated by medical care, are for the most part a random harvest. To the extent they are not random, they are in fact more likely to befall the poorest and most vulnerable among us. We don't feel compelled to do very much about their poverty and vulnerability, but we are compelled to do something about their imminent death or disability. It's just the right thing to do.

Next time: The rest of what health insurance is.

A must-read

The new issue of PLoS Medicine is a theme issue on disease mongering. Go there. Read it.

PLoS Medicine is also a new permanent link on my sidebar. (Firedoglake, which for unknown reasons dropped me from their blogroll, has suffered retaliation. So there.) PLoS, Public Library of Science, is a leader in the open access scientific publishing movement. My readers know that I am continually frustrated by not being able to give you access to the latest literature in medicine and public health which I discuss here. As a medical school faculty member, I have access to nearly all of the leading journals, but the rest of the world does not. That means that information that is vital to your health and well being is information that you can't get, unless you can get access to a medical school library.

According to its mission statement:

About PLoS
Mission and Goals

The Public Library of Science (PLoS) is a nonprofit organization of scientists and physicians committed to making the world's scientific and medical literature a public resource.

Our goals are to:

* Open the doors to the world's library of scientific knowledge by giving any scientist, physician, patient, or student - anywhere in the world - unlimited access to the latest scientific research.
* Facilitate research, informed medical practice, and education by making it possible to freely search the full text of every published article to locate specific ideas, methods, experimental results, and observations.
* Enable scientists, librarians, publishers, and entrepreneurs to develop innovative ways to explore and use the world's treasury of scientific ideas and discoveries.

PLoS is funded in substantial part by grants and donations. How many journals can be supported in this way is not clear. Sustainable open access models depend largely on funding by authors -- that is, authors pay a fee for publication, which it has been calculated would be something on the order of $3,000/article to sustain a typical scientific journal. This does not imply corruption or payola -- articles are still peer reviewed and accepted only on merit, and the idea is that the budget for a research project has to factor in the cost of publication, i.e. research grants would include that cost on the front end. If results don't merit publication, presumably that funding would be recovered for another purpose. PLoS journals charge an author fee, but much less than $3,000, because they have that subsidy.

An editorial in the new NEJM (which you can't read, ha ha ha) by Martin Frank disparages this idea, on the grounds that grant funds would be "diverted" to publication. "At a time of shrinking budgets for biomedical research, does it make sense to spend scarce dollars on publication costs instead of on research to develop treatments and cures for disease?"

I got three snappy answers for you Dr. Frank:

A) $3,000 out of a typical NIH grant of anywhere from $250,000 to $5 million and up is chicken feed;
B) Medical schools are already paying the cost by buying all those expensive subscriptions. They could divert that money to support for faculty research. Tah dah!
C) Open sharing of scientific information will speed scientific progress.

Oh yeah -- the NEJM doesn't need subscription or author fees - it makes millions of dollars in profits every year, by selling advertising. NEJM could go open access now, today. They can sell advertising on-line as easily as in print. Hell, they'd probably make even more money. Why don't they? Because the idea of privilege and exclusivity is even more important to them than money.

The End of Evil?

Tracy Hampton in the new JAMA (subscription only)* reports on a February conference called Resilience in Children, sponsored by the New York Academy of Sciences. She discusses work presented at the conference along with earlier published research, in particular work by Caspi and colleagues (relevant abstract here) which finds that of people who are maltreated as children, those who have a certain genotype that confers high levels of the enzyme Monoamine Oxidase A, which regulates the level of a neurotransmitter, were less likely to develop antisocial behavior. Other work by Caspi and colleagues has found an additional effect of a genotype affecting serotonin levels. (Hampton goes on to discuss similar research in animals which finds that variant genotypes can protect against the behavioral effects of deprivation of maternal nurturing. Such animal studies are suggestive, at best, about human social psychology, but do constitute a proof of principle, at least.)

Now, it is well known that mistreated children are at elevated risk of addiction, failure in school and work, criminality and even severe antisocial behavior. The criminal justice system may take a history of child abuse and neglect into account as a mitigating factor in sentencing, but not as an excuse for criminal behavior. And indeed, while it is usually present in the worst criminals, including most candidates for the death penalty, in the case of truly heinous crimes it seems to have little effect on juries.

The most important argument for why being mistreated as a child does not relieve one of moral responsibility for later crimes is that most people who are mistreated do not go on to depravity. But what if this too is just a roll of the dice, attributable to the random substitution of adenine for guanine in a single gene, or in any case some combination of genetic polymorphisms? Even without this knowledge, of course, thoughtful people have already recognized that there must be an additional element of luck involved, such as encountering a caring, effective adult at a crucial time.

There are also some sociopaths, such as Michael Ross (whose case I have discussed before) who do not have any known history of maltreatment. The gene variants that fail to protect abused children do not, apparently, cause any elevated risk of antisocial behavior for children who are well nurtured, but no doubt there are other explanations, in genes or environment, for the Michael Rosses and Ted Bundys of this world. Functionalist arguments can still be made that there is a social need for punishment, stigmatization and retribution, but a complete science of the mind renders these actions ethically suspect. In effect, everyone is innocent, and the commission of evil is merely a misfortune for the perpetrator as well as the victim. What then, is the morally defensible response to intolerable behavior?

* I will have more to say soon about open access publishing, and will link more to PLoS Medicine as well.

More apocalypse . . .

Just so you know we're fair and balanced, Eric Pianka believes that the probability of an emergent infectious disease (or perhaps more than one) causing a human population crash is substantial:

Some politicians, economists, and corporations want us to believe that technology will come to our rescue. But we have a false sense of security if we think that science can respond quickly enough to minimize threats from emerging diseases. Microbes have such short lifecycles that they can evolve exceedingly fast, much faster than we can respond to them. Many bacteria have evolved resistance to most antibiotics, and viruses are resistant to just about anything. Defense always lags behind offense. So far, modern humans have just been lucky. A reactive approach to problems isn't enough, we also need to be proactive and anticipate problems before they become too severe to keep them from getting out of control.

I'm still skeptical about that, but he does make the point that since the globe is far more crowded with human beings today than ever before, and since travel around the globe is possible in a few hours, a plague would not be limited to a single continent, as the Black Death was to Europe or the demographic disaster caused by smallpox was to the Americas. I will just reiterate what I have said here many times: we need to take the problem of antibiotic resistance very seriously, and we need to develop new vaccine manufacturing facilities based on cell culture techniques that can ramp up manufacturing of novel vaccines quickly and in large quantities.

And then, yes, we need to work to reduce the human population over time, by making contraception universally available and raising the status of women. We need to do whatever we can to reduce the use of fossil fuels, since global warming increases the dangers from infectious diseases. We need to build strong public health infrastructure around the world. We need to provide everyone with clean water. We need to change our methods of animal husbandry (and eat less meat while we're at it.) Whether an emerging infection kills 1%, or 10%, or 90% of the population, it won't be pleasant. Pianka isn't exactly wishing for it, as he has been unjustly accused. But he seems to see that 90% event as inevitable. Let's make sure he's wrong.

