.
After the House of Representatives passed HR 3962 recently, I celebrated the defeat of the opponents of health reform. I tried to make it clear, and I will emphasize here below, that the bill is not only far from perfect, it is bad. I just think it would have been worse, a victory for those who wish to keep the status quo (for example, virtually all the Republicans). To my knowledge, Ohio congressman Dennis Kucinich is the only representative who voted against it from a progressive perspective, and I applaud him for that.
I was at a conference recently at which former Senator Tom Daschle spoke. He invited us to envision a huge stadium with the 300,000,000 Americans in it, and the President at the center asking “what should we do about health reform?”, and the huge multiplicity of opinions that would come. He then suggested that the Congress, with its 535 representatives and senators, was a microcosm of those people, expressing all their multiple beliefs. Well, maybe the multiple beliefs, but not in the same proportion. I feel quite certain that, while there would have been a lot of opponents, the 300,000,000 Americans would have been a lot more supportive of health reform, much more meaningful health reform, than the 535 representatives. This is because they don’t get huge contributions from lobbyists from the insurance industry, pharmaceutical industry, hospital industry, and other big corporations, as well as doctors and lawyers and other rich people. Congress does, and it definitely affects their way of seeing things.
HR 3962 is a bad bill that will finance insurance companies, not save money, and not cover all people. I think, I know, we can do better than that. A single-payer plan, for example, such as that proposed in the Medicare for All bill sponsored by Rep. John Conyers (D, MI), and almost voted on by the house in an amendment by Rep. Anthony Weiner (D, NY) to include single payer. This is actually quite a victory, that it came so close, given the efforts of both the Administration and the Congressional leadership to keep it “off the table” from the beginning of this debate. We can hope that, at least, the amendment sponsored by Rep. Kucinich permitting states to pilot single-payer plans, that passed out of committee with bipartisan support, will be considered. It would be a scandal to not allow those states that wished to to try to model a single-payer program.
Speaking of scandals, HR 3642 is further poisoned by the inclusion of the “Stupak-Pitts Amendment”, named after its sponsor, Michigan Democrat Bart Stupak, which not only continues the Hyde Amendment’s ban on the use of federal funds for abortions, it expands on it, by forbidding any plan that may have anyone getting a federal subsidy from offering coverage for abortion care. No “public option” can offer abortion coverage. This will mean that virtually no insurance policy will offer coverage for abortions, including the ones that do at the current time. Companies could offer two separate policies, so that portion of the population not getting subsidies (above 400% of poverty) could buy the other policy, but there is no evidence that they will do so. Under current state laws, five states offer the possibility of insurance companies offering “abortion riders”, allowed under Stupak-Pitts, but there is no evidence that any of them do. Women do not anticipate that they will need an abortion; like other medical care that may come unanticipated (such as the need for emergency surgery, or a diagnosis of cancer) it needs to be covered in the “regular” policy. See the excellent analysis by Jodi Jacobson, “The ‘Real Life’ Effects of Stupak-Pitts: An Analysis by Legal Experts at Planned Parenthood”, or at the Planned Parenthood site, http://plannedparenthoodaction.org/healthreform/668.htm.
The only exceptions allowed under Stupak-Pitts are for abortions resulting from rape, incest, or danger to the life of the mother. Note that this would not only include danger to the mental health of the mother, but would exclude terminations for fetal anomalies, even those incompatible with life. Thus, as is already the case in states such as Mississippi and Louisiana, which have such laws, women can get prenatal testing with ultrasound and amniocentesis, but have no legal access within their states for terminations if something is demonstrated to be wrong. They cannot even be referred. Luckily, at this time, they can go to other states. The Stupak amendment would make the current situation worse.
A group of at least 40 women in Congress, led by Diana DeGette of Colorado, have signed on to a letter demanding that Stupak-Pitts be removed from any final health reform bill. They deserve all the support that they can get, from other members of Congress, from their constituents, and from those who are residents in districts with representatives who voted for Stupak-Pitts. Note that this effort is led by women in Congress. This, obviously, is not a coincidence. Women are the people who get pregnant, including when it is not planned, including when the fetus has anomalies incompatible with life. There are many women, as well as men, who oppose abortion in the sense that they would not have one, that they might counsel friends and relatives not to have one, but also believe that the ultimate decision about what happens to a woman is hers, not theirs. There are also many women, as well as men, in Congress and in the public, who support the concept of Stupak-Pitts and Hyde and other restrictions on abortion, who believe it is their right to make decisions for other women. But none of the men will ever get pregnant themselves. There are many women who were strongly opposed to abortion who have had abortions because their circumstances were special. No men have had to. The role of men, including, obviously, the Catholic Bishops – who, amazingly, are all men! – in fighting for restrictions on abortion, is grossly immoral and offensive.
President Obama has indicated that he will seek some revision of Stupak-Pitts, as described in the New York Times article “Obama seeks revision of plan’s abortion limits”, but even his position would continue the Hyde Amendment restrictions. This has to stop. Women’s lives and health need to stop being the pawns of politicians.
Thursday, November 12, 2009
Sunday, November 8, 2009
Celebrating the Defeat of the Opponents of Health Reform
.
Last night, late on November 7, 2009, HR 3962, the health reform bill jointly worked out by 3 House committees, passed the House by the narrow margin of 220-215. All Republicans but one (Anh "Joseph" Cao of Louisiana) plus 39 Democrats voted against it. This is reason enough to be glad that it passed, despite the limitations of the bill itself. It did not come so close because of progressives concerned about those limitations voting against it; it came so close because there are so many in Congress who are opposed to any improvement in the access to health care for the American people. It is important that they were defeated, even if by a slim margin, because they are voices for an untenable and unjust status quo.
The bill that passed the House is not a good health reform plan on the face of it. It will leave millions of Americans uninsured. It will not provide a significant limit on the ability of insurance companies to profit from the health problems of our people. A wise and clear analysis of the limitations of the bill is provided by John Geyman, MD, Professor and Chair Emeritus of Family Medicine at the University of Washington and author of the official blog of Physicians for a National Health Program (PNHP). In his piece Health Care Reform 2009: No Bill is Better than a Bad Bill, he makes the case that it should not pass. PNHP’s official position before the vote was: “We have been asked how to tell members to vote on the House bill. Our response is that the bill is ‘like aspirin for breast cancer’.” I agree with their analysis of the bill, and still hope (but am not optimistic) that a better bill will eventually emerge from conference, but have to disagree that it would have been better for it to have been defeated, because that would not have been seen as a victory for progressives, but rather have been a victory for the forces of darkness.
Herb Freeman, a long-time social activist and observer (and a close relative), writes:
“Because of the tenor of the health bill discussion in the House today [November 7] on C-span, and after receiving an e-mail showing what cost of living and earnings were in the US 100 years ago, I started to Google how and when other changes were made. In looking up information on other federally-mandated social modifications (or improvements), such as abolition of child labor (1938), compulsory public education (early 1900s), fair labor standards (especially the 40-hour week, 1938) and food standards and examination, I came across some surprising things:
Wikipedia mostly quotes libertarian approaches to public education as destructive to the "educable" and wasteful to the "others."
