Archive for the ‘Health Care’ category

Your Daily Apocalypse, Outsourced Antibiotic Edition

November 21, 2013

Go read this piece by Maryn McKenna — who is, in my never humble opinion, one of the handful of very best reporters on matters of infectious disease, global health, and really scary stuff.

I was born in 1958, fifteen years into the era of clinically-available antibiotics.  I was my mother’s third child.  Had we shifted that timeline back a few years, that would have meant that there would have been a measure of luck in mom simply making it to and not through her third lying in.  As Maryn writes, before antiobiotics, five out of 1,000 births ended with the death of the mother.  No worries by the time I popped my head out into the maternity floor at Alta Bates.

But this a must read not because of any remembrance of the pre-antibiotic era, but because Maryn plausibly analyzes a post-antibiotic future.

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Here’s a sample:

Doctors routinely perform procedures that carry an extraordinary infection risk unless antibiotics are used. Chief among them: any treatment that requires the construction of portals into the bloodstream and gives bacteria a direct route to the heart or brain. That rules out intensive-care medicine, with its ventilators, catheters, and ports—but also something as prosaic as kidney dialysis, which mechanically filters the blood.

Next to go: surgery, especially on sites that harbor large populations of bacteria such as the intestines and the urinary tract. Those bacteria are benign in their regular homes in the body, but introduce them into the blood, as surgery can, and infections are practically guaranteed. And then implantable devices, because bacteria can form sticky films of infection on the devices’ surfaces that can be broken down only by antibiotics

Dr. Donald Fry, a member of the American College of Surgeons who finished medical school in 1972, says: “In my professional life, it has been breathtaking to watch what can be done with synthetic prosthetic materials: joints, vessels, heart valves. But in these operations, infection is a catastrophe.” British health economists with similar concerns recently calculated the costs of antibiotic resistance. To examine how it would affect surgery, they picked hip replacements, a common procedure in once-athletic Baby Boomers. They estimated that without antibiotics, one out of every six recipients of new hip joints would die.

As Maryn reports, the problem is tangled and complex — but there are clear actions that could be taken and aren’t, most obviously ending the reckless use of antibiotics in agriculture, which consumes something like 80% of the total produced.  But don’t waste time here: go read the whole thing. Get scared; get mad; call your congressfolk.

Image: Josse Lieferinxe, St. Sebastian prays for plague victims, 1497-99.

Ted Cruz’s Texans Are Getting The Democracy They Want…

October 3, 2013

And so are we…getting it good and hard, as my man Mencken preached it so long ago.

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This is just a quick addendum to my recent posts on the connection between the Republican party’s passion for denying millions of Americans access to health insurance coverage.

As everyone not resident at Bag End knows, the self-anointed leader of those who think that providing health care for millions is the gateway to the dictatorship of the usurper is  “Tailgunner” Ted  Cruz, R-TX.

That made me wonder — how many of his own constituents is the freshman Senator trying to roger?

The Texas Medical Association has the goods:

One quarter of the Texas population is uninsured (compared with a US proportion of 15.7% as of 2009). 17% of Texan kids are without insurance, compared to 10% nationwide. One third of Lone Star adults 19-64 lack insurance; the national total is 22%…and so it goes.

Don’t lose sight of what all this means.  Folks are dying now in Ted Cruz’s Texas when they shouldn’t — and he’s aiming to make sure that moral outrage continues.

Texans and, alas, the rest of us are stuck with Senator Cruz for another four years and change.  Let’s make sure we do whatever we can to see that his BFFs in the House pay the price much sooner than that for conspiring before the fact in the deaths of American citizens.  And let’s help our countrymen and women in the great state of Texas rid themselves of this noxious pest at the first opportunity.

Image: William Hogarth, An Election Entertainment,  1754

The Difference Between Democrats and Republicans

October 1, 2013

In California, a Democratic Party-run state:

Dozens of workers at a call center in the Sacramento suburb of Rancho Cordova began fielding calls after a countdown to 8 a.m. Tuesday, the time the state’s health exchange opened for business. The agency that runs the exchange, Covered California, reported on Twitter that more than 30,000 telephone calls were received during the first 90 minutes of operations. Another 1,200 were on hold and about 4 percent had hung up.

