Tuesday, June 30, 2009

The Myth of Our Great Healthcare System

In response to my latest entry (and an additional remark in which I noted that we have been attempting without success to achieve some kind of health care reform for almost 100 years), a Facebook friend writes:

Of course--we have had the best health care system in the world for the last 100 years--so I can't believe we have not changed it. (Please don't tell me you believe Michael Moore and go to Cuba for your healthcare needs). And I'm sure we can agree that a public option is not the only one way to radically ... Read Morechange the system [sic]. Examples are: delink insurance from your job--it should be similar to car insurance--I have had the same car insurance for 15 years because they pay my claims, I trust them, they provide a plan I like, etc---ahhhh--liberty is great!!! Or we could go with health savings plans, or just up the level at which people can go on Medicaid--and don't tell me Medicaid is horrible---where ever I have worked Medicaid patients received the exact same treatment as everyone else.

A couple of points are worth making:

"We have had the best health care system in the world." This used to be a claim about which people could actually have spirited disagreement; now it's demonstrably false by any objective metric one chooses. Before we even discuss the cost of our "best healthcare system in the world" let's just focus on what we get for it: our actual health. Here the US is pretty shabby. Here is a quick summary of the average life expectancy, by country, according to the CIA World Factbook (well known for its commie leanings), where we learn that, leaving aside teeny non UN-member states, the United States ranks 30th at 78.06 years. That is well behind other industrialized nations of its caliber: Japan (2nd, 82.07); France (5th, 80.87); Australia (8th, 80.62); Canada (10th, 80.34); Germany (24th, 78.95); and even the only country with actual, bona-fide socialized medicine, the UK (26th, 78.70). If we want to make the rallying cry "we're better than Cyprus!" (31st on the list), then we're in good shape, I suppose, but I can't believe most politicians or policy wonks will find this fact comforting...which is why you (almost) never hear anybody, even people who ostensibly want a better system, like Obama, say this out loud. We don't have the best system in the world; we stink. (A nice pic showing life expectancy by country in a world map format can be found here.)

Now for the best part: we pay a lot for that 30th slot. Our per-capita expenditure for health care for 2007 is $6096. That is, we spend six thousand dollars per person on health care each year in the US--not just people who have health insurance, all people (UN statistics, the link here). Congrats, we are number one. More telling is how far off a cliff you fall in the next few spots: funny little Luxembourg comes in 2nd at $5,178 (too many MRIs out there? too much plastic surgery? hard to say), then Norway and Switzerland come in at just over $4000, and every country's per capita expenses are under four after that. France, which has been the butt of Republican party jokes for at least the last 20 years on any number of political issues amounting to a shorthand meaning "if it's dumb then France does it," has a per-capita expenditure of $3040, precisely half the amount of the US.

These are two simple and indisputable facts, the very two facts that should be driving the debate on healthcare reform in the US and barely ever mentioned: we spend more that twice as much as most countries on healthcare, and for that cash outlay, the health of our nation is toward the back of the pack of industrialized countries.

Which brings us to Cuba. Michael Moore's documentary Sicko floats out some stats about the state of healthcare in the US, and although he does this is his own inimitable agit-propstery way, he nails the basic gist of the above paragraphs. Recall, the gist is we stink in terms of what we get out of how much we spend; everything else is details. He noted that Cuba--little, backwards, poor and commie Cuba--gets a lot more bang for its buck in terms of life expectancy. According to UN stats, Cuba spends $229 per person per year on healthcare. That's a whole lot less than the gaudy six thousand figure for the US, and what does that get them? If you take the UN figures that average expenditures over a five-year period, it's exactly one rank higher than the US on the life expectancy list (on the list I cite above, it ranks lower at 53rd, 75.08 years).

