Minor Thoughts from me to you

Survey Finds 43.6 Million Uninsured in U.S.

About 43.6 million people in the United States, or 14.8 percent of the population, had no health insurance in 2006, according to a survey by the Centers for Disease Control and Prevention released Monday.

The finding, based on a survey of 100,000 people, is lower than previous federal estimates of 46 million.

That's about all of the information that the article has. Unfortunately, I'm sure that these numbers will be used to argue for universal healthcare -- after all, that's a lot of people without insurance!

But who are these people and why don't they have insurance?

Free Market Cure created a video, Uninsured in America that answers exactly that question.

Stuart Browning:

So why don't you have health insurance?

Faye Chao:

I'm young right now and currently don't need health insurance. Probably don't want to spend $200 a month.

Stuart Browning:

In this state, a 26-year-old non-smoker with no preexisting conditions can get a policy for $96 a month.

Faye Chao:

It's 96 dollars a month, but that's twelve hundred dollars a year you're spending on health insurance. And honestly, I feel it's ridiculous that we live in a first world country where I have to pay for basic health care.

...

Stuart Browning (voice over):

But, what if they get sick or injured and they don't have any savings? They know that the U.S health care system will still give them medical care.

Faye Chao:

I bike everywhere in the city, so I have gotten hit by drivers twice - and one time I ended up in the hospital. No, I didn't have health insurance, but I was treated - and billed for it later.

Stuart Browning (off camera):

Umm hmm. How much was the bill for? Do you remember?

Faye Chao:

Honestly I don't because I didn't bother to pay for it.

Alzheimer's is one of the diseases that scares me the most. I absolutely hate the idea of losing my memory and being completely unable to function -- or even remember who my family and friends are. That's why I was thrilled to read about an upcoming Alzheimer's vaccine.

A revolutionary drug that stops Alzheimer's disease in its tracks could be available within a few years.

It could prevent people from reaching the devastating final stages of the illness, in which sufferers lose the ability to walk, talk and even swallow, and end up totally dependent on others.

The jab, which is now being tested on patients, could be in widespread use in as little as six years.

Existing drugs can delay the progress of the symptoms, but their effect wears off relatively quickly, allowing the disease to take its devastating course. In contrast, the new vaccine may be able to hold the disease at bay indefinitely.

Early tests showed the vaccine is highly effective at breaking up the sticky protein that clogs the brain in Alzheimer's, destroying vital connections between brain cells.

When the jab was given to mice suffering from a disease similar to Alzheimer's, 80 per cent of the patches of amyloid protein were broken up.

If this pans out, it would be absolutely fantastic news.

From the New York Times:

It's a seemingly simple solution to a nationwide problem: if people do not have health insurance, just require that they buy it.

Yes. It is seemingly simple. That's why most of the Democrat candidates for President, one of the Republicans (Romney), and an ever-growing list of states are considering the idea. It's so simple -- if people don't have something that you want them to have, just force them to buy it. The power of government is a wonderful thing.

Of course, there are a few downsides.

But [Massachusetts] is discovering that making health insurance mandatory is easier said than done. It has spent the past year dealing with questions about how much basic coverage people need, and how much they can be expected to pay. (The poorest residents receive free or subsidized coverage.)

Step 1: Require everyone to buy an expensive, all-inclusive healthcare plan. Step 2: Give government handouts to everyone who can't afford to buy the expensive, all-inclusive plan. People of all income levels will be using services that they don't directly pay for. Worse, many people will be using services that they don't even indirectly pay for. This sounds like a fantastic way to keep prices down.

Who are all of these uninsured anyway? And why don't they want health insurance?

Almost half of the roughly 400,000 uninsured people in Massachusetts are single males, and many young men think "health insurance is for sissies," Mr. Kingsdale said. Because young males are generally healthy, adding them to the pool of insured would most likely reduce the average cost of coverage over all, given that this particular group is not liable to need expensive treatment.

That sounds like an implicit tax on young males. They're being forced to buy insurance just as a way of getting more money into the pool. That money can then be used to be for treatments for all of the chronically ill and elderly in the pool. Why would any young man want to be part of such a scheme?

A low-premium, high-deductible health plan (combined with a Health Savings Account) would be a far better option for these men. Instead of blowing all of their money on premiums, they could be saving it up for the next 10-20 years. When they do need medical care, they could pay for it out of their savings, rather than out of a common pool that other people are forced to pay into.

Indeed, the problem with healthcare isn't that too few people have it. The problem is that the people who do have healthcare are completely insulated from the actual cost of their care. How much did your last checkup cost? Do you have any idea? How about your last prescription? Other than the copay, do you have any idea how much it cost? Was it the most cost-effective prescription possible or would a different drug have been just as effective with a cheaper price tag? Almost no one knows the answers to the questions.