Peter Lee, executive director of Covered California…said Tuesday was just the starting point, and it was evident that exchange officials had work to do after the website and phone system were hit with a crush of inquiries.

Gov. Jerry Brown, meanwhile, announced he had signed a package of bills to help implement the new law and expand the state’s Medi-Cal program for those who are too poor to pay for the subsidized insurance.

“While extreme radicals in Washington shut down our government, here in California we’re taking action to extend decent health care to millions of families,” Brown said in a statement, referring to the impasse in Congress that has led to a partial shutdown of federal government operations.

Meanwhile, as a result of the government shut down triggered by those GOP extremists, there’s this news:

Cecil_Beaton_Photographs-_General;_China_1944,_Canadian_Mission_Hospital_in_Chengtu_IB2569C

At the National Institutes of Health, nearly three-quarters of the staff was furloughed. One result: director Francis Collins said about 200 patients who otherwise would be admitted to the NIH Clinical Center into clinical trials each week will be turned away. This includes about 30 children, most of them cancer patients, he said. (From behind the WSJ paywall via the Atlantic) (h/t a tweet from science writer extraordinaire Steve Silberman aka @stevesilberman.)

So there you have it:  Democrats strive to get sick people care (and the well, protected), and labor to fix  the bits that don’t work.

Republicans leave kids with cancer on the street.

Update:  H/t commenter Baud, it turns out   that Americans in those (GOP-led) states that have chosen to abandon their responsibility to their citizens actually do twant healthcare from the Feds (via TPM):

Nearly three million people have visited the federal health insurance marketplace created by Obamacare on its first day, according to the U.S. Department of Health and Human Services.

Since midnight, 2.8 million people have visited the website, which will serve consumers in more than 30 states, and 81,000 have called the marketplace’s call center. Those numbers were current as of late Tuesday afternoon.

Image:  Cecil Beaton, A mother resting her head on her sick child’s pillow in the Canadian Mission Hospital in Chengtu, 1944.

One Dares Call It Murder

September 30, 2013

It’s not just this DFH anymore.  Senator Angus King (I-ME) goes there:

….he [King] doesn’t mince words with those who’d take risks with other people’s health security.

“That’s a scandal — those people are guilty of murder in my opinion,” Sen. Angus King, a Maine Independent who caucuses with Democrats, told me in a Friday interview. “Some of those people they persuade are going to end up dying because they don’t have health insurance. For people who do that to other people in the name of some obscure political ideology is one of the grossest violations of our humanity I can think of. This absolutely drives me crazy.” (h/t TPM)

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Just to go over the ground once again:  health insurance saves lives.  When you deny our fellow citizens coverage — well take it away, Senator:

…ACA opponents are loathe to grapple with the life-or-death nature of their advocacy and tend to lash out when confronted with it. As such, the debate over the law tends to center around other moral questions. But King doesn’t think they should be let off the hook.

“That’s bunk. You can’t wish that reality away because you don’t like the policy outcome,” he said.

…“To me it boils down to a moral question, and that is would you allow someone sitting in front of you on the subway to die, or would you take some action — call 911 or a doctor or do CPR yourself. Most people would say no I would not allow someone to die. You have to realize that as a society we’re answering ‘yes’ to 25,000 a year who are dying before our eyes and saying we don’t care.”

The House Republican caucus and their allies in the Senate and in the Koch et al. penumbra are demanding those deaths everytime they attempt to defund or “delay” Obamacare as the price for keeping government open.  I’ve tried, but I just don’t have any polite words to describe those actions or those actors.  King dares call it murder — and he’s right.

Good for him for saying so.  May others pick up the message.

Image: Pieter Breughel the Elder, The Triumph of Death, c. 1562

The House Republican Caucus: Conspiring to Murder American Citizens

September 28, 2013

The breathlessly awaited Saturday meeting of House GOP caucus is over, and we now know what these feral children want in exchange for not blowing up the American economy:

 The federal government on Saturday barreled toward its first shutdown in 17 years after House Republicans, choosing a hard line, demanded a one-year delay of President Obama’s health care law and the repeal of a tax to pay for the law before approving any funds to keep the government running.

In all the talk about defunding or delaying Obamacare, there’s one thing that hasn’t been discussed  much, certainly not by the Village.  That would be what  delaying Obamacare would actually mean in the real world.