Kicking them while they're down

Around this time last year I mentioned that our friend here, Pharmy, from the Prescription Access Litigation Project's Bitter Pill Awards, would likely be paying us visits from time to time. So here he is again, to promote this year's awards. Stop by and make a nomination for most outrageous drug company advertising tactic!

We're also beating up on Big Pharma over at Critical Condition, in connection with another PAL campaign. So I might as well get in a few more knocks here. Those of you who pay attention to these issues are no doubt aware that drug prices are much higher in the United States than elsewhere -- hence all those criminal senior citizen smugglers taking bus trips to Canada and Mexico. Big Pharma, with strong endorsement from the current compassionately conservative administration, claims that they need the high prices to pay for research and development. Supposedly, people in those other countries where the pills are much cheaper are "free riders" on the miracles of Yankee innovation. The Commerce Department even called for other countries to raise their prices on patented medications. (Now that's compassionate!)

Is it any surprise that this is, er, not true? Donald Light and his colleague Joel Lexchin, in the British Medical Journal (abstract only available to the common folk) prove it. Actually, their desire to use the "L" word is almost palpable.

• Drug companies in countries with lower prices, such as the UK, invest a higher percentage of their revenues in R&D than do U.S. companies;
• Drug companies in lower price countries fully recover their R&D costs from sales and make high profits;
• Drug companies in lower price countries spend as high a percentage of GNP on drug R&D as does the U.S. (Specifically the U.S. is at about the median, investing .24%, compared with .55% in Switzerland and .35% in Sweden, for example.)
• European companies are just as innovative, proportionate to their share of the world market. The U.S. accounts for 48% of world pharmaceutical sales and discovered 45% of new drugs* that were introduced in 2003; Europe accounts for 28% of world sales and introduced 32% of new drugs.

Light and Lexchin go on to point out that drugs are sold in a global market, and it doesn't make any difference where the revenues come from, i.e. whether domestic revenues cover a company's R&D costs is irrelevant. Drug companies invest 3 times as much in marketing, advertising and administration as they do in research; if they really couldn't afford their R&D costs, they might look to cut funds there before they cut back on R&D. Furthermore, fixed costs such as research have little influence on prices; marginal costs are much more important, and the marginal costs of actually manufacturing drugs are almost trivial. The marginal costs that are important for the U.S. industry are marketing costs. As the authors conclude, "The pharmaceutical industry and the U.S. government want to blame other developed countries for these higher prices rather than make drugs more affordable."

* Meaning real new drugs, so-called "new molecular entities," not including reformulations of old drugs intended to maintain exclusive marketing rights.

Apocalypse please?

The Christian millenarian movement (those folks who expect to be raptured up to the heavenly kingdom while the rest of us have to deal with the tribulations and the reign of the Antichrist and the battle of Gog and Magog and what not) justly get a lot of attention, because they vote for Republicans and support insane policies like invading Iraq, expelling Palestinians, and stoning homoexuals to death. But there's a lot more of that end-of-the-world stuff going around. Or at least close-to-the-end-of-the-world stuff.

The survivalist movement of the 1990s is still a fresh memory. Supposedly computers wouldn't be able to tell the difference between the Year 2000 and 1900, and the result would be the collapse of civilization and the death of billions in famine, plague and war. Since I've started blogging, I occasionally get e-mails from people who have absolutely figured out that within a year or two there will be a global currency crisis that will destroy civilization resulting in the death of billions in famine, plague and war. (I can save myself and my family by hoarding silver, or joining their society which is going to issue its own currency, or heading to the hills and developing a self-sufficient lifestyle.)

The threat of emerging infections is real enough, but there are those who seem convinced that we aren't just talking about a disruptive event with a lot of sick people, economic losses and a spike in mortality, but the collapse of civilization resulting in the deaths of billions in famine, plague and war. Sometimes these fears are concatenated -- the flu pandemic brings about the currency crisis, leading to etc. etc.

One starts to suspect that, at least in the case of many people, these are expressions not of fears, but of wishes. Certainly that is true in the case of the Christian millenialists, but is the psychology of the secular apocalyptics similar? Do they yearn for a better world on the other side of the Great Dying?

Ecologist Eric Pianka of the University of Texas gave a speech at the Texas Academcy of Sciences in March in which he warned of plague that might kill billions. He was falsely accused by creationists and other nut cases of advocating this, and even of trying to manufcture pathogens. However, it does seem that Pianka thinks the world would be better off with something like 10% of the human population we have now.

Now personally, I don't think there is anything outrageous or immoral about having that opinion. The earth once had a much smaller human population, and perhaps it will again one day, and people on the whole might be happier in a world with fewer humans. It is perfectly logical and ethically defensible to like humans in the particular but to believe that humanity in the mass is a destructive force. However I do not think it is ethically defensible to want to get there by slaughtering vast numbers.

I don't know exactly what Pianka hopes for, I have never communicated with the man and published excerpts of his remarks don't make it entirely clear. This is not about him or his bizarre case. But it is about the phenomenon of actually hoping for some form of acpocalypse, either consciously or unconsciously. I think that a human population crash could result from nuclear war, although given the present distribution of nuclear weapons it would have to be a war between the U.S. and Russia, which is not at all likely. (That could change, some day.) A war between the U.S. and China could be nearly as horrific, but seems an extremely remote possibility. A regional nuclear war, involving such nuclear powers as Israel, Pakistan, or India, is more probable. It would be locally devastating and might have very severe economic consequences, particularly by eliminating much of the supply of petroleum. But a global depression will not cause the human population to crash. After all, we had one in the 1930s, followed by the most terrible war in history, and the population just kept growing.

Similarly, even the worst infectious disease outbreak that is in any way plausible would not cause a human population crash. The 1worst flu pandemic in known history, in 1918, caused a transient spike in mortality but scarcely interrupted the upward curve of human population. The Black Death, the most destrutive known plague of any kind, killed perhaps 1/3 of the population of Europe over a generation or so, but that was before people understood pathogenicity. We have the knowledge today to far more effectively control such an event, even in the case of a novel pathogen for which we lack a vaccine or a pharmacological treatment.

So it seems to me that predictions of apocalypse are either paranoia, or wishful thinking, and I'm inclined to believe that the latter is more prevalent. A decline in the human population is desirable, in my view, but we are very unlikely to get there by a massive spike in the death rate, and we certainly should not wish for that. A long-term decline in the birth rate will get us there, although there are certainly great difficulties to be overcome from the epoch of radically aging population through which we would have to pass. That is a surmountable challenge, though, and we ought to be thinking about how to take it on.

And for all the wishful thinkers out there, if civilization does collapse and 90% of the people die, you should not expect to see the utopia on the other side -- even if you do stockpile a year's worth of biscuits.

Don't wait up for me . . .

I will probably be away from Your Internets for a couple of days while I do some construction work and study up for my Jeopardy! audition (seriously -- I'm going to be memorizing all the presidents, state capitals, and Foods that Begin with the Letter Q).