The impact of the 40-hour week is largely negated by 12-hour work days, elimination of overtime after an 8-hour day, partially because of the lack of a national health plan, which makes insurance too expensive for employers and partially from lost vacations to compensate from static wages.
I reviewed the arguments made, both at the time of passage and to this day, against 68 or more laws that protect people from gross exploitation as workers, and they are exactly what I heard today on C-Span for several hours on the health bill from these dinosaurs from Texas, Mississippi, Wisconsin and Utah, etc.”
The cruel and vicious racist and classist arguments that were made against child labor laws and a 40-hour week and fair wages, that were based in ideas that some people were “educable” and others were not, that exploitation was ok, are the same ones we heard in the health care debate. They were evil and wrong back then, and they are evil and wrong now. The laws that Mr. Freeman refers to, which offer some protection for workers, have indeed been eroded, but to the extent that they exist, and that there is a strong belief on the part of most people that they are good things, help to protect against the worst of exploitation. Many of them also passed, in their day, by narrow margins. I think that the importance of passing HR 3962 was that, by a narrow majority in the House (representing, of course, a much larger majority in the country, that of the people who are not rich or corporations to give money to congresspeople), is that it rejected the narrow-minded selfishness and toadying-to-their-wealthy-benefactors of its opponents
I am not optimistic that the Senate bill will be better (Professor Leonard Rodberg, PhD, Chair of Urban Studies at Queens College/CUNY, describes in Don McCanne’s Quote of the Day how the current plan is bad (he calls it a DOG, but I like my dogs!) or that there will be much improvement in the bill that comes out of conference. It is very unfortunate that there is not a single-payer plan, and that Rep. Anthony Weiner’s single-payer plan was not brought to a vote. I still hope that the proposal by Rep. Dennis Kucinich to allow states to pilot single-payer programs (which passed the committee with support from even some Republicans) may yet happen. Single payer got much further along in the debate than the administration and leadership, which tried to kill it at the beginning of the debate, hoped.
But the most important point is that, whatever, the content of the bill, on this one night, by a narrow margin, a bill passed that says the American people should have access to health care, whatever its limitations in actually providing for it, passed, and it passed over the opposition of those who only support legislation that benefits the privileged minority, and opposed, as they have always opposed, programs that benefit all of our people. I celebrate their defeat.
Last night, late on November 7, 2009, HR 3962, the health reform bill jointly worked out by 3 House committees, passed the House by the narrow margin of 220-215. All Republicans but one (Anh "Joseph" Cao of Louisiana) plus 39 Democrats voted against it. This is reason enough to be glad that it passed, despite the limitations of the bill itself. It did not come so close because of progressives concerned about those limitations voting against it; it came so close because there are so many in Congress who are opposed to any improvement in the access to health care for the American people. It is important that they were defeated, even if by a slim margin, because they are voices for an untenable and unjust status quo.
The bill that passed the House is not a good health reform plan on the face of it. It will leave millions of Americans uninsured. It will not provide a significant limit on the ability of insurance companies to profit from the health problems of our people. A wise and clear analysis of the limitations of the bill is provided by John Geyman, MD, Professor and Chair Emeritus of Family Medicine at the University of Washington and author of the official blog of Physicians for a National Health Program (PNHP). In his piece Health Care Reform 2009: No Bill is Better than a Bad Bill, he makes the case that it should not pass. PNHP’s official position before the vote was: “We have been asked how to tell members to vote on the House bill. Our response is that the bill is ‘like aspirin for breast cancer’.” I agree with their analysis of the bill, and still hope (but am not optimistic) that a better bill will eventually emerge from conference, but have to disagree that it would have been better for it to have been defeated, because that would not have been seen as a victory for progressives, but rather have been a victory for the forces of darkness.
Herb Freeman, a long-time social activist and observer (and a close relative), writes:
“Because of the tenor of the health bill discussion in the House today [November 7] on C-span, and after receiving an e-mail showing what cost of living and earnings were in the US 100 years ago, I started to Google how and when other changes were made. In looking up information on other federally-mandated social modifications (or improvements), such as abolition of child labor (1938), compulsory public education (early 1900s), fair labor standards (especially the 40-hour week, 1938) and food standards and examination, I came across some surprising things:
Wikipedia mostly quotes libertarian approaches to public education as destructive to the "educable" and wasteful to the "others."
The impact of the 40-hour week is largely negated by 12-hour work days, elimination of overtime after an 8-hour day, partially because of the lack of a national health plan, which makes insurance too expensive for employers and partially from lost vacations to compensate from static wages.
I reviewed the arguments made, both at the time of passage and to this day, against 68 or more laws that protect people from gross exploitation as workers, and they are exactly what I heard today on C-Span for several hours on the health bill from these dinosaurs from Texas, Mississippi, Wisconsin and Utah, etc.”
The cruel and vicious racist and classist arguments that were made against child labor laws and a 40-hour week and fair wages, that were based in ideas that some people were “educable” and others were not, that exploitation was ok, are the same ones we heard in the health care debate. They were evil and wrong back then, and they are evil and wrong now. The laws that Mr. Freeman refers to, which offer some protection for workers, have indeed been eroded, but to the extent that they exist, and that there is a strong belief on the part of most people that they are good things, help to protect against the worst of exploitation. Many of them also passed, in their day, by narrow margins. I think that the importance of passing HR 3962 was that, by a narrow majority in the House (representing, of course, a much larger majority in the country, that of the people who are not rich or corporations to give money to congresspeople), is that it rejected the narrow-minded selfishness and toadying-to-their-wealthy-benefactors of its opponents
I am not optimistic that the Senate bill will be better (Professor Leonard Rodberg, PhD, Chair of Urban Studies at Queens College/CUNY, describes in Don McCanne’s Quote of the Day how the current plan is bad (he calls it a DOG, but I like my dogs!) or that there will be much improvement in the bill that comes out of conference. It is very unfortunate that there is not a single-payer plan, and that Rep. Anthony Weiner’s single-payer plan was not brought to a vote. I still hope that the proposal by Rep. Dennis Kucinich to allow states to pilot single-payer programs (which passed the committee with support from even some Republicans) may yet happen. Single payer got much further along in the debate than the administration and leadership, which tried to kill it at the beginning of the debate, hoped.
But the most important point is that, whatever, the content of the bill, on this one night, by a narrow margin, a bill passed that says the American people should have access to health care, whatever its limitations in actually providing for it, passed, and it passed over the opposition of those who only support legislation that benefits the privileged minority, and opposed, as they have always opposed, programs that benefit all of our people. I celebrate their defeat.
Wednesday, November 4, 2009
Poverty and Uninsurance Diverge: So let’s solve the problem!
.
Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.
Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.
This means, obviously, that there are many non-poor uninsured people, and this is a national phenomenon. For most of this century, poverty and uninsurance rates tracked together. But in the late 1990s, with poverty rates decreasing, uninsurance rates continued to rise. With the recent recession, both have climbed, but uninsurance is rising at a higher rate. (See graph).
This dissociation between poverty and uninsurance is a very troubling phenomenon; while it is bad enough for poor people to not have financial access to health care, more and more of the uninsured are not poor.
