Archive for the ‘Health Care’ category

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.

Why We Fight (Kind of Meta)

July 21, 2012

Attention Conservation notice [w. apologies to Cosma Shalizi, from whom the phrase is stolen]What follows is what in the newspaper business used to be called a thumbsucker  — in this case, yet another way to see the GOP as not just wrong, but so steeped in an error of principle, of worldview, as to be irredeemable.  It’s got a nice anecdote in it, lifted from someone else, but there’s no need to read on if you don’t like such stuff.  Which last is, of course, a PGO of its own.  See:  I’m fractally unnecessary.

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I don’t recall an election in which two such strikingly opposite visions not just of the United States, but of human nature, so clearly set the stakes.  Let me get to part of what I see by some indirection:

I’ve been doing a lot of reading lately, with (thanks to the exceptional luxury of a sabbatical) much more to come.  I’ve started out by trying to catch up on some of the political books I’ve missed recently — and I’ll probably have some thoughts to share about Christopher Hayes’ Twilight of the Elites before long.  I just finished Michael Sandel’s What Money Can’t Buy too, though I found it perfectly interesting, but less compelling than Hayes’ book for a number f reasons.  Still that’s a philosopher’s take on the same problem explored in the book that prompts this post, Virginia Sweet’s God’s Hotel.  

Sweet’s work is a memoir of her doubled journey as a doctor at the last surviving American big city alms house, San Francisco’s Laguna Honda Hospital, and as a scholar trying to understand Hildegard von Bingen’s spiritual and practical approach to her form of medicine.  Sweet’s book has been enthusiastically received, and I can see why, though it didn’t move me in quite the same way it seems to have for some others.  It’s Sweet’s lack of struggle that gets me, I guess; there’s no doubt in my mind she did sweat and suffer over her 20 years caring for the poor, but in recollection the life  unfolds with an easy rhythm, no matter how tumultuous the world around her might be.

That said, though, the core message of the book is that there is a profound difference between health care and medicine, and that we ignore the virtues of the art and practice of medicine at our great cost.  As one of  her reviewers notes, this is a subversive thought:  Medicine is a craft, performed one-on-one, slowly…

…while health care is a commodity, something that can be abstracted and, in a sense, mass-produced:

Sweet doesn’t romanticize much, and she never suggests that she, her patients or anyone should trade modern medicine and its quantifying tools for Hildegard’s actual practice.  But she makes the point a good historian of ideas should: one studies the past not to recreate it, but to understand what its thoughts meant to its thinkers — and then what meaning those same insights may have in the radically different time and place in which the historian lives.  Use Hildegard as a tool to probe what the consequences may be if we commit ourselves to life within Mitt Romney’s vision of America.

In that frame, here’s just a brief passage, in which Sweet describes her even-tempered reaction to the consequences of an infestation of her hospital by the kind of consultants that Romney’s parent firm Bain produces:

Above all, the [consultants’] report said, they’d been amazed by the anachronistic presence of a head nurse on every one of the hospital’s thirty-eight wards.  As far as they could tell, this head nurse did nothing but sit most of the day in  her chair in the nursing station.  She answered the phone, to be sure, and kept the charts tidy; now and again she when out and inspected a patient with one of her nurses.  Also, she made coffee, kept the TV room and lounge neat, organized patients’ birthed parties and in general, did whatever needed to be done. It was a pleasant job [the consultants] observed, helpful, no doubt, but one hundred years after Frederic Taylor’s description of scientific management, and in a time of tightening health-care budgets, such a use of a skilled RN was excessive.  They’d even seen one head  nurse whose only task was knitting.  That’s right, a head nurse who, as far as they could tell, spent all day in her chair at the head of her ward, doing nothing but knitting blankets and booties for her patients.

So their main recommendation was to change the nursing structure at Laguna Honda.  The job of head nurse should be eliminated.  Instead, a new nose manager position should be created, where each nurse manager would be responsible for two wards instead of one.  She would no longer answer the phones, tidy the charts, or help out with patient care.  Rather she would manage the staff…

It was a lesson in the inefficiency of efficiency.  And the best way to explain is to tell you about the head nurse who knit….[hers] was a little-old-lady-ward, with thirty-six little old ladies — white-haired, tiny and old — and sure enough almost everyone one was wrapped in or had on her bed a hand-knit blanket; white and green, white and red, white and yellow.  And there was the head nurse sitting in her chair at the nursing station, answering the phone, fussing with the charts, observing her charges, and knitting one of the few blankets remaining to be done.