Meanwhile, my friends have asked me to be constructive and positive about the new Massachusetts health care legislation. Okay. The deal is, what happens from here, over the next couple of years, is what really matters. This is the beginning, and we're starting on the top of a very steep ridge. We could fall off to either side. It's because he hopes we'll fall to the wrong side that the Republican governor and candidate for president supported the bill. It's because they hope we'll fall off to the right side (which I suppose would be the left side) that Health Care for All, unions and other progressive organizations supported it.

The wrong side is that there isn't enough money to make the subsidized plan for low income people really affordable, and the "affordable" plan for moderate income people is crappy insurance that still isn't affordable; while employers continue to bail out of providing decent insurance because they can dump people onto the subsidized and "affordable" plans for only $295 a year. Most people end up with high-deductible insurance that they are forced to buy, that doesn't cover their routine and preventive care, for which they now pay out of pocket. Poor people are forced to buy insurance they can't afford, and the political pressure forces the legislature to make that insurance worse and worse -- less comprehensive, with higher cost sharing. Massachusetts enters the Cato Foundation utopia.

The right side is that the subsidized plan really is affordable and comprehensive. Because a much higher percentage of the population is in the public insurance pool, the state gets a real handle on health care costs, by gaining the leverage it needs over hospitals while promoting good quality care and giving people at risk the prevention and early intervention services that will really save money in the long run. At some point, the legislature raises the $295 assessment on employers that don't provide insurance and turns it into a payroll tax with an exemption for the first $10,000 or so in pay per employee, so that it is both progressive (instead of the regressive job tax we have now) and provides enough incentive that employers won't stop providing insurance. Eligibility for the public plan is extended, so that moderate income people can buy in at full price instead of buying the crappy "affordable plan," and the public plan is affordable for them because it has buying power and can effectively control costs while maintaining quality care. We start to move toward where we really want to go.

Can that work in a single state? Therein lies a real and possibily insurmountable problem. More on that later.

Boooooooooorrrrrrinnnnnng . . . .

Yup, I'm talking about insurance. Hartford, once the "Insurance Capital of North America," was not so much celebrated as mocked for that distinction. "America's file cabinet" was one popular epithet.

It's painful I know but I'm going to press on. As you will recall, in our last episode, we discussed Fred's Insurance Company and his problem with people buying life insurance because they figured they were about to shuffle off this mortal coil, whereas people who figured they had plenty of time left to make their fortune and write their novel weren't likely to pony up. That is called adverse selection -- people who really need the insurance are more likely to buy it, which is not good for John Hancock's profits.

As a commenter pointed out, another problem that Fred has is called Moral Hazard. Basically, if you know you have fire insurance, you might not be as diligent about fire protection. You might not be as inclined to buy fire extinguishers, to clear the brush from around your house, to make sure your chimney is cleaned, etc. Of course you have other incentives not to let your house burn down -- danger to life and limb, loss of articles of sentimental value, major inconvenience. But on the other hand, if your house is old and crummy, or you can't pay the mortgage, you might be tempted to set a fire -- the ultimate form of moral hazard. Most people with life insurance won't be more likely to die because they have it, but people who are desperate about being unable to provide for their families might -- as in Death of a Salesman.

Note that we still haven't said anything about health insurance. As I said before, health insurance isn't actually insurance, at least not if that term is supposed to refer to the kind of product we have been discussing. Unfortunately, a lot of supposedly smart people, including the denizens of conservative think tanks and the Republicans in the executive branch and the Congress, are confused because health insurance and fire insurance have the same last name. They know all about the moral hazard problem, so they think it must be a big problem with health insurance. Therefore, they want us to have high deductibles in our health insurance policies so that health insurance companies won't be subject to moral hazard.

What's wrong with this picture? Tune in next time, when we actually begin to discuss health insurance.

WaPo Bombshell is old news

The "bombshell" in today's Washington Post, showing that U.S. intelligence had known since May 2003 that the "mobile biological weapons labs" in Iraq were just hydrogen generators for filling weather balloons was reported in the United Kingdon in June, 2003. Here's the story from The Guardian.

Iraqi mobile labs nothing to do with germ warfare, report finds

Peter Beaumont, Antony Barnett and Gaby Hinsliff
Sunday June 15, 2003
The Observer

An official British investigation into two trailers found in northern Iraq has concluded they are not mobile germ warfare labs, as was claimed by Tony Blair and President George Bush, but were for the production of hydrogen to fill artillery balloons, as the Iraqis have continued to insist.

The conclusion by biological weapons experts working for the British Government is an embarrassment for the Prime Minister, who has claimed that the discovery of the labs proved that Iraq retained weapons of mass destruction and justified the case for going to war against Saddam Hussein.

Instead, a British scientist and biological weapons expert, who has examined the trailers in Iraq, told The Observer last week: 'They are not mobile germ warfare laboratories. You could not use them for making biological weapons. They do not even look like them. They are exactly what the Iraqis said they were - facilities for the production of hydrogen gas to fill balloons.'

The conclusion of the investigation ordered by the British Government - and revealed by The Observer last week - is hugely embarrassing for Blair, who had used the discovery of the alleged mobile labs as part of his efforts to silence criticism over the failure of Britain and the US to find any weapons of mass destruction since the invasion of Iraq.

The row is expected to be re-ignited this week with Robin Cook and Clare Short, the two Cabinet Ministers who resigned over the war, both due to give evidence to a House of Commons inquiry into whether intelligence was manipulated in the run-up to the war. It will be the first time that both have been grilled by their peers on the Foreign Affairs Select Committee over what the Cabinet was told in the run-up to the war.

The curtain of censorship over North America at the time, however, meant that we never heard about it here. (I screamed and yelled about this at the time, wrote letters to the editor, etc. Got nowhere, of course.)

An absolutely literal post

requiring no sense of humor to understand.



This graph, which I have posted here before, shows trends in life expectancy at birth in the U.S. for white and Black men and women. (Other groups are not shown because of lack of adequate historical data, and the complicating effects of immigration.) As you can see, women live longer than men, and white people live longer than black people. By coincidence, the effects cancel out so that white men and black women have about the same life expectancy. (Life expectancy is an artificial construct based on the idea that everybody born today will have the same probability of dying when they are 1, 5, 10, 15 . . . 80 years old as people in their demographic category do today.) Although life expectancy overall has been increasing, the disparities have remained.

The greater longevity of women holds throughout the wealthy countries. It didn't used to be true, in large part because of the risk of dying during childbirth. Fortunately, in the 1850s, Ignaz Semmelweis discovered that by having birth attendants carefully wash their hands and instruments, the risk of women contracting fatal post-partum fevers could be nearly eliminated. He was scorned at first, but eventually his ideas were accepted. Subsequently, medical technology greatly reduced the risk from other complications of childbirth as well, notably pre-eclampsia and hemmorhage.

Female longevity is thought to be a basic characteristic of our species. The shorter male life expectancy is partly caused by higher rates of smoking, and a far greater risk of death by violence. However, even accounting for known, controllable factors, the relative fragility of the male remains.

