The Power of Blogging

“In Ender’s Game, Peter and Val influenced world opinion by blogging on well-read message boards using assumed identities created for that purpose. You can tell it was fiction, because of all the people willing to listen to something besides their own opinion.”

-Mark Bates, 8/28/2009 email

Ray’s Link Farm

I’ve added a link to the RSS feed for my Link Farm to the navagation panel on the right side of the blog.   Now you can see all the fun and interesting links that I find while I’m waiting for my next interview, without having to check for them in Facebook.  My free time is your gain.

Subscribe to the feed using your RSS reader (I use Google’s).

Why we need “Death Panels”

The “vast right-wing conspiracy” is trying to scare people into opposing health care reform by distorting the issues.  Those wingnuts, most famously Sarah Palin, are promoting the idea that President Obama is trying to create government “death panels” that will cut off your medical payments and force you to die, just to save money.

The spin here is dizzying.  Obama has not made any concrete reform proposals.  He’s trying to stay above the discussion for now.  There is a proposal in a House plan that would allow coverage for patients who discuss end-of-life options in advance with their doctors.  Since the wingnuts have nothing to contribute themselves and Obama is giving them nothing to attack, they twisted this House proposal into “mandatory Obama death panels”.

The supply of health care money is not infinite, so decisions have to be made.  This is not a bad thing, if patients and their families get the help they need to contribute to the decisions.  Without the information in a typical “death panel” discussion,  patients can’t make informed decisions, families may ask for ineffective but expensive care out of guilt or an inability to let go, and doctors may recommend treatment options that have no chance of curing the patient to avoid accusations that they didn’t do everything possible.   Sometimes these choices do nothing other than prolong a life of agony.

End-of-life care is an important part of the medical care budget.  A look at Medicare, the government program that provides health care for older Americans, shows that 30% of Medicare’s annual costs are spent on the 5% of beneficiaries who will die in a given year. About one-third of the dollars spent in the last year of life are spent in the last month. Researchers found that if only 50 percent of people discussed end-of-life care with their physician, the savings could be more than $76 million a year.

In a study of terminal cancer patients at the Dana-Farber Cancer Institute in Boston, those who had end-of-life conversations spent about one-third less in their last week than those who didn’t. Those who didn’t talk about options had more aggressive treatment, like ending up on ventilators in intensive care or receiving resuscitation. These patients had an inferior quality of death by any measure, they left their families in more emotional and financial distress, and in the end they didn’t live any longer.

These aren’t “death panels”.  Federal law actually bars Medicare from paying for services “the purpose of which is to cause, or assist in causing,” suicide, euthanasia or mercy killing. Euthanasia is not part of the health care reform discussion, no matter how hard the wingnuts try to make you think it is.

Health care reform is complicated enough as it is.  There’s a lot of money at stake, enough to make people switch their positions or use whatever means they can to influence the decision.  When you’re thinking about the issue, weed out the lies, take the time to understand what’s really at stake, make your own decision, and let the politicians know what you want.  And think about having your own “death panel” discussion with your doctor.

There is no Health Care Reform plan yet. How can you be against it?

People talk about the “Obama Health Care Plan” like there actually is one.  The president has proposed some worthy high-level goals, but he hasn’t provided any details about how we can accomplish those goals.  You still have a chance to influence the process of developing a plan, but it’s critical that you make your voice heard now, before it’s too late.

Obama may have decided on his health care strategy after seeing the fate of the Clinton reform plan.  The Clintons went to Congress with a plan, and Congress took that plan and tore it to pieces.  The reform movement collapsed before Congress had to present an alternative plan of its own, so Clinton absorbed the fallout from the failure, and the Republicans took over Congress in the 1994 elections.

President Obama appears to be biding his time, hoping for a sensible plan from Congress, or for an increase in pressure from the public to implement some kind of reform.  So far, he hasn’t invested any of his own political capital to nudge the discussion towards a resolution.  Maybe the president thinks that public disgust with business as usual will allow him to swoop in with a plan towards the end of the process and ram it through to approval.  If he can get Democrats on board, he does have the votes to pass a plan no matter how the Republicans vote.

The vacuum created by the lack of a plan from the President has allowed the “vast right-wing conspiracy” crowd to mobilize against a mythical version of “Obama’s plan.”  Since there is no concrete plan, you can be confident that their opposition is based solely on partisan politics.  There’s no plan, so every detail they rail against has to be made up out of whole cloth.  But that doesn’t stop them from coloring the debate, making it more about irrelevancies like the “death squads” or the lie that England’s health care system wouldn’t have allowed Stephen Hawking to live.  Some key players admit their goal is to block changes, rather than help create a successful reform plan.