Thus the case for health reform: let’s do something about this. Let’s dissociate the “privilege” of having health insurance from being employed by an entity large enough to afford to provide it, and make sure everyone has financial access to high quality care. Unfortunately, the current plans in the Congress will not do so. The recent assurance by Senate Majority Leader Reid that the Senate bill will contain a “public option”, as will the House bill, obscures the fact that the public option it contains will be weak; in an ostensible effort to not give the public option an “unfair advantage” over private insurance plans, it has been given an unfair disadvantage – it will not be able to use its public status to set rates for provider compensation, as does Medicare, or for drug prices, as Medicare (under the bad restrictions of Part D) also does not.
This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?
Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.
The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.
Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.
I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.
*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.
[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
.
This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?
Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.
The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.
Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.
I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.
*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.
[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
.
Saturday, October 31, 2009
Dietary Supplements can be Dangerous for your Health
.
Lots of people take non-prescription “food supplements”, nutritional additives, “vitamins”, “energy tonics”, etc. These are particularly attractive if they are labeled “natural” or “organic”. For some folks, the goal is “general health” – the vitamins, minerals, herbs and other preparations, the herbs that. Many of the users of these substances, whether bought from retail outlets or over the internet are precisely those who disdain prescription medications, who don’t like to “take drugs” but take these “natural” substances. Others are taking them for a specific purpose – weight loss, muscle building, pain relief, energy – often when their doctors have refused to prescribe them, because they are dangerous, or illegal, or both.
Thus, we might conceive of two groups of the 114 million of us who take these medications. “Group 1” are those who believe in “natural” and are trying to “naturally” get healthier. “Group 2” wants magic drugs to help them achieve a goal, would be happy to take them if they could find a doctor to prescribe them, but can’t. Unfortunately, this is much a more hypothetical than real distinction, as there is considerable overlap. Many people in the first group can find their way into the other when they develop symptoms. Especially if the treatments are ostensibly “natural”.
A “Perspective” article in the New England Journal of Medicine, October 15, 2009, by Pieter A. Cohen, MD, titled “American Roulette – Contaminated Dietary Supplements”, discusses these issues. Cohen starts by discussing a police sergeant who lost his job after random drug tests found him positive for amphetamines – an unlabeled ingredient present in the weight-loss supplement he had been taking. It goes on to discuss contaminants found in many such over the counter supplements, both imported and made in USA, sold in retail stores and over the Internet. He notes that the 140 contaminated supplements that the FDA has identified are only a small percentage of those on the market; recently 75 weight-loss drugs were found to be contaminated. And “contamination” is not always the correct word. It implies inadvertent (although perhaps through inadequate quality control) substances present that are not on the label – such as rodent hairs or lead or other heavy metals (beryllium, cadmium, arsenic, etc., which are all poisons that accumulate in the body), bacteria, and plant molds. However, frequently the “off-label” ingredients are there on purpose – they are the drugs that are actually having the desired effect – amphetamines for weight loss or energy, anabolic steroids for muscle building, corticosteroids for arthritis relief, opiates for pain. And these are drugs that are illegal to sell without a prescription (and often heavily restricted even with a prescription!) so they are left off the label. And, in part because the FDA has had its budget gutted and has too few inspectors, are undetected.
There are other reasons that the FDA does not detect such accidental or purposeful adulteration. One is the Dietary Supplement Health and Education Act (DSHEA) of 1994, that limited the ability of the FDA to regulate them. The DSHEA was pushed by the supplement manufacturers, with support of many ordinary people who feared that increased FDA regulation would lead to loss of free access to these substances. Before 1994, Cohen writes, “These supplements, which include botanical products, vitamins and minerals, amino acids, and tissue extracts…were considered food additives, and their manufacturers were required to show proof of safety before marketing them. Since the passage of the DSHEA, dietary supplements are presumed to be safe and can be marketed with very little oversight.” And American consumers, looking for magic potions, pay the price in their health.
There are a few things to remember when considering purchasing and taking dietary supplements, even ones you have long taken. They include:
--“Natural” does not mean “good” or even “safe”. There are plenty of natural poisons, and most substances, taken in excessive amounts can have adverse effects. Similarly, “made in a pharmaceutical laboratory” does not mean “bad”; usually, if it is a reputable and inspected lab (including the pharmaceutical manufacturers I often criticize) it means that there is much more quality control.
--If a substance actually has “good” effects, it can also have “side effects”. Substances only have effects. They don’t know what you want and don’t want. If a substance is actually having biological effects on your body (as opposed to psychological placebo effects), it doesn’t matter if it is “natural” or manufactured, from a plant or a chemical. If, for example, the estrogens in plants “work” just as well as those from animals (mare urine) or chemically produced, they will have the same sort of risks.
--Unregulated or under-regulated substances are often “contaminated”, and this is particularly true for those made in other countries and often bought over the Internet. In this case I mean truly “contaminated”, with the lead, bacteria, molds, and toxins I mention above.
--Plants vary in potency. Thus “1 leaf” or “1 ounce” of a plant may have very different amounts of active ingredient depending upon where and what season it was grown in, and just in terms of random variation. If you buy the actual plants – and if you are a skilled enough botanist to be sure of what you are buying – the variable potency needs to be considered. If, however, you are buying capsules said to contain a specific plant, you are, as described above, shooting craps with your health, because these are subject to much less regulation than “standard” pharmaceuticals.
--If it seems too good to be true, it almost certainly is. If a substance you buy, over the Internet or from a retailer, works amazingly well, it is likely that it contains, probably unlabeled, a very potent drug such as steroids, amphetamines, or opiates. Maybe you knew that and wanted it because your mean doctor would not prescribe them. Maybe that makes you unwise. However, if you bought them under the impression that they were “natural” and “safe”, you may be in for a big surprise. And this is likely to be in terms of the serious adverse effects that led them to be highly regulated in the first place.
Finally, the people manufacturing and selling these “supplements” are profit-making companies. Calling themselves “organic” or “natural” does not make them automatically nice, safe, good guys. As in any other industry, as we have seen so often over the last year, there are opportunists who will lie, cheat, steal, and poison you to make a buck. Strong regulation, well-funded regulation, is the only thing we have on our side to protect us. Limiting regulations of substances that can affect our health is almost always wrong. The DSHEA was a mistake, and well-meaning people who supported it made a mistake in doing so. They now need to demand that their legislators protect them at least as much from over-the-counter dietary supplements as they do from prescription drugs!
.
Lots of people take non-prescription “food supplements”, nutritional additives, “vitamins”, “energy tonics”, etc. These are particularly attractive if they are labeled “natural” or “organic”. For some folks, the goal is “general health” – the vitamins, minerals, herbs and other preparations, the herbs that. Many of the users of these substances, whether bought from retail outlets or over the internet are precisely those who disdain prescription medications, who don’t like to “take drugs” but take these “natural” substances. Others are taking them for a specific purpose – weight loss, muscle building, pain relief, energy – often when their doctors have refused to prescribe them, because they are dangerous, or illegal, or both.
Thus, we might conceive of two groups of the 114 million of us who take these medications. “Group 1” are those who believe in “natural” and are trying to “naturally” get healthier. “Group 2” wants magic drugs to help them achieve a goal, would be happy to take them if they could find a doctor to prescribe them, but can’t. Unfortunately, this is much a more hypothetical than real distinction, as there is considerable overlap. Many people in the first group can find their way into the other when they develop symptoms. Especially if the treatments are ostensibly “natural”.