I’ve thought a lot about those blankets since the disappearance of the head nurses and their well – run neighborhoods of wards.  About what the blankets meant and what they signified.  And here’s the thing: The blankets made me sit up and take notice.  Made me pay attention. Marked out that head nurse as especially attentive, especially present, especially caring.  It put me and everyone else on notice.

It’s not that the ladies for whom they were knitted appreciated them or even noticed them. Who did notice was — everyone else. Visiting family noticed.  Looking down the center aisle, they saw two rows of little white-haired ladies — their mothers, great-aunts, and sisters — each lady bundled up in a bright, many-colored hand -knit blanket. They also saw that each had makeup on, and her hair done and her nails polished by the nurses who knew that, down at the end of the ward, was the head nurse, knitting. The Russian ambulance drivers noticed, when they rushed onto the ward to pick up one of the ladies…Even the doctors noticed.  The blankets put us all on notice that this was a head nurse who cared.

…those blankets signified even more than attention and caring. The click of that head nurse’s knitting needles was the meditative click of — nothing more to be done.  Although it had seemed to [the consultants] that the head nurse  did nothing except knit, that nothing was, as the Tao says, what the Superior Man does when everything that was supposed to be done has been done.

We did get used to the new system eventually.  The remaining staff learned to answer the phones, tidy the charts, talk to families, help the doctors, survey the ward and support one another at the same tim they were looking on the computer or filling out the forms that the new nurse managers created.  But the new system had a cost.  It was stressful. After the head nurses were cut in half, there were more illnesses and more sick days among the staff; there were more injuries more disabilities, and earlier retirements. Among the patients there war emore falls, more bedsores, more fights, and more tears.  And this, in the broader scheme of things — even economics — is not efficient.

…The [consultants’] report  taught me not only the lesson of the inefficiency of efficiency.  It also taught me the lesson of the efficiency of inefficiency.

Because it wasn’t just the tasks of the head nurse that fell by the wayside with [the] recommendations. It wasn’t even their watchful re-creation of neighborhoods within the village of the hospital.  It was the time they had, the unassigned time, that not only belonged to them but spread itself to all the staff — doctors included. That unassigned time, as inefficient as it seemed to be… turned out to be one of the secret ingredients of Laguna Honda.  With the elimination of the head nurses, so economical on paper, some of that extra time was also eliminated, and with it, some of the mental space to focus and care.  There was, I discovered, a connection between inefficiency and good care…

I don’t want to romanticize here, any more than Sweet does through her long narrative.  To channel my inner Freud, sometimes the old ways of doing stuff really are outmoded.  No one who has recently spent four years in academic administration needs to be reminded of that.

But Sweet’s point is one I’ve been thinking of more and more as each Bain vulture capitalism story makes its way in and out of the Look! Shiny! media narrative.  Sweet mentions that the consultants who got rid of half of the head nurses shifted $2 million in the budget.  They collected $200,000 for their recommendation — an agreed 10% bounty on all “savings” their study produced. They correctly determined an individual inefficiency, and missed, in Sweet’s account, the systemic advantages of what seemed to their analytical framework, their faith, to be an obviously flawed system.

And so it goes throughout the current GOP worldview.  We know that the private sector is the GOP solution to (putative) problems in the public schools [paywall] by selecting the right measurement criteria.  Bobby Jindal can determine the cost of libraries, but not the cost in money or possibility of their loss. The number wins; the uncertain future weighs for nought.  The usual catchphrase for all this is privatizing profit and socializing risk — which is what the GOP seeks for social capital as much as the financial kind.  Hence the stakes of this coming election.

But beyond that pretty familiar notion, what came to front-of-mind as I read Sweet’s story was the reminder, if any were needed that the basic worldview of the two sides in this election are not the same, for all the overlap of interest and elite corruption and all that the circular firing squads of the left can (sometimes accurately) describe. I said this was meta, and it is, and I should probably let y’all get back to your Saturdays.  But behind the consultant’s technical apparatus is a vision of a world of individual action and reaction. Cut here, save the money, Profit!