Underneath the public discussion, Congress is quietly putting together a “reform” plan that basically protects the existing structure, perpetuating the existing problems.  Why?  The health care industry has spent hundreds of millions of dollars (dollars you paid, that were supposed to go towards your health care) lobbying and contributions.  They’ve bought a seat at the table to protect their interests.

I strongly recommend that you read the excellent job Matt Taibbi does in describing the whole sordid process in the September 5^th Rolling Stone. (At this time, there are videos of Taibbi discussing his story online – the full article is usually posted after the issue of the magazine goes off sale.)

Economic uncertainty is fueling the public’s interest in health care reform, the way it did back in the Clinton years.  In 1993, when the economy improved the public lost interest in change, and the chance was lost.  Now, 16 years and trillions of dollars later, in the midst of an even worse recession, we’re trying again.  Support the effort.  Decide what you want, and then let your government officials know.  If you don’t, someone else will.

I have a dream (for health insurance reform)

In my fantasy world, we’d all realize that society reaps significant benefits when people look out for each other.  Universal health care insurance is one of the core features of that world.  A system that guarantees adequate health care to everyone provides solace to those who crave security and helps with risk management for those who take the entrepreneurial chances that drive progress for us all.

Health care isn’t free.  No matter what health care system we choose, it behooves us to make that system as inexpensive as possible while still providing quality care.

The most “efficient” system for funding health care is one where you pay for your health care when and if you make use of it.  You’d only pay for the care you need, and you’d pay the provider directly, avoiding all the overhead associated with third-party payments.

That’s fine if you’re healthy.  But what if you need an expensive procedure like heart surgery, or you have a long-term ongoing expense like kidney dialysis?  Few individuals can assume the risk of having to pay cash for something like that.  So we have insurance, which allows us to pool the risk and spread the costs around.  Everyone in the insurance pool pays into the system regularly, whether they need care or not, but their liability is covered in the event medical care is needed.

The most effective insurance pool is one that includes everyone.  Anyone without insurance is unlikely to be able to pay for their care themselves, but we don’t let people die because they can’t pay, so the rest of us end up paying somehow.  If we had universal care everyone would pay in to the system, distributing the costs more evenly.  The people who are currently uninsured probably have less money, so they’d put in less than the rest of us, but whatever they put in is more than they’re paying now.  Maybe you’d pay a little more, maybe not.

Even if you do pay more, for that additional money your risk of losing your health care goes away. Without universal health care, if you lose your income or if you need to change your insurance carrier and you have a pre-existing condition that the new carrier won’t cover, you lose.

Then there’s the morality of helping your neighbor in need.  Maybe you believe that everyone should always fend for themselves.  You may think that “handouts” for the poor, like welfare or free health care for the poor, just help keep them poor.  If you believe that, you probably have the care you need, at least for now.  Be careful though.  Karma can be a bitch.

The most effective way to fund basic health coverage for everyone is by a government-managed single-payer system.

Moving to a government-managed, single payer system won’t change the nature of insurance services.  Insurance does not drive health care investment or improved medical techniques.  It’s the desire to profit from the desire that people have to live longer, healthier lives that drives medical progress.  Insurance is just a way of managing risk.  Insurance programs actually resist paying for new, “unproven” treatments, since they’re often initially more expensive and both public and private insurance systems have an interest in keeping costs down.

There are good reasons why the government can do a better job of managing our health care dollars.

First, you have to discard the idea that a private organization is inherently more efficient than a government organization.  Both types of organizations are made up of people.  On average, people are the same, smart or stupid, hard-working or lazy, friendly or cranky, whether they get checks from Uncle Sam or from Aetna.  There are no management secrets unique to one side or the other.

The main difference between the two types of organizations is their goal.  Managers of a public health insurance plan strive to perpetuate their jobs and those of their political bosses by maximizing the perceived health care benefits for the voting public.  A private insurance company’s primary goal is to generate a profit for the owners of the company.  That may involve providing a service to their policyholders, but only to the extent it helps make money.