A “Perspective” article in the New England Journal of Medicine, October 15, 2009, by Pieter A. Cohen, MD, titled “American Roulette – Contaminated Dietary Supplements”, discusses these issues. Cohen starts by discussing a police sergeant who lost his job after random drug tests found him positive for amphetamines – an unlabeled ingredient present in the weight-loss supplement he had been taking. It goes on to discuss contaminants found in many such over the counter supplements, both imported and made in USA, sold in retail stores and over the Internet. He notes that the 140 contaminated supplements that the FDA has identified are only a small percentage of those on the market; recently 75 weight-loss drugs were found to be contaminated. And “contamination” is not always the correct word. It implies inadvertent (although perhaps through inadequate quality control) substances present that are not on the label – such as rodent hairs or lead or other heavy metals (beryllium, cadmium, arsenic, etc., which are all poisons that accumulate in the body), bacteria, and plant molds. However, frequently the “off-label” ingredients are there on purpose – they are the drugs that are actually having the desired effect – amphetamines for weight loss or energy, anabolic steroids for muscle building, corticosteroids for arthritis relief, opiates for pain. And these are drugs that are illegal to sell without a prescription (and often heavily restricted even with a prescription!) so they are left off the label. And, in part because the FDA has had its budget gutted and has too few inspectors, are undetected.
There are other reasons that the FDA does not detect such accidental or purposeful adulteration. One is the Dietary Supplement Health and Education Act (DSHEA) of 1994, that limited the ability of the FDA to regulate them. The DSHEA was pushed by the supplement manufacturers, with support of many ordinary people who feared that increased FDA regulation would lead to loss of free access to these substances. Before 1994, Cohen writes, “These supplements, which include botanical products, vitamins and minerals, amino acids, and tissue extracts…were considered food additives, and their manufacturers were required to show proof of safety before marketing them. Since the passage of the DSHEA, dietary supplements are presumed to be safe and can be marketed with very little oversight.” And American consumers, looking for magic potions, pay the price in their health.
There are a few things to remember when considering purchasing and taking dietary supplements, even ones you have long taken. They include:
--“Natural” does not mean “good” or even “safe”. There are plenty of natural poisons, and most substances, taken in excessive amounts can have adverse effects. Similarly, “made in a pharmaceutical laboratory” does not mean “bad”; usually, if it is a reputable and inspected lab (including the pharmaceutical manufacturers I often criticize) it means that there is much more quality control.
--If a substance actually has “good” effects, it can also have “side effects”. Substances only have effects. They don’t know what you want and don’t want. If a substance is actually having biological effects on your body (as opposed to psychological placebo effects), it doesn’t matter if it is “natural” or manufactured, from a plant or a chemical. If, for example, the estrogens in plants “work” just as well as those from animals (mare urine) or chemically produced, they will have the same sort of risks.
--Unregulated or under-regulated substances are often “contaminated”, and this is particularly true for those made in other countries and often bought over the Internet. In this case I mean truly “contaminated”, with the lead, bacteria, molds, and toxins I mention above.
--Plants vary in potency. Thus “1 leaf” or “1 ounce” of a plant may have very different amounts of active ingredient depending upon where and what season it was grown in, and just in terms of random variation. If you buy the actual plants – and if you are a skilled enough botanist to be sure of what you are buying – the variable potency needs to be considered. If, however, you are buying capsules said to contain a specific plant, you are, as described above, shooting craps with your health, because these are subject to much less regulation than “standard” pharmaceuticals.
--If it seems too good to be true, it almost certainly is. If a substance you buy, over the Internet or from a retailer, works amazingly well, it is likely that it contains, probably unlabeled, a very potent drug such as steroids, amphetamines, or opiates. Maybe you knew that and wanted it because your mean doctor would not prescribe them. Maybe that makes you unwise. However, if you bought them under the impression that they were “natural” and “safe”, you may be in for a big surprise. And this is likely to be in terms of the serious adverse effects that led them to be highly regulated in the first place.
Finally, the people manufacturing and selling these “supplements” are profit-making companies. Calling themselves “organic” or “natural” does not make them automatically nice, safe, good guys. As in any other industry, as we have seen so often over the last year, there are opportunists who will lie, cheat, steal, and poison you to make a buck. Strong regulation, well-funded regulation, is the only thing we have on our side to protect us. Limiting regulations of substances that can affect our health is almost always wrong. The DSHEA was a mistake, and well-meaning people who supported it made a mistake in doing so. They now need to demand that their legislators protect them at least as much from over-the-counter dietary supplements as they do from prescription drugs!
.
Tuesday, October 27, 2009
PSA Screening: “One of Medicine's Great Success Stories"?
.
Guest blog by Robert Ferrer, MD MPH
I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special Report: Cancer Treatment Options," paid for by some of our finest cancer centers. [1] In the prostate cancer section, I found this interesting assertion, in big capital letters: "The PSA test for prostate cancer detection and management is one of medicine's great success stories." It goes on to say that 90% of prostate ca is now diagnosed when curable and that the death rate has declined by 40% since the PSA test began to be widely used in the 1980's. The source is the chair of urology and senior vice president for translational research at Roswell Park Cancer Institute in Buffalo, where the the PSA test was developed.
I found the assertion curious because this past March the New England Journal of Medicine published 2 long-awaited studies[2],[3] on whether PSA testing was effective: one found a modest benefit and the other virtually none. Both noted that a very large number of men had to be screened and treated for every one who benefited. These articles received extensive press coverage. And just as I was going to my laptop today to assemble this and other maybe-not-such-a-great-success-story evidence for PSA screening, this week's JAMA showed up with a terrific paper by Esserman, Shieh, and Thompson.[4] They have this to say about PSA screening:
"After 2 1/2 decades of screening for [breast and] prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has some effect, but it comes at significant cost, including over-diagnosis, overtreatment, and complications of therapy."
So how do we get from "great success story" to "troubling"? How can diagnosing cancer early not be a good thing? The answer lies in the kind of cancers we can detect with screening. Slow growing cancers, the kind unlikely to kill you, grow... slowly and so are around for a long time to be detected by screening. On the other hand, fast growing cancers can go from undetectable to lethal even in the year between cancer screenings. So the cancers we detect through screening are more likely to be the non-lethal kind. Well, isn't that still a good thing? Can't cancer harm without killing?
Yes, but the issue here is what we call "cancer." Our screening tests can detect collections of cells that are, by pathologists' standards, "cancer" when viewed under the microscope, yet not every collection of such cells is destined act like cancer; that is, to grow or spread (metastasize) to other parts of the body. Some are destined to remain dormant until the person eventually dies of something else. And therein lies the problem with PSA screening. It detects many of the ones destined to be dormant or slow growing for every one destined to be lethal. The exact number is uncertain, but the large European study in the NEJM this March estimated 1410 men needed to be screened and 48 cases of prostate cancer treated to prevent 1 death. [2] The American study released in parallel found the benefits to be even smaller. [3]
What this means, is that the consequence of PSA testing for many men is adding 6-12 years of life diagnosed -- and often treated -- as a cancer patient, without actually living any longer.