There, we’re looking at dead Americans, needlessly and avoidably cut down before their time.

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Here’s the train of thought behind that claim:

The primary goal of the health care reform is to cover as many Americans who lack insurance as possible. As of this year, that is in the neighborhood of 48 million people — roughly 15% of the total US population.  Under the terms of the ACA, that number will be cut by 14 million next year, with more to come as the law persists.  That’s still well short of the goal for a civilized society, in my view, but 14 million people with access to health care is a real and important social and ethical good (not to mention an economic plus, in many analyses).

Those 14 million people — 14 million individual human beings with hopes and aspirations and real desires to avoid pain, misery and worse — are the primary victims of the morally bankrupt cabal that calls itself the House Republican caucus.  If they were to get their way and either fund the government or commit to allow the Treasury to continue to meet obligations already undertaken only on condition that those 14 million must once again go without health care coverage then the suffering that follows is on their heads.

In that context, it’s important to note that this means that the House GOP caucus will thus almost certainly be guilty of causing some significant number of unecessary, premature deaths.  The study of the connection between mortality and health insurance status is somewhat complicated, and a couple of very well publicized studies recently [PDF] have suggested that there isn’t any correlation and/or that Medicaid coverage in particular makes things worse.  Those studies and even more, the trumpeting by such deep thinkers as our old friend, Megan McArdle, have in their turn been strongly criticized, to put it mildly, and they are outliers against a background of some decades of work that show real and deadly links between whether or not you are covered and whether or not you die.

To put this all in a nutshell, take a look at the good recent-ish summary of the state of play of the uninsurance-death argument  comes from Dr. David Gorski writing in the Science Based Medicine blog.  The key point:

analysis of survey data from patients who were uninsured but then became old enough to be enrolled in Medicare suggests that “acquisition of Medicare coverage was associated with improved trends in self-reported health for previously uninsured adults, particularly those with cardiovascular disease or diabetes.” In summary, there is a large and robust body of evidence suggesting that people do, in fact, die because of lack of health insurance.

J. Michael McWilliams, MD, PhD, Assistant Professor of Health Care Policy and Medicine at Harvard Medical School and an associate physician in the Division of General Medicine at Brigham and Women’s Hospital … speculates:

How many lives would universal coverage save each year? A rigorous body of research tells us the answer is many, probably thousands if not tens of thousands. Short of the perfect study, however, we will never know the exact number.

In other words, it’s hard given our current state of knowledge to point to John Doe over there, and say that lack of coverage killed him.  The Republican House doesn’t have to worry about answering a bill of indictment charging them in Mr. Doe’s murder.  But next year, were the House Republican branch of the Bolshevik party to succeed in delaying (or killing) health care reform, the some significant number of uninsured Does and Roes will die.  My truly primitive back of envelope calculation yields an estimate  of the number to be sacrificed to meet Republican Congressional priorities in the single digit thousands.  Let’s just say the death toll would be on the scale of  a couple of 9-11s.

The men who flew planes into the towers were terrorists.

What, then, should we call the House Republican Caucus, and their Ted Cruz-led Senate colleagues?

As our Roman friends would have said:  “res ipsa loquitur.

One more thing:  Factio Grandaeva Delenda Est.

Image: Josse Liefernixe, St. Sebastian interceding for the plague-stricken,  1497-1499.

American Exceptionalism, Healthcare Division

September 18, 2013

With a h/t to my spouse, this piece from a couple of days ago offers a beautiful (not really the mot juste) window onto the multiple levels of fail of US medical business and (or rather, hence) practice.  The action gets going as a young physicians assistant named Andrew T. Gray describes waking up an upset stomach, which over the course of the day blossoms into really nasty pain.  Then comes the twist:

Crawling into bed, however, I realized that my pain had coalesced in the right lower quadrant of my abdomen. Could it be appendicitis?

Panic flooded me. After six weeks at my new job, I now qualified for health insurance, but I’d neglected to fill out the necessary paperwork.

Only an hour after leaving the clinic, I returned. Almost hysterically, I completed and faxed in the insurance forms.

“Go to the emergency room right now,” urged one of my supervising physicians.

Instead, Gray waited overnight so as to reduce the odds of insurance company shenanigans.  The next morning, though he can’t wait anymore:

Waiting for the ER doctor, I recalled that, at some point in my schooling, I’d read a Swedish study about treating appendicitis with antibiotics. Googling the study on my smartphone, I found it.