Let's leave the commies of Cuba behind and look at this through a different lens: the bankruptcy of General Motors. Here in Warm & Wunnerful Capitalism USA there has been much that has been said and written about the downfall of GM, and one of the critiques from the laissez-faire crowd is that this is how the system should work: it rewards the ingenious and punishes the inept. Oddly, GM is the maker of the critically acclaimed Chevy Malibu and also won the 2007 Motortrend Car of the Year Award for its Cadillac GTS. These ain't K-cars, so why is the second-biggest (just surpassed by Toyota last year) car maker in the world in such dire straits? Well, if the health insurance drag on its bottom line ain't the single critical factor, it's certainly one of them. Nate Silver of fivethirtyeight.com has a brief piece about this here, and references a WaPo article here. Money quote (literally!): "most of the excess costs it requires to produce a Buick versus a Toyota come in the form of legacy costs, not what those employees are receiving in salary and benefits today." I don't think it's too much to suggest that that the piece that brought down one of American capitalism's greatest icons, General Motors, was the lack of government involvement in healthcare insurance. (And, incidentally, we were on the verge of having a form of nationalized health insurance just when GM was entering its juggernaut phase in the late 1940s. The reason why it couldn't pass then? Not because of any nonsense used in today's debates, but because southern Democratic party politicians refused to allow for racial integration of hospitals, which a nationalized insurance structure would create since hospitals wouldn't be reimbursed if they didn't integrate.)

This is what we have of our medical insurance system, the only one of industrialized nations whose policies are created by a philosophy that government involvement in the healthcare of its citizens is somehow an encroachment on personal liberties. So I ask: ain't "liberty" great?

A couple of final points: after a Google search I don't know what "Morechange the system" is but assume it was an error of quick typing. I do highly recommend Jonathan Cohn's book "Sick," which is not to be confused with the more popularly-known movie by Michael Moore, as it is a considerably more sober, though less funny, discussion. In it he includes a lengthy discussion of the possible rational solutions, a subject that I've not even ventured to touch upon here.

And my friend refers to Medicaid's popularity, which only makes my point for me as this is a government-run insurance program, although I suspect that she means Medicare rather than Medicaid, but I could be wrong. Medicare is the highly popular government-run health insurance program for seniors, while Medicaid is also a government-run health insurance for the very poor. Why the politicians in favor of reform haven't figured out that the simple phrase "Medicare For All" is a much more winning slogan than all of the jargony claptrap that they use is totally beyond me.

My guess is this: if the debate continues to revolve around what seems to me the overly facile distinction of "liberty" versus "the cold dark hand of government" then we ain't getting nowhere. If we could burst the myth that the system we've got is so good, even if viewed from the perspective of American capitalist interests (as I tried to explain with reference to GM, and the same could be said of even the smallest of companies these days that struggle with offering insurance as a benefit to employees), we might start on the road to fixing it.

Thursday, June 25, 2009

The AMA and Health Care Reform

Nick Kristof has a great op-ed today in the NY Times about the AMA and its very, very puzzling reluctance to support the "public insurance option" as part of the health insurance legislation currently working its way through congress. For those not aware, the AMA has, for the past several years, unambiguously supported the notion that all Americans deserve basic medical care. (This is a seeming departure from decades of AMA philosophy, which has been remarkably conservative on a number of issues.) However, as the rubber meets the road and legislators discuss the brass tax required to meet such a lofty goal, the AMA has settled back into its more comfortable position of opposing progressive policies and has decided to oppose any bill that includes a public plan. Their logic is priceless: "the introduction of a new public plan threatens to restrict patient choice by driving out private insurers," they note in a letter to the Senate Finance committee. That is, if we have a public option, and that option is so good that people might want to opt for it over private insurance, we should not do so because it hurts the...sit tight for this...insurers! One might have thought that the AMA was an organization representing the interests of patients, but apparently they are much more concerned for the welfare of insurers. And "welfare" is a particularly apt word.