You can argue about how effectively either group accomplishes their goal.  You can’t argue that removing profit from the equation will save money.  According to Fortune Magazine, the health insurance companies in the Fortune 500 had a 6.2% profit margin in 2008.  They also pay significantly higher salaries to upper management.  Private insurance overhead and profits eat up 20% and more of health care premiums while overhead for Medicare, a government-run insurance system (with no profit) is closer to 3%.  Eliminate the profit and the high salaries and you can save billions of dollars.

On top of eliminating profit, if you change health insurance to a single-payer system, you further increase the efficiency of the health insurance system.  If one organization processes claims, that eliminates an enormous amount of duplication of effort on the part of the insurance industry.  Providers will only need to deal with one set of claim processing rules, so their job gets easier (and cheaper).  And there’ll only be one set of rules for coverage, making it easier for providers to advise patients and easier for patients to understand the system and make it work for them.

The only downside is that “efficiency” for the most part means “fewer people.”  The health insurance industry employs about 444,000 people.  Many of those people will lose their jobs in a transition to a government-run, single-payer system.  Some of them will be able to find work with the public insurance system, but most won’t.  A sudden switch to a public single-payer system would be traumatic.  That’s why a reform plan that calls for adding a public option to the existing stew makes more sense.  As long as the public option is unfettered by regulations designed to protect existing systems, the elimination of profit gives the public option a natural advantage that will over time increase its market share until we get close enough to a single-payer system to make the final transition relatively smooth.

Private insurance companies can still provide supplemental, “gold-plated”, insurance to those who want it, but that would be a much smaller industry.

Insurance is only one part of our health care costs, but it’s the low-hanging fruit for reform.  Once we get insurance straightened out, then we can look at other pieces of the puzzle, like drug and equipment prices, and fees for hospitals and practitioners.  A single, universal insurance system will have more leverage to manage those costs.  Who knows, maybe along the way, people will even begin to take responsibility for the parts of their health care they can control as individuals.

I want to live in a society where we work collectively to help each other, not one where the haves leave everyone else to fend for themselves while they strive to have even more.  Government is our main tool for collective activity.  Many Americans see the idea that a government program could be more efficient than private industry as sacrilegious.  And no one ever wins a religious argument.  There’s a cultural bias towards individualism that we need to overcome before we can look objectively at health insurance.  But if we succeed in making the discussion about using our wealth as effectively as possible to provide the best health care for everyone, and not about communism, socialism, capitalism, or any other “-ism”, it’s pretty clear that universal, single-payer health insurance is the way to go.

Let’s make the fantasy come true!

Health care spending – US vs. the World

How effective is our current health care system?  We could easily do better by going to any other first-world country and copying their system.  Let’s run some numbers.

The charts below were all created using data from 2004/2005 provided by the United Nations Development Programme.  They all use estimated life expectancy as a metric for health.  The first chart plots life expectancy versus health care expenditures.

People in countries that spend more on medical treatment tend to have longer lives, but the biggest spenders don’t necessarily get the best results.

There’s an upper limit to human lifespans, so the rate of return per dollar of wealth (or spending) levels out as life expectancy approaches that limit.  This reduces the correlation between spending and life expectancy to .56 (on a linear scale where a value of 1 indicates a perfect correlation, 0 indicates no correlation at all, and -1 indicates a perfect inverse correlation).

If you focus on the “first-world” countries at the top of the curve, defined as the countries where the life expectancy is 75 years or more, the correlation increases to .61.

The trendline on the chart, calculated using linear regression, summarizes the data.  The countries furthest above the line get the most for their health care dollar, while those below are less effective. The biggest spender, the United States, has by far the least efficient health care system by this measure.  If you remove the US, the correlation between spending and life expectancy rises to a robust .69.

Japan ranks as the most efficient system.  Other countries that we often use as examples, like Britain, Canada, or Germany, all rank well above the US.  All these countries have universal health care systems.  Japan, Britain, and Canada all have single-payer systems, and are all more efficient than Germany, which has a multi-payer system closer to the US system, though the German government is still the primary source of insurance funding.

In health care, as in so many other things, it’s good to be rich.  Luckily, the United States is a wealthy country.  We have to be, because we do a miserable job of spending our wealth effectively.   To improve our health care, we don’t have to develop a new plan.  All we have to do is take one of the more effective ones from another country (the list is long) and copy it.  Ta-da!