Taken to the level of politics and national elections, it’s a vision (sic!) of a country best understood as an assemblage of 300 million individuals. Hence, among the adherents of this view, the furor over the suggestion that business folk had any help building their businesses.

If you think that such a view of the lack of connection between one person’s endeavor and the next is the way to educate a population, receive health care in a timely and useful fashion, to innovate, then the GOP is for you.  If you think we live in society in which individuals  gain freedom of opportunity and access to experience supported by the links between the lives of all those 300 million — if you inhabit reality, that is — then we need to destroy the current GOP root and branch, now and for the forseeable future.

Put another way:  we need to recall that I didn’t build this blog…without the internet, without its readers, without…you get the idea. 😉

And that’s enough meandering.  I’ve just finished my next, post-Sweet book in this orgy of reading, Elaine Pagels, Revelations. Interesting, culminating in a very good explanation of what from my perspective I read as the reason Isaac Newton so excoriated what he saw as the theft of Christ’s church by Athanasius, his imperial patrons and his allies.  Not sure what to grab next.  No matter.  What a joy it is to read and read and read…

Images: Jan Steen, The Sick Woman, ​ before 1679.

Max Liebermann, The Canning Factory, ​1879.

 

Things I Hate #476.4: Sloppy Writing About Cancer

June 2, 2012

In Thursday’s New York Times Andrew Pollack wrote a mostly unobjectionable, informative piece on an innovation in treatment for a variety of cancers.  The trick he described involves attaching chemotherapeutic agents to antibodies that bind to specific markers on cancer cells — compounds dubbed antibody-drug conjugates.  Such therapies aim at more precise targeting of cancer drugs, which researchers, drug companies and patients hope will yield more effective results with fewer side effects.

Pollack lays out the basic technology in the piece nicely, and he frames the science within the usual sorts of anecdotes about patients on some of the drugs under trial…all pretty bog-standard medical reporting.

So why am I pissed off?

This sentence:

By harnessing antibodies to deliver toxic payloads to cancer cells, while largely sparing healthy cells, the drugs are a step toward the “magic bullets” against cancer first envisioned by Paul Ehrlich, a German Nobel laureate, about 100 years ago.

Two thoughts:  first, the lesser offense, the phrase “envisioned by Paul Ehrlich, a German Nobel laureate,” is an attempt to assert unearned authority.  The dreamt-of “magic bullets” gain a quality of respectability from association with some long-dead smart guy.

That Nobel cover helps set up the second, greater claim, and the more damaging flaw in this piece: the implied outcome for someone actually receiving the hinted-at magic bullet.

Pollack, were he here, might try stop me at this point, noting that he only suggests “a step toward” the miraculous promise of a bullet to strike cancer down — and not that cure itself.  And so he does.

But really, the whole framing of magic bullets  is the problem.  Pollack gives evidence of why this is so — at least by implication — later in the piece.  The patient in his lede has breast cancer.  for breast cancer.  Much further down the piece we learn that the antibody-drug conjugate treatment she receives only applies to those 20% of breast cancers that express an excess of a particular protein.  That speaks to one reason why magic bullets remain so elusive almost half a century into the “war on cancer:”  cancer is not a disease. Rather it’s a family of illnesses that share the property of unconstrained cell division — but respond often very differently to given choices of treatment.

Again, there’s no doubt in my mind that Pollack knows of the real harm to be done by talk of cures for cancer; almost all of the article is sober enough about the gains achieved so far by this approach (real, but not curative) and of the limits the given therapies face.

But even good reporters can fall prey to the easy phrase or the inaccurate shorthand of the beat.  Sometimes it doesn’t matter.  No one cares if a football writer uses the phrase “smash mouth” in every piece about the Steelers-Ravens rivalry.

Cancer is different.  The hunger for a cure is obviously and understandably overwhelming. But such hopes run straight into the basic science of cancer — which has undone seemingly imminent magic bullets time after time.