Money quote, from President Obama's former private-practice internist Dr. David Scheiner, in criticizing the AMA: "they’ve always been on the wrong side of things. They may be protecting their interests, but they’re not protecting the interests of the American public. In the past, physicians have risked their lives to take care of patients. The patient’s health was the bottom line, not the checkbook. Today, it’s just immoral what’s going on. It’s abominable, all these people without health care."

One key point not emphasized by Kristof is that while physician membership in the AMA is dwindling (he estimates that only one in five docs are current members), and there are other physician groups such as the American College of Physicians who are supportive of a more robust public health care policy, the AMA still is regarded by most laypeople as the definitive body that speaks for America's physicians. As a consequence of the AMA's Good Houskeeping Seal of Approval, their opposition to the public finance option makes it seem like physicians as a whole are opposed to it, and while I have not seen polling data, I suspect that this is not the case. Such short-sightedness thus makes us all look bad.

Tuesday, June 23, 2009

N of One, part II

Self magazine--which advertises itself as "the first-ever magazine of total well-being, merging beauty and health, fitness and nutrition, and happiness and personal style together in one package...for the woman who wants to stay informed, get inspired, grow and achieve her personal goals"--recently ran an in-depth story about generic medicines entitled "Bad Bargain." The subtitle captures the essence of the piece: All of us want cheaper medicine—but not if it costs us our health. Troubling reactions and a series of recalls are making some doctors wonder, Are generic drugs as safe as the FDA says they are? SELF investigates.

I am not a journalist but I'll give the piece a generally good grade for doing in-depth research, taking great pains to explain in detail how the generic medicine industry is regulated, and even devoting a few paragraphs to those who are skeptical about the claims that generics aren't safe. As articles on medicine and industry go I've seen and read a lot worse. But despite some impressive homework by the Self staff they still make at least one and possibly two major errors of contextualization that, from my standpoint, casts doubt on their claim that generics are scary. Boo.

The first problem, the more minor of the two, shows up at the beginning of the article, when Self describes the medical odyssey of Beth Hubbard, a woman whose life came undone when she was switched from the brand-name anti-depressant Wellbutrin to the generic Budeprion. The article devotes many paragraphs to Hubbard's story (nearly 20 percent of the article), and her discovery that the switch to generic was the likely cause of her decline. During her trials she ended up being prescribed a large number of other medications (more on this anon), but eventually sorted out that the problem lay somehow in the generic formulation, and Self moves on from there to discuss the problem of generics.

Health journalists love using this particular conceit, which is a classic "N of One" scenario. If a journalist looks hard enough, he or she will find all number of strange tales of odd reactions and failures to respond to medications. How much can one conclude from such isolated stories? Not much. The important question is whether or not such a story is representative of something larger. In this case Self at least tries to use the story as an entree to discuss larger trends, and while it makes a few key points to support its claim I remain skeptical that they've demonstrated that this is a massive systemic problem. You be the judge; I'd love to hear feedback.

The second and much more troubling problem is that they pluck the issue of generic medicine regulation out of context and discuss it as if there are no problems with brand-name drugs. The article clearly implies that buying generics is more dangerous than buying brand-name drugs, yet does no comparison of the relative safety of brand-name versus generic drugs (that could be done easily enough). They note that the part of the FDA charged with oversight of generics is overwhelmed and understaffed--a claim that seems all too plausible to me--but don't bother to point out that the same situation applies to the FDA as a whole, especially including regulation of patented and new drugs. In fact, in one of the richest bits in the article, the writer notes that as part of Ms. Hubbard's trials, she took the drug Zelnorm to help cure her symptoms. Zelnorm, made by Novartis Pharmaceuticals, was approved in 2002 to treat Irritable Bowel Syndrome (about which much more could be written, but not today), and not long after approval advertisements on television started popping up showing women revealing their happy midriffs to the world, gleeful with satisfaction from being relieved of their IBS. Alas, the drug was removed from the market in March 2007 at the FDA's request because "data from 29 clinical studies with more than 18,000 patients showed that patients taking Zelnorm were eight times as likely to have heart attacks and strokes compared with those taking placebos." That's your brand-name industry working for you! At its height, Zelnorm prescriptions numbered two million annually. Not so great if you're a 30-something lady suffering from intermittent constipation and suddenly find yourself suffering from a heart attack.