In much of the world, however, until recently women did not expect to live as long as men. The continuing danger of maternal death among poor women in poor countries explains much of the phenomenon. In much of Asia selective female infanticide was of major importance. Also, in times of scarcity, again particularly in Asia, boy children would tend to be favored. Given the presumed biological advantage of women, that women now at least equal male life expectancy in all the world does not mean they do not continue to suffer from discrimination, so it is actually a somewhat meaningless milestone, but there it is.

The UN, among its other millenium development recommendation, proposes some readily affordable ways to make childbirth safer, and to raise the status of women generally, which is essential to eradicating poverty.

Still, I presume most people will agree that it is not good news that men are doomed to be outlived by their female friends. Perhaps it isn't really true after all, and there is something we are missing about male aging. The tendency of men to develop heart disease earlier than women is a major factor, and that may well be preventable. The important thing, in any case, is not to try to live forever, but to have a good life and enough life span to achieve what matters to us.

Call me an old grump . . .

. . .but for some reason I'm just not joining this celebration as enthusiastically as I should.

According to Anna Barford and colleagues, editorializing in the April 8 BMJ, "The year 2006 should not be allowed to pass without at least a quiet celebration that this is the first year in human history when -- across almost all the world -- women can expect to enjoy a longer life expectancy than men. . . . Almost 30 years ago, amid much fanfare, the eradication of smallpox was announced. But when it becomes certain that women everywhere can expect to live longer than men, also a remarkable achievement, a similar announcement is unlikely."

I dunno, I can't quite put my finger on it, but it seems to me there's bad news in there somewhere . . .

The Immigration Wars . . .

What's going on right now -- a campaign driven largely by bigotry to purge the country of "illegals" -- those people who according to CNN anchor Jack Cafferty "are becoming ever bolder. March through our streets and demand your rights. Excuse me? You have no rights here, and that includes the right to tie up our towns and cities and block our streets. At some point this could all turn very violent as Americans become fed up with the failure of their government to address the most pressing domestic issue of our time."

It is never clearly stated how these people are supposed to be harming the United States, just that they are "criminals" and guilty of "bad behavior" for being in the country illegally. Of course, their criminal bad behavior is motivated by a reprehensible desire to feed their children.

We've been through this before, again and again. The last time was in 1996. A very good friend of mine wrote about it back then. I couldn't have said it better myself.

The full dimensions of the crime

will never truly be known. We won't necessarily hear from our TV news about the full toll of assassinations, car bombings, roadside bombings, firefights, drive-by shootings, massacres, mortar strikes and air strikes in Iraq every day, but there are news outlets that do their best to keep track of these. (As usual, I have to tout Today in Iraq, but there are other places you can go as well, including the excellent Reuters AlertNet Foundation). However, death by violence doesn't begin to tell the story of the carnage and suffering in Iraq.

We are often told that the problems are exclusively in the Baghdad region and the so-called Sunni triangle in the middle of the country, with the Shiite south, along with Kurdistan, being peaceful and enjoying all that "progress" -- newly painted schools, re-sodded soccer fields, and so forth. But now representatives of the European agency Saving Children from War have visited the southern city of Basra and found the following:

As a result of water-borne diseases and a lack of medical supplies, infants born in the southern city of Basra are subject to abnormally high mortality rates, say officials of an international NGO devoted to child health issues.

"For weeks, there were no I.V. fluids available in the hospitals of Basra," said Marie Fernandez, spokeswoman for European aid agency Saving Children from War. "As a consequence, many children, mainly under five-years old, died after suffering from extreme cases of diarrhoea."

Fernandez went on to cite a number of problems facing local hospitals in Basra, which is located some 550km south of the capital, Baghdad. "Hospitals have no ventilators to help prematurely-born babies breathe," Fernandez said. "And there are very few nurses available, so hospitals often must allow family members to care for patients."

Many doctors in the area say that the local health situation has deteriorated markedly since the US-led invasion of the country in 2003. "The mortality of children in Basra has increased by nearly 30 percent compared to the Saddam Hussein era," Dr Haydar Salah, a paediatrician at the Basra Children's Hospital, pointed out. "Children are dying daily, and no one is doing anything to help them."

Fernandez added that, for the last three years, the Maternity and Children's' hospital in Basra had not received any cancer drugs from the health ministry. "In all of Basra, a city with nearly two million inhabitants, there's no radiotherapy department available," Fernandez complained.

Khalid Ala'a, spokesman for local NGO Keeping Children Alive, said that Basra hospitals lacked many essential drugs and antibiotics used to treat infections common to the area. "We've asked for help from the Ministry of Health, but they only tell us they don't have money to supply hospitals," Ala'a said. "They tell us we must wait for investment, which could take months."

Iraq, which once had a highly advanced public health and medical system, and population health status and life expectancy commensurate with the developed European states, is now in a condition comparable to the most impoverished parts of rural Africa. Weapons of mass destruction, anyone?

It's hard work

If the long and winding tale of the recent Massachusetts health care legislation teaches us anything, it's that most people basically don't understand what exactly the heck is going on here -- and that includes state legislators and even quite a few activists who have been pushing for something vaguely defined as universal health care or universal coverage. It's always my goal here to provide the entoxicatingly delicious bite-sized chunk of wisdom that will produce immediate enlightenment about the pressing issues of the day, but when it comes to health care policy, I just can't do it. It's complicated, the standard vocabulary is misleading, a lot of different parts have to be fitted together to make sense of it all, and it's just wonkish, and boring, and it makes your head hurt, and that's all there is to it, so there.

So I've decided to take this in pieces. First I'm going to talk about insurance that isn't health insurance. The product or service we call health insurance is only partly insurance, and to the extent that it is insurance, it is unlike other insurance in very important ways. But the mere fact that we call it insurance muddles things up. So for now, let's not even talk about it. Let's talk about automobile insurance, homeowner's insurance, and life insurance.

Insurance, in the original and still most common sense of the term, is a financial instrument for spreading risk. Most people would have their lives utterly ruined if their house were to burn down, but fortunately, only a few people's houses ever do burn down. A lot of people will willingly pay a sum they can afford -- these days typically less than 1,000 dollars a year -- for the peace of mind of knowing that if their kid plays with matches and their little Blandings Castle burns down to the root cellar, they'll be given the money to rebuild. If people have a mortgage, the bank will insist that they have insurance, because they want their collateral protected. Life insurance and automobile insurance are basically similar -- they compensate you or your heirs for an unwelcome eventuality.

Liability insurance has this function, plus one more -- it protects others who might be injured by your negligence. Therefore it is also required in some circumstances, for example in order to legally operate an automobile.