New hope, the prospect of more time, improved quality of life, and — with good fortune — increased remission rates.  Those are all fine as ways to frame the real advances in cancer therapy.  Present them with all the optimism one may reasonable feel.  But to imply that we’ve moved meaningfully closer to what amounts to a cure?  Until and unless that’s really true, it is beyond misleading to suggest that particular advances offer more than they do.  Very rapidly we’re into the territory of the cruel.

So yeah, even as a throwaway.  Even with the imprimatur of a Nobel laureate, alive or dead.  Even with good intentions. This kind of carelessness bugs the living crap out of me.

No snark, no jokes, a dark subject, no fun.  Nothing new here, either; I’m guessing everyone reading this has a pretty good idea that cancer is a bear of a disease(s).

What can I say?  This one strikes close to home.

Image: Zacharias Wagner, Crab, from Thier Buch (Animal Book), 1641.

Hurts Too Much To Laugh; I’m Too Old To Cry

April 6, 2012

This is how one sad story begins:

May the justices please meet my sister-in-law. On Feb. 8, she was a healthy 32-year-old, who was seven and a half months pregnant with her first baby. On Feb. 9, she was a quadriplegic, paralyzed from the chest down by a car accident that damaged her spine. Miraculously, the baby, born by emergency C-section, is healthy.

This is what follows that terrible moment:

My brother’s small employer — he is the manager of a metal-fabrication shop — does not offer health insurance, which was too expensive for them to buy on their own. Fortunately, my sister-in-law had enrolled in the Access for Infants and Mothers program, California’s insurance plan for middle-income pregnant women. AIM coverage extends 60 days postpartum and paid for her stay in intensive care and early rehabilitation. But when the 60 days is up next week, the family will fall through the welfare medicine rabbit hole.

And here is what those people will have to deal with for the rest of their lives:

When the AIM coverage expires, my sister-in-law will be covered by Medi-Cal, California’s version of Medicaid, because she is disabled and has limited income. But because my brother works, they are subject to cost-sharing: they pay the first $1,100 of her health costs each month. Paying $1,100 leaves them with a monthly income of just 133 percent of the federal poverty level. If my brother makes more money, their share of the cost increases.

They must also meet the Medi-Cal asset test: beyond their house and one vehicle, they can hold $3,150 in total assets, a limit last adjusted in 1989. They cannot save for retirement (retirement plans are not exempt from the asset test in California, as they are in some states). They cannot save for college (California is not among the states that have exempted 529 college savings plans from their asset tests). They cannot establish an emergency fund. Family members like me cannot give them financial help, at least not officially. If either of them receives an inheritance, it will go to Medi-Cal. Medi-Cal services that my sister-in-law uses after age 55 will be added to a tab that she will rack up over the rest of her life. When she and my brother die, the state will put a lien on their estate; their child may inherit nothing. Even my brother’s hobby runs afoul of the asset test: he enjoys working on old cars, which he can no longer keep.

This is what this story reminds us:  for too many of our fellow citizens, our health care system, when it delivers care at all, turns families permanently poor.

This is what “Repeal” means.  Welcome to the Republican vision for health care.*

Oh — and, yes, of course, this is what the case before the Supreme Court is alll about.  Which is why the willed and faux-naive ignorance of  Scalia, Alito and others earns the name of evil.

Go read the whole piece.  Get angry, then angrier.  If you live with GOP representatives, send this column to them.  If you have friends or family or acquaintances who might be able to make the same leap John managed, pass it on to them too.  Pressure is a daily accumulation of little taps and nudges, and there is no time the present.

*I won’t insult you by adding the reflexive “and Replace,” as there is no replacement on offer; vouchers are not a health care system, and would, as now proposed, do that quantity of good that asymptotically approaches zero for this family.

Image: Gustave Doré, A Couple and Two Children Sleeping Under the London Bridge 1871.

Scary Diseases; Agribiz Denialism; and Why We Need Health Care Reform (It’s more than just coverage)

March 28, 2012

Just a quick heads up.  I’ll be talking at 5 Eastern Time today with Maryn McKenna, aka Scary Disease Girl on Virtually Speaking Science. You can listen, but if you’re a virtual kind of person you can also head over to the open air theater in Second Life see Maryn’s magnificent avatar with its gloriously purple hair.  (One commenter compared the shade to Beaujolais Nouveau, but I’m not so sure.)