Occupational hazards

From your friends at ImprovBoston’s Fun List:

A computer sales executive with a slipped disk

A roofer with shingles

A baker with bunions

An interior designer with rheumatism

A gardener with rosacea

A jeweler with ringworm

An editor with an irritated colon

A tailor with hemorrhoids

A Catholic Priest with cholera

A gymnast with the bends

A lobbyist with influenza

A statistician with polio

A chemist with the vapors

A jockey with the trots

One of the Three Stooges with “Larryngitis”

A cliff diver with cataracts

A relief worker with AIDS

A fisherman with Chlamydia

A beekeeper with HIV

A fruit-picker with Lyme’s Disease

A longshoreman with crabs

A Prius dealer with priapism

A construction worker with erectile dysfunction

A reference librarian with appendicitis

A supervisor with a staff infection

A videographer with tapeworm

A duck hunter with downs syndrome

An oceanographer with diverticulitis

A stenographer with type 2 diabetes

A valet with Parkinson’s disease

A witch with Crohns disease

A postal route planner with male pattern baldness

A wheat farmer with a migraine

A baker with a yeast infection

A doctor with muscular dystrophy (MD)

A math teacher with multiple sclerosis

A knight with cirrhosis

A Jewish lawyer with Epstein-Barr Syndrome

A craps dealer with diarrhea

An executioner with a hangover

A telephone operator with Bell’s Palsy

A geometry teacher with sinusitis

A chiropractor addicted to crack

A DJ with a slipped disc

A worker at a Chinese restaurant with megalomania

And…

An unemployed person who is completely healthy.

Health care, not just sickness care

Health care reform should have two goals: to make health care cheaper, and to make health care better.  These goals seem contradictory, but really they’re not.  The apparent contradiction is because the reform debate isn’t really about “health” care, it’s about “sickness” care. It’s about managing the cost of treatment when something goes wrong.  True “health care” starts before that, by leading the sort of life that reduces your need for medical treatment.

Cheaper sickness care is only a component of a more effective health care plan.  Complete health care involves managing:

• Diet
• Exercise
• Stress
• Your environment
• and only then, if necessary, sickness care

“Sickness care” reform is important, since sickness care spending is the biggest component of government spending. But managing sickness care costs is only a portion of improving health care.  If our health improves, our sickness care costs will go down since we’ll require less of it.  Can the government do more to help?  Should the government do more?

The diet issue consists of two parts.  First and foremost, people need to get enough food.  Government has a role there directly by providing assistance to the poorest people and indirectly to the extent government manages the economy to reduce the number of the poor.  Only after you have enough food can you begin to think about whether you’re eating the right food.  Government could have an indirect role there, encouraging healthy eating by a system of tax credits for healthy food or surcharges for junk food.  But no one really wants the government cast in the role of mommy, watching over what you eat.

The proper amount of exercise can have a positive impact on health.  Not enough exercise and you’re weak and prone to obesity and all that entails (heart disease, diabetes, high blood pressure, etc…).  But too much exercise can also create problems, by driving stress levels up too high or by causing injuries.  Again, government can have an indirect role, by supporting the costs associated with athletic facilities or allowing tax credits for the purchase of exercise equipment.  We could also choose to tax equipment for activities that discourage exercise, like videogames , televisions, books, or other passive forms of entertainment.  But no one wants the government to manage our lives at that level.

Excessive pollution will definitely detract from your health.  Ask the people who lived in Love Canal or Three Mile Island.  Pollution has been shown to contribute to all kinds of problems.  The government has a definite role in regulating pollution.  The trick is to balance the need for a healthy environment against the economic damage caused by costs associated with complying with regulations.

High levels of stress can cause all kinds of physical issues.  The government’s role in managing stress is indirect, but multi-faceted.  Given the government’s power and central role, everything it does has an effect on our quality of life.  But stress is an area where the individual can do more to help himself than the government can, whether by meditation, moderation, or just by cultivating a positive attitude towards life.

Most people would resist the level of government intervention into their personal lives necessary to manage all facets of health care (though many people (bloggers, for example) are perfectly willing to tell others what they need to do). Government has a big role in managing sickness care costs, but that’s only a small part of the total health care package.  Preventative measures are important too.  The government’s most effective role may be providing the information necessary to help people make the best choices for themselves. In the end, if people want better health, they need to take responsibility for their own health care.

Rating Health Care Systems

Don’t listen to anyone who tries to tell you which health care system is best. If you’re going to prove one country’s health care system is better than another, or if you’re going to figure out whether any changes in health care will make a system “the best”, you need an objective metric you can use to compare the quality of any given system, and that metric doesn’t exist.