Just how much over-diagnosis can we attribute to PSA? In the August 2009 issue of the Journal of the National Cancer Institute, H. Gilbert Welch and Peter Alberson calculate than in the first 19 years of the PSA era, 1987 to 2005, about 1.3 million additional cases were diagnosed and 1 million more men treated.[5] They estimate that about half of these extra cases represent over-diagnosis, meaning that the diagnosed man was very unlikely to die from prostate cancer. So of the roughly 4 million men diagnosed from 1985 to 2005, half a million were over-diagnosed.
What about the fact that, as the Roswell Park urologists note, mortality rates have fallen since PSA testing began in the mid-80's? Doesn't that suggest that PSA is helping? The authors in this week's JAMA paper address this in their analysis. For that claim to be credible, we should be seeing a sharp fall in number of advanced stage prostate cancers, which is what would happen if screening was finding the "bad" cancers early, before they could reach an advanced stage. Although we have indeed seen a fall in advanced cancers it has been nowhere near as sharp as we would expect, given the many more cancers we are finding in the PSA era. We should thus probably look elsewhere to explain the fall in prostate cancer mortality, likely improvements in treatment.
So, given what we know about how well PSA testing performs as a screening test, how can it be advertised as one of medicine's great success stories? As potential explanations, I offer two themes that I believe also offer some larger lessons for why health care is less effective and more expensive than it should be.
Theme 1: Thinking about organs rather than people: If your focus is the prostate, then finding and removing cancerous prostates is the goal. This works well at the level of prostates, but not so well for whole men. With a test as imperfect as the PSA, a small or nonexistent reduction in the risk of dying from prostate cancer is sometimes traded for diminished quality of life, most commonly the incontinence and impotence that affect about 1/4 of men treated for prostate cancer.
Theme 2: Economic incentives favoring procedures. As the numbers above demonstrate, PSA has expanded the number of prostate cancer patients by about a third. The professional urology association has long recommended PSA screening even when the US Preventive Services Task Force, tasked with providing rigorous assessments for screening procedures, has consistently recommended against routine PSA screening.
Themes 1 and 2 intertwine. Greed is not what drives PSA testing. When a urologist can make a prostate cancer diagnosis and provide a "cure," doctor and patient alike perceive it as a valuable service. A life-saving intervention. That the service is well reimbursed appears justified when the stakes seem so high. It is only from the application of healthy skepticism and careful analysis -- of outcomes for people, not organs -- that we can reach better conclusions about the value of what we do.
The topic of PSA screening was previously addressed (if less well) in PSA Screening: What is the Value? March 21, 2009
[1] Anonymous. Health and Wellness Outlook Special Report: Cancer Treatment Options [advertising supplement]. New York Times Magazine, 11 October 2009. p. 33-46
[2] Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine. 2009a;360:1320.
[3] Andriole GL, Crawford ED, Grubb III RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009b;360:1310.
[4] Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. c;302:1686-1692.
[5] Welch HG, Albertsen PC. Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst. 2009c;101:1325-1329
This topic was also addressed previously in PSA Screening: What is the Value? March 21, 2009
.
Guest blog by Robert Ferrer, MD MPH
I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special Report: Cancer Treatment Options," paid for by some of our finest cancer centers. [1] In the prostate cancer section, I found this interesting assertion, in big capital letters: "The PSA test for prostate cancer detection and management is one of medicine's great success stories." It goes on to say that 90% of prostate ca is now diagnosed when curable and that the death rate has declined by 40% since the PSA test began to be widely used in the 1980's. The source is the chair of urology and senior vice president for translational research at Roswell Park Cancer Institute in Buffalo, where the the PSA test was developed.
I found the assertion curious because this past March the New England Journal of Medicine published 2 long-awaited studies[2],[3] on whether PSA testing was effective: one found a modest benefit and the other virtually none. Both noted that a very large number of men had to be screened and treated for every one who benefited. These articles received extensive press coverage. And just as I was going to my laptop today to assemble this and other maybe-not-such-a-great-success-story evidence for PSA screening, this week's JAMA showed up with a terrific paper by Esserman, Shieh, and Thompson.[4] They have this to say about PSA screening:
"After 2 1/2 decades of screening for [breast and] prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has some effect, but it comes at significant cost, including over-diagnosis, overtreatment, and complications of therapy."
So how do we get from "great success story" to "troubling"? How can diagnosing cancer early not be a good thing? The answer lies in the kind of cancers we can detect with screening. Slow growing cancers, the kind unlikely to kill you, grow... slowly and so are around for a long time to be detected by screening. On the other hand, fast growing cancers can go from undetectable to lethal even in the year between cancer screenings. So the cancers we detect through screening are more likely to be the non-lethal kind. Well, isn't that still a good thing? Can't cancer harm without killing?
Yes, but the issue here is what we call "cancer." Our screening tests can detect collections of cells that are, by pathologists' standards, "cancer" when viewed under the microscope, yet not every collection of such cells is destined act like cancer; that is, to grow or spread (metastasize) to other parts of the body. Some are destined to remain dormant until the person eventually dies of something else. And therein lies the problem with PSA screening. It detects many of the ones destined to be dormant or slow growing for every one destined to be lethal. The exact number is uncertain, but the large European study in the NEJM this March estimated 1410 men needed to be screened and 48 cases of prostate cancer treated to prevent 1 death. [2] The American study released in parallel found the benefits to be even smaller. [3]
What this means, is that the consequence of PSA testing for many men is adding 6-12 years of life diagnosed -- and often treated -- as a cancer patient, without actually living any longer.
Just how much over-diagnosis can we attribute to PSA? In the August 2009 issue of the Journal of the National Cancer Institute, H. Gilbert Welch and Peter Alberson calculate than in the first 19 years of the PSA era, 1987 to 2005, about 1.3 million additional cases were diagnosed and 1 million more men treated.[5] They estimate that about half of these extra cases represent over-diagnosis, meaning that the diagnosed man was very unlikely to die from prostate cancer. So of the roughly 4 million men diagnosed from 1985 to 2005, half a million were over-diagnosed.
What about the fact that, as the Roswell Park urologists note, mortality rates have fallen since PSA testing began in the mid-80's? Doesn't that suggest that PSA is helping? The authors in this week's JAMA paper address this in their analysis. For that claim to be credible, we should be seeing a sharp fall in number of advanced stage prostate cancers, which is what would happen if screening was finding the "bad" cancers early, before they could reach an advanced stage. Although we have indeed seen a fall in advanced cancers it has been nowhere near as sharp as we would expect, given the many more cancers we are finding in the PSA era. We should thus probably look elsewhere to explain the fall in prostate cancer mortality, likely improvements in treatment.
So, given what we know about how well PSA testing performs as a screening test, how can it be advertised as one of medicine's great success stories? As potential explanations, I offer two themes that I believe also offer some larger lessons for why health care is less effective and more expensive than it should be.
Theme 1: Thinking about organs rather than people: If your focus is the prostate, then finding and removing cancerous prostates is the goal. This works well at the level of prostates, but not so well for whole men. With a test as imperfect as the PSA, a small or nonexistent reduction in the risk of dying from prostate cancer is sometimes traded for diminished quality of life, most commonly the incontinence and impotence that affect about 1/4 of men treated for prostate cancer.