Okay then. Let us suppose that Europeans land for the first time on an island in estuary of the Hudson River, kick out the local oyster gatherers, and build a city of 8 million people. Suddenly, in 2006, Fred invents life insurance, and Fred's Insurance Company enters the virgin market. Now, Fred could figure out the percentage of adults in Manhattan who die every year -- let's say it's 1% -- and sell a $100,000 life insurance policy for $1,001 dollars a year. (We'll ignore the income he makes on the money he holds on to before he has to pay out claims -- that's important to Fred but it doesn't really matter to our point.) If he sells 100 policies, he collects $100,100, and at the end of the year he makes one $100,000 payout. He's made a hundred bucks, just for sitting on his keister signing deposit slips and writing one check. Of course, he could be unlucky and have two people die that year, or be lucky and have nobody die, so he evens it out by selling many hundreds of policies and doing it for many years -- it should work out in the long run, right?

Nope. If Fred tried that, he'd be very sorry, because a whole lot of people with terminal cancer would have bought his policies, while all those twenty-somethings jogging in the park would never even consider it. If Fred wants to make money, he's got to try to figure out the individual customer's chances of kicking the bucket in the near future, and then by some combination of differential pricing and selective sales get enough people to buy policies and not die to pay him for the customers who expire.

But wait a minute -- I thought the purpose of insurance was to spread risk. Now you're charging more to the risky people, or refusing to sell to them at all. In fact, if Fred can do a very good job of predicting your life expectancy, his product will become worthless. If he knows you are going to die in exactly 3 years, 4 months, he'll charge you exactly enough to cover the cost of the payout at that time in the future, plus his expenses and his profit, minus whatever investment income he expects to make on your premiums. Your heirs would be better off if you just invested the money yourself and didn't pay Fred.

Now, the insurance industry can't precisely predict your life expectancy, but in order to compete with each other, insurers need to do the best they can. If you are young and healthy, you're going to look for a company that will sell you cheap insurance. If you know you are sick, the insurance companies better be on the lookout for you or you'll take them for everything they've got. So insurance companies need to be able to sell cheaply to low risk customers and charge more to high risk customers, or their competition will get all the desirable sales and they'll lose their shirts.

So it's fortunate for the insurance industry that they can't precisely predict people's life expectancies, or they'd put themselves out of business because their product would become worthless. At the same time, they continue to work as hard as they can at predicting individual risk in order to keep up with the competition.

This is one reason why insurance markets are highly regulated. In order to accomplish some of the social purposes of insurance, insurance companies have to be restricted from segmenting their customers as thoroughly as they can -- and actually, insurance companies appreciate those restrictions, even if they won't admit it, because their business would be much more difficult without them. It would be impossible to buy affordable homeowner's or automobile insurance in some neighborhoods, for example, if states didn't force insurers to put customers into relatively broad pools. This does have the effect, however, of making people in relatively safe neighborhoods subsidize the insurance costs of people in dangerous ones.

Sorry to bore you. Now you can entertain yourself by thinking about ways in which health insurance is similar, and different, while I prepare to discuss that very subject.

The memory hole.

No doubt you will recall April 9, 2003, when the television newscasts all led off with film of a crowd of jubilant Iraqis pulling down a statue of Saddam Hussein, with the help of U.S. Marines. The front pages of all the newspapers had a shot of the joyous scene the next day, so reminiscent of the statues falling in the former Soviet Union, and the crowds hammering away at the Berlin Wall. Iraq had been liberated and was greeting the triumphant Marines as heroes!

Sadly, no.

Army report confirms Psy-ops staged Saddam statue toppling
by Jon Elmer

July 3, 2004 – An internal Army study of the war in Iraq has confirmed that the infamous toppling of the statue of Saddam Hussein in Firdos Square in central Baghdad on April 9, 2003 was stage-managed by American troops and not a spontaneous reaction by Iraqis. According to the study, a Marine colonel first decided to topple the statue, and an Army psychological operations unit turned the event into a propaganda moment.

At one point during the stunt Marines draped the statue of Saddam Hussein with an American flag. When the crowd reacted negatively to that gesture, the US flag was replaced with a pre-1990 Iraqi flag, missing the words "God is Great," by a sergeant from the psychological operations unit. The Marines brought in cheering Iraqi children in order to make the scene appear authentic, the study said.

Allegations that the event was staged were made in April of last year, mostly by opponents of the war, but were ignored or ridiculed by the US government and most visible media outlets.

So, what do we read today, on the third anniversary of this phony event?

By VANESSA ARRINGTON
The Associated Press

Iraq police and soldiers bolstered security in the capital to prevent attacks on "Freedom Day." The holiday marks the April 9, 2003 event in which a huge crowd of Iraqis cheered as U.S. Marines hauled down the statue of Saddam Hussein on Firdous Square, marking the collapse of his regime.

Don't believe anything you read in the newspapers, and TV news lies.

And the walls come a tumblin' down

Bill Blakemore at ABC News notes that the corporate media have finally gotten around to teling us that, yes, global warming is real, it's caused by humans, and it's a big problem. He notes that this same corporate media has spent the last couple of decades telling us that the whole subject was controversial and did not represent a scientific consensus, because they were happily bamboozled by a disinformation campaign run by the oil companies. And oh yeah, GW Bush and the administration were co-bamboozlers.

Major corporate media reported on the discovery of the fossil of a transitional creature between fish and amphibians, and just flat out said that it was over 300 million years old and enhanced our understanding of the evolution of tetrapods. Yeah, they featured rebuttals from creationists, which is kind of like giving equal time to the flat earth society every time there's a satellite launch, but they made it pretty clear who was full of oats processed through a horse on this one.

We've had plenty of coverage of regulatory agencies failing to protect the public because they are beholden to industry -- the EPA in the case of arsenic and mercury, the Nuclear Regulatory Commission in the case of nuclear power plant security being two recent examples.

Career civil servants in the Department of Justice are ripping the K Street project to shreds along with the Republican one-party state, and reporters are actually covering the story, so Gonzales can't do anything about it, at least he hasn't so far, as far as we can tell.

Poor Scottie is getting the crap beat out of him every day over illegal surveillance and lying about it, those historic lies about the imminent threat from Saddam's Iraq, the manipulative leaks of classified information, and all that sordid stuff.

A good part of the talking headocracy, for reasons which are not entirely clear, continues to serve as the Office of the Imperial Panegyrist, and editors still don't want us to really understand what is happening in Iraq, but one gets the impression that reporters at least, as a class, are actually starting to do their jobs. Why now, and not last year, and especially why not in 2004? Who knows. It's too little, too late, but we'll take it.

The Good News

The corporate media aren't telling you the good news out of Iraq, which is that it is still possible to get accurate information about what's going on there even though they don't want to tell you about it.

That's not to say it's a secret -- AP, Reuters, AFP and independent journalists continue to do their best to provide a window into daily events in that most unhappy of countries, and Arab media in English are available over the Internet as well. But the TV news has stopped transmitting most of it, and for that matter so have many newspapers, at least the ones I read. The Boston Globe, in particular, has decided to stop reporting news from Iraq almost entirely, including the deaths of U.S. troops.

So, please read Dancewater's post today at Today in Iraq. It's painful, terrifying, discouraging -- definitely wouldn't be good for ratings to actually tell people all of this. Who wants to hear that? It's much more inspiring to listen to the president vowing to win total victory. We have to do that, after all, because we are good.

I'll have a post here on another subject later today.