Healthcare costs are widely variable. And more expensive doesn't always mean better.

In a Pennsylvania government survey of the state's 60 hospitals that perform heart bypass surgery, the best-paid hospital received nearly $100,000, on average, for the operation while the least-paid got less than $20,000. At both, patients had comparable lengths of stay and death rates.

Still, the Pennsylvania findings support a growing national consensus that as consumers, insurers and employers pay more for care, they are not necessarily getting better care. Expensive medicine may, in fact, be poor medicine.

"For most consumers, the fact that there is no connection between quality and cost is one of the dirty secrets of medicine," said Peter V. Lee, the chief executive of the Pacific Business Group on Health, a California group of employers that provide health care coverage for workers.

It's not just that there's no connection between quality and cost -- there's no connection between anything and cost. A monthly premium disappears into a black hole. At some point in the future, healthcare services may or may not come floating back through the black hole. No one understands how or why different services are covered by their plan or what the relation is between the cost of their plan and the services delivered by that plan. All they can see is that each year the amount of money thrown into the black hole gets a little bit bigger.

Is it any wonder that people are dissatisfied with American healthcare? Worse yet, none of the reform proposals on the table address this fundamental disconnect. Rather than improving transparency, most of their reform plans simply aim to get more people to throw money into the black hole. That's not thinking different on healthcare, that's just following the same broken formula over and over again. Insanity.

The best way to lower prices, increase transparency, improve quality, and deliver higher quality services for lower prices is to make consumers directly responsible for paying for healthcare. Third party payor setups will never be able to deliver a great service at a low price. As long as the person paying for care and the person receiving care are different, true satisfaction will never be achieved.

As you may have heard, Michael Moore will soon be releasing a new documentary on the American healthcare system -- "Sicko". In the film, Moore favorable compares the Cuban healthcare system to the U.S. healthcare system. In the film he claims -- among other things -- that Cubans live longer than Americans. The New York Times investigated these claims:

[M]any people regard any figures about Cuba as at least partly fiction. But even if the longevity statistics are correct, they are open to interpretation. Carmelo Mesa-Lago, a professor emeritus of economics at the University of Pittsburgh, said statistics also show that Cuba has a high rate of abortion, which can lower infant mortality rates and improve life expectancy figures. The constant flow of refugees also may affect longevity figures, since those births are recorded but the deaths are not.

That would certainly help the statistics out. As if that wasn't enough, Cuban apologists see a bright side to Cuban poverty:

Dr. Butler said some of Cuba's shortcomings may actually improve its health profile. "Because they don't have up-to-date cars, they tend to have to exercise more by walking," he said. "And they may not have a surfeit of food, which keeps them from problems like obesity, but they're not starving, either."

This may or may not be true. I lean towards believing that it's a pile of crock. After all, if the statistics are skewed by immigration (and why would people want to leave such an island paradise anyway?) and abortion there's no reason to believe that their health profile really is all that good.

Even if all of this were true -- Cuba is a totalitarian dictatorship! It's not a virtue that their citizens walk more and eat less. They have absolutely no choice in the matter. They are dirt poor because their government decreases that no one be allowed wealth. There is no way that I would ever choose such a trade off. I don't believe any other Americans would either.

Finally, there's this:

By the time Dr. Cordova started practicing in 1992, equipment and drugs were already becoming scarce. He said he was assigned to a four-block neighborhood in Havana Province where he was supposed to care for about 600 people.

"But even if I diagnosed something simple like bronchitis," he said, "I couldn't write a prescription for antibiotics, because there were none."

"Actually there are three systems," Dr. Cordova said, because Cuba has two: one is for party officials and foreigners like those Mr. Moore brought to Havana. "It is as good as this one here, with all the resources, the best doctors, the best medicines, and nobody pays a cent," he said.

But for the 11 million ordinary Cubans, hospitals are often ill equipped and patients "have to bring their own food, soap, sheets "” they have to bring everything." And up to 20,000 Cuban doctors may be working in Venezuela, creating a shortage in Cuba.

This is the system that Michael Moore thinks is superior to ours. He's welcome to it. I'll stick with the American system.

Putting drug risks into context:

Is it riskier to take a daily aspirin, drive a car or fight fires? Turns out they all carry about the same risk -- between 10.4 and 11 fatalities per 100,000 person-years, according to a study in the May/June Health Affairs, a policy journal published by Project HOPE.

Their findings surprised them. For example, taking Vioxx (rofecoxib), which was withdrawn from the market in 2004, or Tysabri (natalizumab) for multiple sclerosis was comparable to or exceeded the risk of dying in a car crash, working as a truck driver or rock climbing.