Theme 2: Economic incentives favoring procedures. As the numbers above demonstrate, PSA has expanded the number of prostate cancer patients by about a third. The professional urology association has long recommended PSA screening even when the US Preventive Services Task Force, tasked with providing rigorous assessments for screening procedures, has consistently recommended against routine PSA screening.
Themes 1 and 2 intertwine. Greed is not what drives PSA testing. When a urologist can make a prostate cancer diagnosis and provide a "cure," doctor and patient alike perceive it as a valuable service. A life-saving intervention. That the service is well reimbursed appears justified when the stakes seem so high. It is only from the application of healthy skepticism and careful analysis -- of outcomes for people, not organs -- that we can reach better conclusions about the value of what we do.
The topic of PSA screening was previously addressed (if less well) in PSA Screening: What is the Value? March 21, 2009
[1] Anonymous. Health and Wellness Outlook Special Report: Cancer Treatment Options [advertising supplement]. New York Times Magazine, 11 October 2009. p. 33-46
[2] Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine. 2009a;360:1320.
[3] Andriole GL, Crawford ED, Grubb III RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009b;360:1310.
[4] Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. c;302:1686-1692.
[5] Welch HG, Albertsen PC. Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst. 2009c;101:1325-1329
This topic was also addressed previously in PSA Screening: What is the Value? March 21, 2009
.
Friday, October 23, 2009
"Wall St. Smarts"? Maybe the smart people should be doing something productive
.
The humorist Calvin Trillin had a recent column in the NY Times advancing his theory as to what changed on Wall St. that led to the orgy of greed that both came close to destroying our economy and continues to this day. Because he is a humorist, “Wall Street Smarts” is funny, but its premise is probably, sadly, true. He argues that in his day the smart kids became relatively-low paid professors, judges, etc., while the kids who went on to enter Wall St. careers were from the lower end of his college class, often from families that had long histories of such work and such money (perhaps that is why they didn’t feel they had to work so hard in school). They expected to be rich, but more in the “big house in Greenwich and a sailboat” than the “second oceangoing yacht” rich. But when the “smart kids” entered Wall St. they no longer worked “bankers’ hours” nor were satisfied with the “products” that financiers had long purveyed. They lobbied successfully for changes in laws and regulations and developed new products such as derivatives that nobody understood[1] and made, well, oodles.
And now they are still doing it. We stood at the precipice of global financial collapse and were pulled back only by massive public investment into the finance and banking system. Even “progressives” argued that these institutions, like Goldman Sachs, were “too big to fail”. So we bailed them out and they are now back to making billions of dollars (like Goldman’s most recent quarterly profit) while too many Americans are out of work, and out of hope. The fault lies squarely at the feet of Congress, who is, as on healthcare, totally influenced by the contributions of the wealthy corporations that they continue to do their bidding, and on the administration of President Obama, which has appointed so many insiders that we can’t tell who is actually going to regulate them. The “revolving door” is certainly not new; it has characterized every recent administration, both Republican and Democratic, but we had hoped it would change with this new president.
It hasn’t. Treasury Secretary Timothy Geithner spends all his time on the phone with the executives of Goldman and CitiBank. Chief economic advisor Lawrence Summers comes from Goldman via Harvard. Goldman chief and former Clinton Treasury Secretary Robert Rubin is the current “guru” of financial advice to the President. We keep hoping that the President will, on this issue, on health care, on Afghanistan, take a bold leadership position, but we keep being disappointed. Sunday, Oct 18, 2009’s papers are full of depressing insights. In the NY Times, Maureen Dowd describes in depressing detail President Obama’s history of compromising so much that the baby is lost and the bath water leaks away (“Fie, fatal flaw!”). Frank Rich has a detailed column on the excesses of Goldman Sachs (“Goldman, can you spare a dime?”), comparing them unfavorably to JD Rockefeller’s Standard Oil and the administration’s attempts at regulation unfavorably to Teddy Roosevelt’s. Steve Breen, in his syndicated cartoon in the Kansas City Star, depicts Wall St. at a bar drinking from a bottle labeled “Risk” and saying “I keep drinking ‘cause I have a designated driver”, while a car with the license plate “Bailouts” and Uncle Sam at the wheel idles outside.
This has to stop. The administration needs to fire all the Summerses, Rubins, and Geithners, and get some hard-nosed prosecutors with no sympathy for these folks, like the legendary Ferdinand Pecora of the 1930s, in to reign in these folks. And Congress, with the urging of the administration, needs to pass laws that take these stolen profits away through both a windfall profits tax and limitations on executive income. How much should they be allowed to make? $50,000? $500,000? $2 million? Some amount, and take the rest.
And do what with it? I have said many times that we – represented by the government that is supposed to be ours – should take all that money so that these Wall St. financiers are reduced to living in surplus FEMA trailers. The President has taken some flak because he just made his first trip to New Orleans since taking office (although he traveled there several times since Katrina as a Senator and a candidate) for a visit that lasted only a few hours (and had to end so he could make a fund-raising event in San Francisco). Let’s use the money to rebuild New Orleans. Then this wealth would be used for a good purpose, channeling it back to the people from whom it was stolen.
We are told by Wall St. that limitations on the income of financiers would make it difficult or impossible for them to lure the “best and the brightest”. Maybe Calvin Trillin is right, and having the “best and the brightest” working on Wall St. is part of the etiology of the problem. Maybe they should go back to being professors, judges, doctors, scientists. Solving real problems that the world faces in the environment, human rights, and health. I can’t see any downside.
[1] That’s because they don’t really exist. They are a Ponzi scheme which, through repackaging, sells the same stuff over and over again. And, like a Ponzi scheme, customers who don’t understand it are happy as long as they are making money, but it always collapses. However our new Wall St. tyros learned one thing from traditional brokers – whether the customer is winning or losing, you always take your cut!
The humorist Calvin Trillin had a recent column in the NY Times advancing his theory as to what changed on Wall St. that led to the orgy of greed that both came close to destroying our economy and continues to this day. Because he is a humorist, “Wall Street Smarts” is funny, but its premise is probably, sadly, true. He argues that in his day the smart kids became relatively-low paid professors, judges, etc., while the kids who went on to enter Wall St. careers were from the lower end of his college class, often from families that had long histories of such work and such money (perhaps that is why they didn’t feel they had to work so hard in school). They expected to be rich, but more in the “big house in Greenwich and a sailboat” than the “second oceangoing yacht” rich. But when the “smart kids” entered Wall St. they no longer worked “bankers’ hours” nor were satisfied with the “products” that financiers had long purveyed. They lobbied successfully for changes in laws and regulations and developed new products such as derivatives that nobody understood[1] and made, well, oodles.