Ju Jitsu?

Universal "coverage" -- however defined -- is not the only issue in health care policy. It's essential to meaningful reform, but there are ways to do it that just make matters worse. The conservative movement, led by the White House, wants to force everybody to buy really crappy health insurance that doesn't pay for basic and preventive care, but only kicks in if you have catastrophic expenses. We would have to pay for ordinary services out of pocket, which is supposed to make us "owners" of our own health care. There are tax breaks which make it even easier for rich people to afford, and don't do much for the rest of us. This system leaves the private insurance industry in control of our money, skimming off their 25% or so, and does nothing to control costs or bring rationality to the allocation of resources. On the contrary, it encourages people to skip preventive care and subsidizes expensive interventions after people have become seriously ill.

The day after celebrating their great victory in getting what is touted as nearly universal coverage passed in Massachusetts, progressive forces are waking up with a nasty hangover and a sneaking fear that they've been taken advantage of. Here's what crusading docs Steffie and Dave have to say. Excerpt:

The legislation promises that the uninsured will be offered comprehensive, affordable private health plans. But that’s like promising chocolate chip cookies with no fat, sugar or calories. The only way to get cheaper plans is to strip down the coverage – boost copayments, deductibles, uncovered services etc. Hence, the requirement that most of the uninsured purchase coverage will either require them to pay money they don’t have, or buy nearly worthless stripped down policies that represent coverage in name only.

Third, the legislation will do nothing to contain the skyrocketing costs of care in Massachusetts – already the highest in the world. Indeed, it gives new infusions of cash to hospitals and private insurers. Predictably, rising costs will force more and more employers to drop coverage, while state coffers will be drained by the continuing cost increases in Medicaid. Moreover, when the next recession hits, tax revenues will fall just as a flood of newly unemployed people join the Medicaid program or apply for the insurance subsidies promised in the reform legislation. The program is simply not sustainable over the long – or even medium – term.

It appears they may have a point. Liz Kowalczyk of the Boston Codfish Wrapper finds out that the premium that families above 300% of poverty (that's about $50,000 a year for a family of three) will have to pay will be around $700 a month, and that won't cover prescription drugs and will have over a $1,000 a year deductible. Meanwhile, there just isn't enough money in the legislation to begin to provide an adequate subsidy for poorer people, and how much they will have to pay to buy into the state-subsidized plan that's supposed to be available for them is still unknown.

Worst of all, there is no reason to think this will encourage more employers to cover their employees. Au contraire, as far as I can tell, if they're paying workers less than $50,000 a year -- which is where the vast majority of uninsured people are already -- they'll have less incentive than ever to offer coverage. The state is promising to subsidize coverage for those folks, so why not dump them? $295 a year is all they'll have to pay, much cheaper than health insurance. It wouldn't be bad in principle for more of the population to be in the state-sponsored plan, but it's bad if you haven't taken care of the financing, which they haven't. The only way to pay for it now is to make people pay most of the cost out of pocket, in other words it's regressive.

In fact, people near the 300% of poverty limit would presumably have to pay nearly full price for the state-sponsored plan, and they won't be able to afford it. In order to avoid a huge fine, they'll have to buy the crappy "affordable" plan that won't pay for their routine care or prescription drugs. Depending on how much money the state can come up with, there's no telling how far down the income scale this will go. If more and more employers drop coverage, and costs keep rising, maybe right down toward the bottom. Sure, we could solve the problem in a trice by raising the income tax, but is that going to happen?

In case anyone has any doubts, the conservative Republican governor Mitt Romney is planning to run on this accomplishment in the Republican presidential primaries. The Heritage Foundation helped write the bill.

I sure hope I'm wrong but we may just have sent our bank account information to a deposed Nigerian prince.

I have good news . . .

and, of course, worse news. The National Association of Attorneys General has just announced that cigarette consumption in the U.S. has hit a 50 year low -- 378 billion sold in 2005, the fewest since 1951 -- although the population has doubled. Credit goes to the Master Settlement Agreement the states reached with the tobacco companies, which restricted tobacco marketing. Since then, state and local restrictions on smoking in public places and workplaces have also helped reduce consumption and help and encourage people to quit.

Smoking just isn't cool any more in the U.S. With pluck and luck, we'll keep driving it down.

Now the bad news. The tobacco companies are doing just fine. In fact, they're doing more than fine. In the words of Dave Wilcox, the young tobacco merchants are still Climbing up the Rungs, by selling you a parasite that's feeding on your lungs. How can this be?

Worldwide, tobacco sales are going up and up and up. According to the World Health Organization, the merchants of death sold 5.5 trillion cigarettes last year. Take a look at the World Tobacco Atlas (pdf), and you will see the hot spots. Asia is where the people are, and not surprisingly, that's where the pushers are. 1/3 of all the cigarettes smoked in the world are now smoked in China.

So, hold on to your Philip Morris --whoops, I mean Altria -- stock, the company which proudly proclaims that "The Philip Morris name has long been associated with high quality tobacco products and globally recognized cigarette brands. Today the name is proudly carried by the leading cigarette manufacturer in the United States, Philip Morris USA, and by Philip Morris International, the world's leading international cigarette business with products sold in 160 countries worldwide."

I think they should try to find something else to be proud of, personally.

Doing My Duty

Like it or not, I am obliged by the insatiable lust of my adoring public to say something about the massive health care reform bill that just passed here in the People's Republic of Massachusetts. The conservative Republican governor is expected to sign it, although he may veto certain line items. If he does, he will no doubt be overriden, so this thing is going to happen.

Now, I'm supposed to be for it, because all my friends were for it - the folks at Health Care for All leading the way. What gives me pause, however, is that a lot of my not so much friends were also for it - including the Gov, the Mass Medical Association (wearing its enrich the doctors hat), the hospital lobby (which spent a fortune lobbying on the bill) and a good chunk of the business "community."

The bill is 145 pages long. I just printed it out but I haven't had time to read it. Based on information from the State House News, the basic ideas are:

• Employers who do not provide health insurance to their workers will be assessed a "fee" of $295/year. This is okay with the Governor because it's not a "tax." Whatever.
• Doctors and physicians get $45 million a year in rate hikes from Medicaid.
• The state will set up an insurance program called Commonwealth Health Care Insurance, that will offer subsidized premiums on a sliding scale for people up to 300% of the federal poverty level. Exactly what the premium and the amount of the subsidies will be apparently remains to be determined by the available funds.
• Everybody else who does not have insurance will be required to purchase it on the open market, so long as an "affordable" plan is available. What constitutes "affordable" will be determined by regulators. People who don't comply will lose their personal income tax exemption and be charged 1/2 the price of the "affordable" product. (What happens when they are hit by a bus is unclear.)
• Based on the assumption that there will be much less need for funds from the so-called "Uncompensated Care Pool," it will be drained to pay for the other stuff.

There are various other goodies in there -- removal of enrollment caps on Medicaid products, increased funding for public health programs, a requirement that hospitals collect data by race and ethnicity and address disparities. One item that some people think is a goodie but is more dubious in my view is a requirement that hospitals post "quality" data on the web. This is supposed to encourage consumers to shop around for the best "quality" care.