On the other hand, it was less risky to take either drug than it was to drive a motorcycle, work as a logger or climb the Himalayas.

We removed Vioxx from the market for this?

Of the 45-50 million people in the U.S. who lack access to healthcare, only 10% lack access because they can't afford it.

We also found ... that the most common reason respondents cited for lacking a usual source of care was that they were seldom or never sick. Cost was cited by only 10.2% of respondents...Overall, 72% of the estimated 42.7 million adults without a usual source of care in 2000 apparently had little or no preference for one, and a minority (28%) appeared to prefer to have one, if they could.

By ignoring the possibility that many adults do not have a usual source of care because they either do not want one or place low value on having one, important implications and true barriers are obscured.

This is why I oppose an individual mandate. Why should I force someone to buy health insurance if they have no need for it or don't want it?

Is it a bigger problem that people can't get access to healthcare or that they when they do get access to healthcare they drive up the cost by getting services they don't need?

Here, single payer advocates like to have it both ways. On the one hand they speak of inability to get care, while simultaneously decrying that up to 50% of care is unnecessary. Which is it? Or is it both? And, again, how is it that an unelected bureaucracy, given complete authority over what care you can choose to purchase with your own money, do a better job of both MAKING people take the doctor's advice, while simultaneously preventing the 50% of care they think is uneeded? Again, single payer advocates have no answer for this other than a 'panel of experts' that will be immune from criticism from individuals, but highly susceptible to the money and efforts of aggressive lobbyists.

My pharmacist wife will sympathize with this lament about prescription refills:

I suspect a great many doctors shoot from the hip when it comes to refills. What makes me think this?

Well there's this weird little loophole in our automated refill request line where someone can request a refill and trigger an auto-fax to the doctor if the script has expired or run out of refills. It's all automatic -- no pharmacy personnel even see the refill request before it gets sent. Our computer systems aren't typically smart enough to check and see if there's a replacement prescription in patient's profile already.*

What's amusing is that often this second prescription differs from the first. Not significantly, but where the first might have 5 refills, the second has 3. Or 11. Or maybe zero. Often we'll get two scripts with the old refill number on it sent back on the same day, each with a different number of refills, usually in the same handwriting. This makes me wonder ... how are you guys charting this stuff?

Is this why we get phonecalls asking what strength of a drug a patient is taking? And how are they taking it? And please give them six months worth of refills?

Geisinger Health System is trying an innovative approach to lowering healthcare costs: offering a warranty for certain surgeries.

Under the typical system, missing an antibiotic or giving poor instructions when a patient is released from the hospital results in a perverse reward: the chance to bill the patient again if more treatment is necessary. As a result, doctors and hospitals have little incentive to ensure they consistently provide the treatments that medical research has shown to produce the best results.

Taking a cue from the makers of television sets, washing machines and consumer products, Geisinger essentially guarantees its workmanship, charging a flat fee that includes 90 days of follow-up treatment.

Even if a patient suffers complications or has to come back to the hospital, Geisinger promises not to send the insurer another bill.

Since Geisinger began its experiment in February 2006, focusing on elective heart bypass surgery, it says patients have been less likely to return to intensive care, have spent fewer days in the hospital and are more likely to return directly to their own homes instead of a nursing home.

Unfortunately, the healthcare system isn't usually an innovator:

But hospitals have been slow to focus their attention on standardizing the way they deliver care, said Dr. Arnold Milstein, the medical director for the Pacific Business Group on Health, a California organization of large companies that provide medical benefits to their workers. Geisinger "is one of the few systems in the country that is just beginning to understand the lessons of global manufacturing," Dr. Milstein said.

Geisinger is improving care by identifying the best practices possible in cardiac surgery and then making sure that those practices are followed in every surgery. It's a simple idea, but one that doctors have been resistent to implement in the past.

Controlling costs are a large reason for the experiment:

Heart surgery and follow-up care, which runs about $30,000, are among the biggest-ticket medical offerings that Geisinger provides. But Geisinger executives say outside insurers and employers have indicated that Geisinger would need to include from 5 to 10 other procedures under its plan before they would have enough of their employees affected to make it worth their while to sign up.

Under the experiment, the hospital charges a flat fee for the surgery, plus half the amount it has calculated as the historical cost of related care for the next 90 days. So instead of billing for any additional hospital stays "” which typically run $12,000 to $15,000 "” Geisinger absorbs that extra cost.

This is the kind of healthcare reform that I get excited about. George Halvorson's idea is quite lame compared to this.

George C. Halvorson, CEO of Kaiser Foundation Health Plan and Kaiser Foundation Hospitals wants to force you to buy healthcare. He doesn't care if you want healthcare or if you think you need healthcare.