McKenna is a science and medicine writer who has focused the last several years of her career on the truly vexing and terrifying issue of antiobiotic resistance, focusing on the scourge of MRSA:  methicillin-resistant Staphylococcus aureus, or drug-resistant staph.  She blogs at Wired.com, under a title shared with the book — Superbug — that will be the leaping off point for our conversation.

So check it out, if not synchronously, then via the podcast, available either at Blog Talk Radio (from about midnight tonight, I think, though it may be tomorrow), via the RSS feed, or as found within the greater Virtually Speaking iTunes podcast.

Just to give a tease of the conversation — we’ll start by talking about the great squander:  how, some 75 years into the antibiotic era, we’re on the verge of destroying what had once seemed to be a truly transformative gift, a way to salve so much human suffering…and we will start to look at the reasons why.  High among them will be the area Maryn’s focused on a lot since publishing Superbug, the use of antibiotics in agriculture in a non-therapeutic situations — that is, not as a response to an infection, but either as a prophylactic, or simply to fatten up livestock before slaughter.

There’s been some news over the last week that makes this issue genuinely hot, but the most interesting aspect of it, to me, is the way agribusiness and their congressional allies (on both sides of the aisle, alas) have simply changed a few of the nouns and then copied the denialist playbook written for the tobacco wars, and updated for use in turning the threat of climate change into a world-wide conspiracy of fanatical socialist-facist greens.

Which is to say, as readers of this blog know, the transformation of science from a source of public knowledge into a post-modern body of jargon to be manipulated by those with the biggest and most sophisticated megaphones, is literally killing us — as we will discuss in a bit.

Oh — and one more thing.  One of the key threads to emerge from Maryn’s work is just how badly we are served by the fragmentary system of health care delivery that we now have, that the GOP wishes to preserve, and that Obamacare goes some way to repair.  The lack of uniform systems of electronic charts, the failure to disseminate key medical knowledge outside of its silos — sometimes single hospitals, or even single services within hospitals — the inability to construct a truly national system of health care knowledge and the dissemination of best practices (Death Panels!) all have contributed directly to the deaths of kids, grown ups, grandma and grandpa from preventable or much earlier-treatable MRSA infections, as Maryn has documented — and much else besides.  Remember:  when our friends who decry the fascism inherent in public regulation of a public good seek to repeal without replacing, they are advocating a policy choice that will kill people.  This is a known, predictable consequence of any swerve to the status quo ante.  In other circumstances, taking actions that a reasonable person understands will lead directly to the deaths of others has a name, and the people who do so have names to.  Now we call them GOP Presidential candidates.  Just sayin.

Just the cheery kind of conversation that will set you up for a truly heroic cocktail hour.  May I recommend either one of these…or,  maybe, doses by mouth of this concoction, repeated as necessary.

Image:  Barent Fabritius, The Slaughtered Pig, 1656

By The Way, David Brooks Is Still Always Wrong

November 13, 2011

I know this is already long since fishwrap, but amidst the many disembowelings of David Brooks discovery that he has always been at war with Eurasia   always  loved Mittens, I have to rage, rage, at the relentless, endless, fetishization of the deepest, most degrading fantasy of the right.  No, not that one.  Nor that one either.  Nor this.

No it’s the almost touching faith evinced by Mr. Brooks and the entire GOP presidential field in the existence of a free market in health care.  So, just to flagellate a truly dead horse, let’s take a look at one specific passage from Our Lady of Perpetual Broderism’s Romney tongue-bath:

True Medicare reform replaces the fee-for-service system with premium support. Government gives people money, rising slowly over time, to shop around for their own private insurance plans. The system would reward efficiency and quality, not just quantity. Competition between providers would unleash a wave of innovation.

The only problem is that the marketplace for health care that exists in the world real people inhabit bears little or no resemblance to Brooks’ pleasant vision of informed consumers, with full information in hand, shopping around for the perfect combination of benefits and price they need — not just now, but through the life (and death) cycle all of us endure.