Okay, this is supposed to result in maybe 95% of citizens of the People's Republic having health insurance by 2008 or 2009 or some such date. Here are some reservations, problems, and questions to which I need answers:

• The employer tax is the most regressive possible kind of tax. It's a tax on jobs, which is even worse than a payroll tax. (It costs the same for a minimum wage worker as it does for an investment banker.) That only comes out of one place -- wages.
• Once the "affordable" product is out there, what's to stop employers from dropping health insurance for their employees? $295/year is still a lot cheaper than paying for insurance.
• How much will poor people have to pay for the Commonwealth Health Care product? Will they be able to afford it, or will it come out of rent and groceries? What will the benefits be? Evidently it can't have a deductible, but can it have co-pays?

Then there's that individual mandate. I can't really explain why it worries me so much without doing a lengthy lecture on the economics of health care and insurance markets, but here are a few points which may or may not make sense to you depending on what you already know.

• An individual mandate drives further fragmentation of the market and encourages insurers to selectively market to young and healthy people and force older and sicker people to pay more. Whether state regulations will prevent this is unclear.
• Think of Medicare Part D -- people are going to have to choose among a bewildering array of options and try to figure out which product is going to be best for them based on what might happen to them in the future.
• These plans will have high deductibles, which will discourage people from getting basic primary and preventive care, and force people who don't have medical educations to try to figure out what medical services to buy or not buy.
• The insurers will try to craft policies to encourage more desirable consumers to enroll. People who have greater medical needs may have great difficulty finding an "affordable" product.
• The mandate is regressive, forcing everybody to pay the same flat rate based on their age, the industry they work in, and other factors considered by actuaries, without regard to their ability to pay.
• The individual mandate will legitimize employers who drop coverage for their workers.
• The mandate will only increase the percentage of health care spending that goes to administrative costs and marketing, instead of health care.
• What's to stop insurers from offering a relatively affordable and decent quality plan now, and then just jacking up the price and cutting the benefits next year? State regulators will be at their mercy because they can always pull out entirely.

Now, I'm going to miss the American Idol results show tonight in order to read the damn bill. In the meantime, maybe somebody out there can answer some of my questions or allay some of my concerns. But I still have the fear that in an effort to satisfy powerful constituencies, the advocates for reform have given away the store. We'll see.

Opportunity Cost

I have been asked to find out how much the U.S. has spent on pandemic flu preparedness, presumably at the expense of other public health priorities. The answer is -- less than nothing. The information I am about to provide comes to me by way of a FOIAA request I made to the Massachusetts Department of Public Health last December. (Sorry, I've been meaning to get around to posting on this.)

There isn't much in the way of a pandemic flu program per se; rather, states are expected to make preparations using two main sources of federal money, the U.S. Health Resources and Services Administration's National Bioterrorism Hospital Preparedness Program (HRSA-NBHPP) and the U.S. Centers for Disease Control and Prevention (CDC) Public Health Preparedness and Response for Bioterrorism Cooperative Agreement.

The word "bioterrorism" in the names of these programs comes from the days when the Bush administration assumed that bioterrorism was the only infectious disease threat facing the country. In Federal Fiscal Year 2004, when they first noticed the possibility of a naturally caused epidemic, the definition of the kinds of emergencies states were supposed to prepare for using these funds was broadened. Hence the CDC program is now called Cooperative Agreement for Public Health Emergency Preparedness, and the HRSA program's mission statement is "is to prepare hospitals and supporting healthcare systems, in collaboration with other partners, to deliver coordinated and effective care to victims of terrorism and other public health emergencies." [emphasis added.]

So, what happened when pandemic flu was added to the scope of these programs? The funds were cut, rather drastically. The HRSA program peaked in FY 2004, and funding declined slightly in FY 2005. I only have the figures for Massachusetts -- $10,686,180 in FY 2004, $10,256,868 in FY 2005 -- but you can find out about your own state's funding if you like at the HRSA web site. The CDC program really got wacked -- Massachusetts' funding in CDC budget year 8/31/03-8/31/04 was $21,141,965. Since then, it's been less than $18 million. The states use part of this funding to support preparedness by local health departments, and that's how the federal money trickles down to the local level. Obviously, that pass-through funding also peaked in 2004 and has been much less since then.

So, those of you out there who are worried about how the fear mongers have stolen billions for more important public health priorities can relax -- although that's not what I'm doing.

Epidemic of fear?

Luc Bonneux and Wim Van Damme, in the new BMJ (off limits to commoners) offer a commentary entitled "An iatrogenic pandemic of panic." They mean to suggest that public health authorities have created such a pandemic by warning the public about the dangers of an influenza pandemic potentially arising from the current zoonotic of H5N1 avian flu. This parallels the dust-up which has been going on at Effect Measure between the proprietors and popular medical writer Marc Siegel, who in most public forums* seems to make approximately the same argument.

I have largely steered clear of this whole bird flu flapdoodle because others are on the case and my social science perspective hasn't really been what is at stake - at least until now. But I feel I should come out and let people know what I think about all this.

First of all, when Bonneux, Van Damme and Siegel actually try elucidate the nature of this devastating mass panic, it doesn't seem to amount to a whole lot. The sole definable ill effect seems to be that a few people are conniving to obtain oseltamivir (Tamiflu) to keep in the medicine cabinet against a rainy day, and the US and UK governments, and some other wealthy countries, are buying up modest stockpiles. There has also been a decline in poultry consumption in some places. It is true that both of these responses are probably inappropriate, however I'm not sure that it is reasonable to label them as "panic." Nobody can point to mobs rioting in the streets to get their allocation of Tamiflu, or terrified masses collapsing with palpitations at the sight of a chicken.

Another rather vague complaint is that pandemic flu preparation diverts resources from other public health problems such as HIV, malaria, waterborne diseases etc. which are already here. I must say there isn't any evident basis for this complaint - it's not as though there was any identifable money in the pipeline to address those problems which has been diverted to pandemic flu preparation. Most of the preparation that is happening -- which is very little indeed -- is essentially generic emergency preparedness which will be equally applicable to any widespread infectious disease emergency, and it is hard to see why anyone objects to that. There is a modestly funded program in vaccine research for H5N1 flu -- so far not very fruitful -- but that hardly seems objectionable either.

Now, just FYI, hording Tamiflu is dumb because a) it doesn't work very well, it only shortens the course of ordinary flu by one day; b) there isn't enough of it in the world to make much of an impact on a pandemic; and c) if there is a pandemic, and lots of people use tamiflu, there's a good chance that resistant strains of the virus will quickly emerge anyway. Also, hording results in misallocation. Rich people in rich countries get it, whereas if it's useful at all its in protecting frontline health workers to some extent so they get back on the job faster, which is really just to say, somebody else ought to be hording it in different places, for different purposes.