"Anything short of an absolute single-payer system requires an individual mandate. If you don't have that, then people will make decisions about coverage that will result in far less than universal coverage."

"Individual mandate": code words meaning that the government will force you buy healthcare and fine you if you don't. "Far less than universal coverage": people might otherwise choose not to purchase health insurance.

The comments were made while Mr. Halvorson was discussing European style healthcare. Several European countries allow private insurerers to sell healthcare, requiring only that every citizen purchase a health insurance plan. This is the model of healthcare "reform" that Mr. Halvorson favors. I can understand why he would be in favor of "individual mandates" -- he heads up an organization that makes quite a good profit selling health insurance. I'm sure Kaiser would earn even higher profits if more people bought health insurance. On the other hand, no one should be forced by their government to make a private company richer.

Individual mandates: just say no.

Innovations like this are why I think I'll live to a ripe old age.

A paralyzed man with a small sensor implanted in his brain was able to control a computer, a television set and a robot using only his thoughts, scientists reported yesterday.

Those results offer hope that in the future, people with spinal cord injuries, Lou Gehrig's disease or other conditions that impair movement may be able to communicate or better control their world.

"If your brain can do it, we can tap into it," said John P. Donoghue, a professor of neuroscience at Brown University who has led development of the system and was the senior author of a report on it being published in today's issue of the journal Nature.

[tags]innovation[/tags]

It's starting to look like the best method may be to let them play in the dirt, stick all sorts of things in their mouths, and, generally, be exposed to everything.

From the linked article:

Here's the new wisdom: Early exposure to pets, peanuts and intestinal worms might actually be good for you, because they program the developing immune system to know the difference between real threats, such as germs, and Aunt Millie's cat.

"When you're born, Day Zero, your immune system is like a new computer. It's not programmed. You have to add software," says Joel Weinstock of Tufts New England Medical Center. "Between the ages of zero and 12, you're learning to read, you're learning to write, and your immune system is learning to react to things. Part of that is learning to limit reactivity."

Although trying to link allergies to autoimmune diseases such as Crohn's might seem like a stretch, scientists say both types of ailments result from an immune system run amok. In allergies, the immune system goes on alert when ragweed or some other allergy-causing protein wafts through the air, settles on the skin or tickles the tongue. In autoimmune diseases, the immune system can no longer distinguish between the self and foreign proteins. Mistaking the self for those proteins, the immune system attacks the bowel in Crohn's disease or insulin-producing cells in Type 1 diabetes.

Weinstock, Elliott and other researchers believe that a low-grade infection with intestinal worms "” pig whipworms because they can't reproduce in people "” can restore the immune system's natural balance. A small-scale study in which 29 people with Crohn's disease drank whipworm eggs in Gatorade found that 23 responded to treatment and 21 of the 23 experienced complete remission.

Will Wilkinson presents his Health Care Fantasia that includes the following prescriptions for cheaper health care: decartelization of doctors, abolishing the FDA, offering real insurance markets, creating a health care ideas futures market, creating electronic diagnostic services, allowing people to have big health care savings accounts, and forcing people to have a catastrophic insurance plan. Along with those ideas, he takes a stab at solving the problem of uninsured citizens. I support all of his ideas. Rather than making me repeat what's good, just go read it for yourself.

Last year, Arnold Kling presented his idea for a Medical Guidelines Commission that would:

consist of, say, seven members drawn from the disciplines of medical research, medical practice, statistics and actuarial science, and economics. It would have a staff with similar expertise to evaluate research and to oversee grants to stimulate research where none is available.

The Commission would have two main functions:

• Collect and summarize research about the effectiveness of various medical practices. For those of us willing to work with doctors to make our own decisions, this information would be sufficient.

• Issue guidelines that could be taken as recommendations for best practices. These guidelines would serve those people who would be intimidated by statistical research and prefer to be told what to do. The guidelines might also serve as industry-wide benchmarks.

Guidelines would not be carved in stone. Patients and doctors would be free to choose treatments that differ from the guidelines. Moreover, the guidelines themselves would change over time, because medicine is a constantly-evolving art.

The trick to making health care cheaper is to make health care more plentiful. The more patients can do for themselves, the cheaper health care will become (because the demand for doctor provided health care will be lower). The easier it is for people to become doctors, the cheaper health care will become (because the supply of doctors will be higher).

I'd like to draw attention to something that Will mentioned in his post: does setting a broken arm really require a full-fledged MD? Setting a broken arm has nothing to do with the liver, heart, lungs, kidney's, or any of the other subjects that MD's study. Why not open up the market for health care and allow people to specialize in specific areas of expertise (splinting broken bones) without requiring them to obtain a full medical degree?

(Hat tip to Arnold Kling)