And now they are still doing it. We stood at the precipice of global financial collapse and were pulled back only by massive public investment into the finance and banking system. Even “progressives” argued that these institutions, like Goldman Sachs, were “too big to fail”. So we bailed them out and they are now back to making billions of dollars (like Goldman’s most recent quarterly profit) while too many Americans are out of work, and out of hope. The fault lies squarely at the feet of Congress, who is, as on healthcare, totally influenced by the contributions of the wealthy corporations that they continue to do their bidding, and on the administration of President Obama, which has appointed so many insiders that we can’t tell who is actually going to regulate them. The “revolving door” is certainly not new; it has characterized every recent administration, both Republican and Democratic, but we had hoped it would change with this new president.
It hasn’t. Treasury Secretary Timothy Geithner spends all his time on the phone with the executives of Goldman and CitiBank. Chief economic advisor Lawrence Summers comes from Goldman via Harvard. Goldman chief and former Clinton Treasury Secretary Robert Rubin is the current “guru” of financial advice to the President. We keep hoping that the President will, on this issue, on health care, on Afghanistan, take a bold leadership position, but we keep being disappointed. Sunday, Oct 18, 2009’s papers are full of depressing insights. In the NY Times, Maureen Dowd describes in depressing detail President Obama’s history of compromising so much that the baby is lost and the bath water leaks away (“Fie, fatal flaw!”). Frank Rich has a detailed column on the excesses of Goldman Sachs (“Goldman, can you spare a dime?”), comparing them unfavorably to JD Rockefeller’s Standard Oil and the administration’s attempts at regulation unfavorably to Teddy Roosevelt’s. Steve Breen, in his syndicated cartoon in the Kansas City Star, depicts Wall St. at a bar drinking from a bottle labeled “Risk” and saying “I keep drinking ‘cause I have a designated driver”, while a car with the license plate “Bailouts” and Uncle Sam at the wheel idles outside.
This has to stop. The administration needs to fire all the Summerses, Rubins, and Geithners, and get some hard-nosed prosecutors with no sympathy for these folks, like the legendary Ferdinand Pecora of the 1930s, in to reign in these folks. And Congress, with the urging of the administration, needs to pass laws that take these stolen profits away through both a windfall profits tax and limitations on executive income. How much should they be allowed to make? $50,000? $500,000? $2 million? Some amount, and take the rest.
And do what with it? I have said many times that we – represented by the government that is supposed to be ours – should take all that money so that these Wall St. financiers are reduced to living in surplus FEMA trailers. The President has taken some flak because he just made his first trip to New Orleans since taking office (although he traveled there several times since Katrina as a Senator and a candidate) for a visit that lasted only a few hours (and had to end so he could make a fund-raising event in San Francisco). Let’s use the money to rebuild New Orleans. Then this wealth would be used for a good purpose, channeling it back to the people from whom it was stolen.
We are told by Wall St. that limitations on the income of financiers would make it difficult or impossible for them to lure the “best and the brightest”. Maybe Calvin Trillin is right, and having the “best and the brightest” working on Wall St. is part of the etiology of the problem. Maybe they should go back to being professors, judges, doctors, scientists. Solving real problems that the world faces in the environment, human rights, and health. I can’t see any downside.
[1] That’s because they don’t really exist. They are a Ponzi scheme which, through repackaging, sells the same stuff over and over again. And, like a Ponzi scheme, customers who don’t understand it are happy as long as they are making money, but it always collapses. However our new Wall St. tyros learned one thing from traditional brokers – whether the customer is winning or losing, you always take your cut!
Tuesday, October 20, 2009
Red, Blue, and Purple: The Math of Health Care Spending
.
The Business section of the New York Times on October 10, 2009, had a small article by Floyd Norris called “The Divided State of Health Care”. It looks at which states and, within those states, Congressional districts, have the highest number of uninsured. In a neat series of graphics, states are divided into “blue” (voted for Obama, have 2 Democratic senators), “red” (voted for McCain, have 2 Republican senators) and “purple” (some other combination). The red states had the highest percent of uninsured, led by my former state, Texas, with 26.5% of those under 65, including 17.8% of children under 18, uninsured. While not linear (the second highest percentage of uninsured is in Florida, a “purple” state, and third is New Mexico, a “blue” state), the association is strong. My home state of Kansas, which has only one (of 4) Democratic congressional districts, and only 2 of 105 counties that voted for the President, is the "best” of the red states. However, its 13.8% uninsured is worse than 14 of the 21 blue states and 7 of the 17 purple states.
From an ideological point of view, this is not surprising, given the vicious opposition of the Republican Party to any type of meaningful health reform. From a practical point of view, it might be surprising – why are the leaders of those states, where there is such great need, not interested in addressing that need? Or, at least, why do the people in the states that have such great need keep re-electing folks who oppose meeting their need? Part of the explanation may come from the second half of the analysis, which shows that it is the blue (Democratic) congressional districts within the red states that have the highest number of uninsured people. This is because these districts have a lot of poor and minority people and vote Democratic, but to the majority of people in the rest of those states, are the “other”: “Of the 10 Congressional districts with the least health insurance,” writes Norris, “seven are in Texas, two in California and one in Florida. Nine of those districts are largely black or Hispanic, and are represented by Democrats who faced little if any Republican opposition in the last election.” Whether this is explained mostly by classism, racism, or something else is an interesting question, but the result is that if you are a poor or minority person in a conservative state, you are in particularly bad straits.
Of course, it is not only the poor minority inner-city people who are left out. In Kansas, while Wyandotte County (Kansas City), one of the “blue” counties, is the poorest county, and also has a high percent of minorities, the next 6 poorest are in rural, white southeast Kansas. Why do these folks vote against their self-interest for Republicans? (Well, they don’t always.[1]) Some of it is that there are other issues that attract their attention, and some of it is that they believe shamelessly propagated lies.
But some of it, as for so many Americans, is misunderstanding how health care costs work. Most of the money is not spent on most of the people. Journalists, living in their middle-class, young-to-middle aged worlds, are among the worst perpetrators of misunderstanding healthcare usage, writing about their rotator cuff surgery or their neighbor’s strep throat. 50% of people account for only 3% of health care costs; thus half of us are essentially “rounding error”. 5% of people account for 50% of costs. The other 45% are using about “their share”, or 47% of health dollars. If we look at this graphically, using (for fun) red, blue, and purple, we see:
The 45% of people who are using about “their share” are those who have chronic health problems and have to go to doctors more frequently, and get more tests, but don’t have frequent hospitalizations. It also includes the folks who have, in a given year, surgery or physical therapy – like for those rotator cuffs – but usually are in the low use group. This portion of the population includes a disproportionate % of seniors, who have more chronic disease and use more health care services.
Another way to look at it would be for $100 spent on 100 people (whose costs are distributed as per the whole population), 45 people would cost about “their share”, just over $1 each, 50 people would cost $0.06 (6 cents) each, and 5 people would cost $10 each.
Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.
This is an extremely important concept, because it is the reason that insurance exchanges have gone bankrupt in every state that has tried it, and will not work at the federal level. While it is acknowledged that insurance companies “game the system” and “cherry pick” healthier people, the efforts in the current legislation to try to prevent that will not be sufficient, because, given the above data, they don’t have to enroll only people in the “low cost” group (although I’m sure they’d like that!), they just have to find subtle ways to get rid of one or two of those 5 high-cost people. For each one of those people they can avoid, they save the same amount as their cost for 10 “mid-user” people or 167 “low users”. None of the current legislation will be rigorous enough to force each insurance company to enroll 5% of the high users (in part because we don’t always know who they’re going to be – see below – which is also why they can’t have none of them). The insurance “exchanges” for uninsurables will then, soon, just as they have in each state that has tried it, become unsustainably expensive while the insurance companies continue to make big profits. See the amazing report in the Washington Times “Insurer ends health program rather than pay out big” to get a sense of what we can expect from insurance companies. (And note that this is from a very conservative newspaper!)