The most direct way to measure the effectiveness of health care in a country is to take the amount of money a country spends on health care per person and divide it by the life expectancy in that country.  The amount spent per person is probably the most straightforward way to represent the resources allocated to a system.  Obviously, the healthiest life is a long life, so average life expectancy is probably the best way to summarize the health of a population.

Conveniently, the United Nations Development Programme publishes the statistics for health care spending and life expectancy for each country.  The most recent data available is from 2004 and 2005 for 176 different countries.  I ran the numbers to create a “Length Of Life – Cost Against Total” chart (aka LOLCAT).

The United Stated rates dead last, way over at the right side of the chart, worse than Austria or anyone else.  We get less than 5 days of life for each dollar spent on health care.

All this demonstrates is that the most direct, brutally simple, metric is a joke (thus the acronym).  The United States certainly don’t have the worst health care system in the world.  LOLCAT fails because the range in spending is so wide, it overwhelms the comparatively small differences in life expectancy.  Life expectancy ranges from 82.3 years (Japan) to 40.5 (Zambia)  (the US is 30^th at 77.9 years) while health care spending per person runs from $6096 (the US) to $15 (the Congo).  Generally countries that spend less have a lower life expectancy, but LOLCAT fails to relate that to poor health care.

Is it possible to create a valid ranking system if you consider more factors? The World Health Organization created a rating system that they used to rate 190 countries using data from 1997.  They published the results in 2000.  In that list, the US ranked 37^th.  The result may have some value if you fully understand the process that went into creating it, but the WHO itself didn’t think the results were worth the effort, so they have not repeated the rankings since 2000.

There are organizations like The Commonwealth Fund that gather the sort of of health care data you’d need to create a rating system.  The Commonwealth Fund currently posts 195 “Quality and Efficiency” charts.  They make no attempt to summarize the data into a single rating.  Instead, they present the data so you can make your own decisions.

So how do you measure the quality of a health care system?  You need to decide what factors to consider and what weight to give them.  That’s a complicated job, and the decisions that go into creating a rating are subjective, not objective.  Here’s just one example of a topic that could generate endless discussion: should abortions be covered by any government funded health care plan?  Whatever you may believe, there are plenty of people to argue at great length for the opposing point of view.

In short, there’s no such thing as one best health care system.  Keep that in mind when you think about health care reform.  Whatever plan we come up with is going to be complicated, full of compromises, and loaded with possible unintended consequences.  The only thing for sure is that anyone who says there’s a simple answer is either a simple (stupid) person or someone who’s trying to fool you.

Who pays for health care reform?

Who pays for Obama’s health care reform plan?  The short answer?  Almost certainly not you.

If I had my choice, we’d pay for health care reform using the money we’re wasting on the war in Iraq or by using money that’s currently going to help us recover from the excesses of the financial sector.  Too bad those aren’t viable options.

Instead, President Obama has proposed that we fund the health care reform plan by rolling back the recent tax cuts for the wealthiest Americans.  Initially the target was people who make more than $250,000 per year.  The House is currently looking at raising taxes for people who make more than $350,000 (or $280,000 if you’re single).

Even if we use the lower number, only 2% of the US is making as much as $250,000 a year.  So 98% or more of us will not see any impact on our taxes.

Here’s a chart of income distribution from through 2007:

The chart shows that most of us make nowhere near $250,000.  Actually, fewer than 20% of us are within $100,000 of that amount, so there’s probably no danger of your next raise pushing you over the limit.  Another way to look at it:  If you did happen to make $240,000, would you refuse a $20,000 raise just because you would pay a few dollars more in taxes?  Of course not.

If you are one of the 2% who does make over $250,000, good for you! Can’t you afford a few bucks to help your less fortunate compatriots?  $250,000 a year may not buy you everything you want, but unless you’ve made some incredibly bad choices, you’ve got more than enough to stay fed and keep a roof over your head and still enjoy life.  Why does money for reform have to come out of your pocket?  The same reason Jesse James robbed banks – “because that’s where the money is.”

Health care reform has two goals.  We want to end up saving money overall, even with tax increases, by reducing the overall cost of health care or at least reducing the rate of increase in health care expenses.  And we want to improve the quality of health care coverage by ensuring that good care is available for everyone.   Those are hard problems to solve.  Worry about that first. Compared with coming up with a successful reform plan, figuring out a way to pay for it is easy.