In the end, what people are really disagreeing about, when they pretend to be having some ill-defined ideological battle, is the actual probability of a major flu pandemic in the near future. Here, I'm not exactly an expert, but I'm pretty sure this is the correct answer: it is meaningless to try to assign a probability to this. It's a qualitative judgment.

We're still in the process of learning about the evolution of influenza viruses and the characteristics that make for easy human transmission and virulence. Based on what we know now, the virus that's circulating in birds right now has the kinds of characteristics that could lead to a 1918-type event. Such an event, in the modern world which has many times more dense centers of population, which are much larger; which has far more extensive and rapid networks of international commerce and travel; which has a far more complex and densely connected global economy; and which has a fragile international order; could be a big problem, cost a lot of money, cause a lot of disruption. It would be irresponsible not to imagine such a possibility and try to prepare for it. Nobody can say "there's a 64.3% chance it will happen before September 1, 2008," or "There is less than a 19.5% chance." Nobody knows. But it very well might happen and it would be foolish to pretend otherwise.

Now, people may well exploit fears and various scenarios, likely or unlikely, for ill purposes. For example, Mr. Bush's first reaction, on learning of the possibility of pandemic flu, was to talk about making preparations for mass quarantine and martial law. But that's because he's a malignant clown, it's not reflection on the virologists who drew attention to the possibility of a pandemic. The Emperor Chimpoleon has exploited other fears for malevolent purposes as well, but that doesn't mean that anybody who talks about proliferation of dangerous weapons is being irresponsible. Scientists and public health authorities who work in this area have a duty to inform the public of their findings and concerns, honestly and directly. Other people in authority, and the news media, have responsibilities pertaining to how they respond, which they may or may not discharge appropriately. That's on them.

*(Latin pedantry alert: "forums" is now the standard plural form in English.)

A slightly puzzling result . . .

. . . followed by "Aha!"

In 1999, the last legitimately elected president of the United States directed that the Federal Employees Health Benefits program provide parity in coverage of behavioral health services -- mental health and substance abuse treatment -- with coverage of other health care services. This has long been a major bone in the throat of people in the behavioral health field -- that most health plans sharply limit benefits.

The main justification for relegating behavioral health to second class status is the argument that the need for such services is not sharply defined. The insurance companies are afraid that if they offered open-ended benefits, half of their customers would end up like Woody Allen, in psychoanalysis for life. So, Clinton also directed that there be a comprehensive evaluation of the policy to find out how it affected cost, access and quality of behavioral health care for federal employees.

The results are reported by Howard Goldman et al in the New England Journal of Medicine (abstract here, full text available only to the elect). Federal employees have a buffet of plans to choose from, so the evaluators could compare plans that introduced full parity with others that did not. They found that consumption of behavioral health services went up over the years in both groups of plans, but by similar amounts. The difference, obviously, was that people who lacked parity in coverage paid more out of pocket.

My first reaction was that it seems very surprising that having to pay out of pocket did not reduce people's use of these services. On grounds of equity, this still seems to support providing parity in benefits -- insurance is supposed to spread risk and obviously it does that successfully in this case -- but it doesn't seem to do anything to increase access and appropriate utilization.

Then it occurs to me that 100% of the sample are people with good, steady, fairly secure jobs that provide comprehensive benefits. If these folks need mental health or substance abuse services, they can afford to pay something out of pocket. Furthermore, they are unlikely to be among the most severely mentally ill or they wouldn't have those good steady jobs in the first place.

So what this tells us is that extending parity for behavioral health services doesn't have to lead to abuse, waste, overutilization, or a nation of Woody Allens permanently preoccupied with their neuroses and pipelining money to Madison Avenue shrinks. For needier and more vulnerable populations, it is still likely that it will lead to better access and more appropriate utilization. So let's do it.

Petitioning the Lord with prayer

All the press coverage I read of the recent negative findings on the power of prayer to enhance recovery from heart surgery were fair and balanced. The reporters all went out and found eminent physicians and/or clergy to say that the study doesn't prove that prayer doesn't work. For example, prayer by family and friends, as opposed to distant religious communities, might well be effective.

Why isn't it obvious to everyone that anyone who believes this has a contemptuous view of God? Think about it. Here's Harvey Havemore, a wealthy corporate lawyer, who is diagnosed with lung cancer. His wife, kids, and siblings all pray furiously for his recovery. The all-powerful, omniscient, benevolent Creator and Lord of the Universe was going to let him die, but he sees the prayers pouring into his inbox so he says, "What the hell, I guess I'll cure this one."

On the other side of town, here's Helen Hasnot, whose husband ran off twelve years ago, whose only son died of leukemia, whose parents are both dead, whose sister lives in Dubuque and they drifted apart years ago, who descended into depression and social isolation. Nobody is praying for her. God says, "Tough shit, I don't have a single card or letter on this one." Helen suffers a protracted and painful death.

Then there are all those bumper stickers and signs that say "God bless America." So the idea is, God wasn't planning to bless America, but he sees the bumper sticker, so he says, "Okay, I guess I'll throw them a blessing"?

If that's your God, you can have him.

Science of the people, by the people, and for the people?

I just got back from a symposium about so-called community based participatory research (and variations on the name and theme such as just participatory research), in particular an effort at my university to develop more of this kind of research through a center pulling together various resources of the university. I am a kind of avatar of CBPR since I work for a community based organization, while I'm on the faculty, and my research is based in the CBO and guided by the interests and needs of our clients and the organization as a community asset.

Typically, public health research is exploitive of its subjects. An academic, motivated by the need to get grants and publish in order to win tenure and promotions, devises a study using the epistemological standards that are required by NIH reviewers -- randomized controlled experiments of strictly specified interventions, or epidemiological studies that extract information from people according to highly programmed procedures. Then the Big Professor goes away and writes a paper, and the community and people who got studied hear nothing about it and get no benefit from it. It probably has little or nothing to do with anything they care about anyway.

So, there are a lot of Mom and apple pie sentiments that usually define CBPR. Representatives of the community are involved from the beginning in defining the research problem. Community people work with the academic investigators to develop interventions and/ or ways of asking questions. Members of the community get hired as interviewers. The results of the investigation are fed back to the community and the academic investigators work with the community to turn knowledge into action -- whether through education of the public, development of services, or political activism and social change.

Who could argue with that? Well, some people can because they just think that people with Ph.D.s know what they're doing and it's a waste of time and an obstacle to good science to drag the riff raff into it. But even those of us who are passionate advocates for opening up the scientific enterprise and making it a public possession know that it isn't easy. There are a lot of conceptual and practical problems.

I'll talk about a few of them as time goes on but for now, just this one. Who decides who "represents" the community? How do you find those people in the first place to join in and help define the problems and chart the path to answers? Are the people you manage to engage with really "the" people, or are you just buying in to some other, less obvious institutional inequalities?

Stay tuned.

The facts of life . . .

Internet bulletin board services and web hosts, including blogger, tend to be pretty tolerant about content. It's no problem to put up porno, racism and hatred, even incitement to murder. But if you even discuss the following topics (no specification of what you say) they'll shut you down:

Conditional Access Systems.

Satellite Test Cards.