So if everyone looks at it from the point of view of their current self-interest, those in that “low use, low cost” group wouldn’t want to pay more for all those high-cost, high-use folks. This year, today, it wouldn’t be in our self-interest. Except…
…we don’t know when we, or our teenage children, will be in a car accident that rockets them from the low-cost to the high-cost group. And we don’t know when we’ll have a premature baby, or be diagnosed with cancer, or have us or our parents move from the mid-cost, have-chronic-conditions-and-see-the-doctor-but-rarely-be-hospitalized group to the high-cost be-hospitalized-a-lot-including-in-intensive-care group.
So we are all in it together. And the only system that prevents “gaming”, “cherry picking” and adverse selection is having one system. And that is what we need to adopt.
With profound thanks to Robert Ferrer, MD, MPH
[1] In 2006, the Kansas 2nd Congressional district that includes SE KS, but also the city of Topeka, elected a Democratic Congresswoman, Nancy Boyda, to replace reactionary Jim Ryun, remembered mostly as a KU mile champion. But in 2008, she was defeated by a Republican. SE Kansas also has a populist history, with Crawford County being one of 3 counties in the nation to vote for Gene Debs in 1920.
The Business section of the New York Times on October 10, 2009, had a small article by Floyd Norris called “The Divided State of Health Care”. It looks at which states and, within those states, Congressional districts, have the highest number of uninsured. In a neat series of graphics, states are divided into “blue” (voted for Obama, have 2 Democratic senators), “red” (voted for McCain, have 2 Republican senators) and “purple” (some other combination). The red states had the highest percent of uninsured, led by my former state, Texas, with 26.5% of those under 65, including 17.8% of children under 18, uninsured. While not linear (the second highest percentage of uninsured is in Florida, a “purple” state, and third is New Mexico, a “blue” state), the association is strong. My home state of Kansas, which has only one (of 4) Democratic congressional districts, and only 2 of 105 counties that voted for the President, is the "best” of the red states. However, its 13.8% uninsured is worse than 14 of the 21 blue states and 7 of the 17 purple states.
From an ideological point of view, this is not surprising, given the vicious opposition of the Republican Party to any type of meaningful health reform. From a practical point of view, it might be surprising – why are the leaders of those states, where there is such great need, not interested in addressing that need? Or, at least, why do the people in the states that have such great need keep re-electing folks who oppose meeting their need? Part of the explanation may come from the second half of the analysis, which shows that it is the blue (Democratic) congressional districts within the red states that have the highest number of uninsured people. This is because these districts have a lot of poor and minority people and vote Democratic, but to the majority of people in the rest of those states, are the “other”: “Of the 10 Congressional districts with the least health insurance,” writes Norris, “seven are in Texas, two in California and one in Florida. Nine of those districts are largely black or Hispanic, and are represented by Democrats who faced little if any Republican opposition in the last election.” Whether this is explained mostly by classism, racism, or something else is an interesting question, but the result is that if you are a poor or minority person in a conservative state, you are in particularly bad straits.
Of course, it is not only the poor minority inner-city people who are left out. In Kansas, while Wyandotte County (Kansas City), one of the “blue” counties, is the poorest county, and also has a high percent of minorities, the next 6 poorest are in rural, white southeast Kansas. Why do these folks vote against their self-interest for Republicans? (Well, they don’t always.[1]) Some of it is that there are other issues that attract their attention, and some of it is that they believe shamelessly propagated lies.
But some of it, as for so many Americans, is misunderstanding how health care costs work. Most of the money is not spent on most of the people. Journalists, living in their middle-class, young-to-middle aged worlds, are among the worst perpetrators of misunderstanding healthcare usage, writing about their rotator cuff surgery or their neighbor’s strep throat. 50% of people account for only 3% of health care costs; thus half of us are essentially “rounding error”. 5% of people account for 50% of costs. The other 45% are using about “their share”, or 47% of health dollars. If we look at this graphically, using (for fun) red, blue, and purple, we see:
The 45% of people who are using about “their share” are those who have chronic health problems and have to go to doctors more frequently, and get more tests, but don’t have frequent hospitalizations. It also includes the folks who have, in a given year, surgery or physical therapy – like for those rotator cuffs – but usually are in the low use group. This portion of the population includes a disproportionate % of seniors, who have more chronic disease and use more health care services.
Another way to look at it would be for $100 spent on 100 people (whose costs are distributed as per the whole population), 45 people would cost about “their share”, just over $1 each, 50 people would cost $0.06 (6 cents) each, and 5 people would cost $10 each.
Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.
This is an extremely important concept, because it is the reason that insurance exchanges have gone bankrupt in every state that has tried it, and will not work at the federal level. While it is acknowledged that insurance companies “game the system” and “cherry pick” healthier people, the efforts in the current legislation to try to prevent that will not be sufficient, because, given the above data, they don’t have to enroll only people in the “low cost” group (although I’m sure they’d like that!), they just have to find subtle ways to get rid of one or two of those 5 high-cost people. For each one of those people they can avoid, they save the same amount as their cost for 10 “mid-user” people or 167 “low users”. None of the current legislation will be rigorous enough to force each insurance company to enroll 5% of the high users (in part because we don’t always know who they’re going to be – see below – which is also why they can’t have none of them). The insurance “exchanges” for uninsurables will then, soon, just as they have in each state that has tried it, become unsustainably expensive while the insurance companies continue to make big profits. See the amazing report in the Washington Times “Insurer ends health program rather than pay out big” to get a sense of what we can expect from insurance companies. (And note that this is from a very conservative newspaper!)
So if everyone looks at it from the point of view of their current self-interest, those in that “low use, low cost” group wouldn’t want to pay more for all those high-cost, high-use folks. This year, today, it wouldn’t be in our self-interest. Except…
…we don’t know when we, or our teenage children, will be in a car accident that rockets them from the low-cost to the high-cost group. And we don’t know when we’ll have a premature baby, or be diagnosed with cancer, or have us or our parents move from the mid-cost, have-chronic-conditions-and-see-the-doctor-but-rarely-be-hospitalized group to the high-cost be-hospitalized-a-lot-including-in-intensive-care group.
So we are all in it together. And the only system that prevents “gaming”, “cherry picking” and adverse selection is having one system. And that is what we need to adopt.
With profound thanks to Robert Ferrer, MD, MPH
[1] In 2006, the Kansas 2nd Congressional district that includes SE KS, but also the city of Topeka, elected a Democratic Congresswoman, Nancy Boyda, to replace reactionary Jim Ryun, remembered mostly as a KU mile champion. But in 2008, she was defeated by a Republican. SE Kansas also has a populist history, with Crawford County being one of 3 counties in the nation to vote for Gene Debs in 1920.
Subscribe to:
Comments (Atom)