By the time the ER resident approached, I was ready.

“I don’t have health insurance,” I said calmly. “Can I be treated with antibiotics instead of surgery?”

“I doubt they’re going to let you do that here,” he said. “But keep expressing interest.”

When the ER attending physician came in, I repeated the question.

“Absolutely not,” he replied flatly. “This is America, not Sweden. If you have appendicitis, we operate.”

The story gets better — which is to say from a policy and medical care point of view, worse.  Go read the whole thing.

As to it’s relevance beyond itself. Well, Gray’s telling an anecdote, of course, a single encounter in a system that touches millions every day.  Even so, there are at least two key points I draw from it:  (a)  there are structural problems with the culture of medical practice in the US that both drive up costs and affect (not for the better) patient outcomes.  “This is America…we operate.”

Hans_Holbein_d._J._-_Henry_VIII_and_the_Barber_Surgeons_-_WGA11566

And (b):  there are lots of reasons medical costs in the US seem both arbitrary and excessive. But (a) they are and (b) it actually matters to know what happens elsewhere, because from such knowledge it finally becomes much easier to see that US health care is exceptional alright — but not how the foaming hordes raving against tyranny in the form of Obamacare would have it.  We sure do lead the world in what we pay. Just not in getting what (we think) we’re paying for.*

*This is not to say that for particular conditions in particular cities there is no better place in the world to receive care than, say, my current dwelling place, Boston.  But brilliant tertiary care available  to those clued in and covered in just the right ways doth not a system make.

Image:  Hans Holbein, Henry VIII and the Barber Surgeons, 1543.

Serious People…

February 17, 2013

It’s getting sad, really, watching Senator Graham twist and turn as he tries to find some way of avoiding being Lugared next election.

Here he is on how to avoid the damage of the sequester:

“Here’s my belief: let’s take Obamacare and put it on the table,” he said. “If you want to look at ways to find $1.2 trillion in savings over the next decade, let’s look at Obamacare. Let’s don’t destroy the military and just cut blindly across the board.”

Here’s the Congressional Budget Office on what the budget would look like without the health care reform measure that is the signature accomplishment of President Obama’s first term:

Assuming that H.R. 6079 is enacted near the beginning of fiscal year 2013, CBO and JCT estimate that, on balance, the direct spending and revenue effects of enacting that legislation would cause a net increase in federal budget deficits of $109 billion over the 2013–2022 period. Specifically, we estimate that H.R. 6079 would reduce direct spending by $890 billion and reduce revenues by $1 trillion between 2013 and 2022, thus adding $109 billion to federal budget deficits over that period.

So forget the fact that there is exactly zero chance that the President or his party would acquiesce in this latest ham-fisted South Carolinian attempt at the nullification of duly passed federal law. Pass over in silence the fact that this kind of nonsense is exactly what is needed to continue to paint the GOP as the party of rigidity, incapable of anything other than fighting the last war…

Matthias_Robinson_Charge_of_the_Light_Brigade_1864

…and ignore all of the reasons that the utterance of this crap may play great on Fox News — and that such theater is exactly what (some) Republicans themselves have noticed constrains the party’s ability to speak past its dwindling core.

Instead, do what is sadly laughable in our politics today:  pay attention to the actual policy.

If you do, you’ll notice that a sitting, senior senator just proposed deficit reduction by increasing the deficit.*

That this fact doesn’t earn immediate ridicule from the mainstream media — and not just us DFH bloggers — is a pretty precise measure of how deep is the sh*t in which our polity now wallows.  To be sure, this is hardly the most risible, or most corrosive of Graham’s recent performances; nor that of the GOP at large.  But the sheer bald obviousness of the big lie here gets my goat. Does he think we’re that stupid?

Don’t answer that.

*I do know that Graham’s statement could suggest something other than the repeal examined in the CBO analysis cited above.  But every GOP proposal on health care that I can recall that calls for something other than a total reversal of Obamacare makes the fiscal picture worse.  So unless and an until Sen. Graham advances a specific plan, I’ll default to the existing corpus of Republican “ideas” on the matter.

Image: Matthais Robinson, Charge of the Light Brigade, 1864.


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