 

That is: most evocations of the free market in just about anything call up spherical cows, simplified (and dangerously convincing) models of what actually happens in the world.  But to imagine a genuine Ec. 101 free market in health care — and to praise someone as “serious” for building policy on the assumed reality of such delusion — that takes real effort, a true commitment to avoid knowing inconvenient facts.

At least, so says such a DFH as Daniel McFadden.  That would be the 2000 Nobel laureate in economics who has taught at such dens of raving lefty lunacy as USC, UC Berkley, and (ahem) MIT.  And that would be the same fellow who has spent quite a bit of time analyzing the notion of consumer driven health care.  Here’s what he had to say in 2008 in a working paper co-authored with Joachim Winter and Florian Heiss:

Most, but not all, consumers are able to make health care choices consistent with their self-interest, even in the face of novel, complex, ambiguous alternatives. However, certain predictable irrationalities appear – excessive discounting of future health risks, and too much concentration on dimensions that allow easy comparisons, such as current cost and immediate net benefit. Some consumers are inattentive, particularly when prior choices or circumstances identify a default “Status quo” alternative.

These behavioral shortcomings imply that some degree of paternalism is essential if Consumer Directed Health Care is to allocate resources satisfactorily. Health care markets need to be regulated to keep out bad, deceptive products, particularly those that offer “teaser” current benefits but poor longer-run benefits. Consumers need good comparative information on products, and they need to have this information brought to their attention. Consumers appear to underestimate the probabilities of future health events, [or] anticipate the resulting disutility, and as a result they systematically underspend on preventative or chronic care. Socially optimality will require that these services be subsidized, or choices regarding them be framed, to induce desired levels of utilization.

[From the second paper listed on McFadden’s website, linked above: “Consumer-Directed Health Care: Can Consumers Look After Themselves?” pp. 19-20]

Note what McFadden et al. do not say.  They don’t say market mechanisms can’t work.

They do say that human beings display predictable behavior that makes it impossible to rely on an unregulated market to deliver health care.  They point out that those irrationalities fall most heavily in the area of guessing what you or I might need some years down the road…i.e. when we are likely to need good care the most.*

Hence, the need for what the authors above call “paternalism,” and what I would term the normal function of the concept of universal insurance — mandated if necessary under the particular policy choice — against risks all members of a society face.

McFadden and his colleagues are hardly the only ones who get this.  This paper is exemplary, not determinative.  And again, it’s not that these writers represent some radical wing of anti-classical economics clinging to the margins of the profession.  In fact, McFadden and his co-authors display some familiar, reflexive thinking.  I’d argue with the Nobel laureate in his offhand dismissal of a different approach, what he terms “a government single payer/single provider program.”

Partly, the difficulty I have with the expert here is that single payer is not the same as single provider.  Conflating the two allows one to damn one with the flaws of the other — which is hardly cricket in a serious policy discussion.  And when anyone — even a distinguished fellow like McFadden — says that he “believes” the problems of such a system will be the same as for private plans, then I become an honorary Missourian: “Show me.”

But that’s an aside.  The core point is that even folks with a deep institutional and disciplinary engagement with the idea of markets understand that you can’t run health care on the principle that the customer knows best.  We don’t — we can’t, really.  And that’s why Romney, and Ryan, and all the other GOPsters trying to transfer risk to the American people and profits to American insurers are never, ever “serious.”

Which is just another long way round to repeating the obvious. David Brooks is always wrong.  He kind of has to be, given how he has dedicated his career to the notion that Republicans belong in power, no matter what.

*Brooks — like the GOP candidates — might argue at this point that they never have contemplated an unregulated private market in health care.  Which may be accurate, but not true (to channel my inner Sally Field).  That is — the degree of regulation in the market to which all calls to repeal Obamacare would return us was the one in which a host of problems along the lines McFadden et al. point out, and many more besides.  More broadly — even if you take the GOP as sincere in its stated principles, they oppose “paternalism” in individual decisions.  Which means they oppose exactly what is needed in the delivery of health care.

Images:  Edouard Manet, The Dead Bullfighter, 1864-1865

Pompeo Batoni, Time Orders Old Age to Destroy Beauty, c. 1746