Might there be real problems with the regulation of generics? Indeed, and Self does a reasonably good job for making that case. Might there be real problems with the regulation of all medications, thus making the attack on generics seem weird? I think so. Might the fact that brand-name drug makers advertise heavily in television and print media, while generic manufacturers advertise much less, have some influence on this asymmetric attack on generics? Hmmm.

For my part, I think that if you had to boil down all useful political punditry, you couldn't do much better than being a regular reader of just two writers: Paul Krugman and Bob Somersby of The Daily Howler. Paul, the more famous of the two due to his perch at the NY Times and that prize he got in Stockholm recently, uses his pulpit not only to discuss economics in a manner intelligible to the educated layperson, but also delves into various political topics. A few weeks back he did the latter, and to my mind made a fairly egregious N of One type mistake.

After the shooting of Dr. George Tiller in Witchita, Kansas, Krugman wrote an article entitled "The Big Hate," in which he provocatively asserted "right-wing extremism is being systematically fed by the conservative media and political establishment." Krugman noted that the shooting at the Holocaust Memorial Museum by white supremacist/anti-Semite James W. von Brunn, in addition to the Tiller killing, represented a definite trend that had been predicted by an internal report for the Office of Homeland Security--a report that was met with howling indignation by conservatives.

Do these two examples show that the Homeland Security report was right? Maybe. One counter example that pops a bit of a hole in the right-wing violence theory is the "left-wing" killing of Private Quinton Ezeagwula in Little Rock AK by "Muslim convert" Abdul Hakim Mujahid Muhammad earlier this month. (Unclear if "left-wing" is a useful designation here, but Muhammad's actions are certainly motivated by political beliefs very different from those of the other shooters, and as such doesn't really fit into the scenarios discussed by the Homeland Security report.)

Is Krugman accurate in his assertion that the conservative media feed the kind of hatred that results in such killings? I think yes--although I think he mixes his examples and ends up with a sticky argument. Sometimes an N of One makes a certain amount of sense, if and only if you can demonstrate it to be the end result of a causal chain. Can one trace the killing of Dr. Tiller to the wide exposure he received on Bill O'Reilly's show, where he was frequently called out by name as a "baby-killer" and one who ran a "death mill"? Definitely maybe--at least it's more than reasonable to see if one can trace a line from O'Reilly to the shooter. (Politifact highlights the number of times that O'Reilly singled out Tiller for abuse here.) But can von Brunn's actions be lumped in with this, and are they attributable to the increasingly violent rhetoric of the right-wing media? I think not; von Brunn was a nut, and his hatred of any form of "establishment" media, whether right or left, was uniform. He threatened conservative publications as much as liberal ones. This was no O'Reilly fan, and while O'Reilly and his ilk certainly should be taken to task for the light and heat of their rhetoric, they can't be blamed for von Brunn's actions.

Sunday, June 7, 2009

N of One

My sense of American political discourse is that it is often shabby, and that one of the key contributing factors to the shabbiness is the absolute lack of scientific and mathematic literacy among the vast majority of its citizens. Mind you, I don’t mean “scientific and mathematic literacy” in its traditional, narrow sense; I don’t really care if your person on the street can tell me whether Pluto has been reclassified as dwarf planet, or if he or she knows how to demonstrate a side-angle-side proof given pencil and paper. I am talking about the kind of math/science literacy that engenders a sophisticated understanding of public policy (not just science policy). This kind of literacy is well within the grasp of persons who are not unusually stupid, and would make political dialogue in the US an order of magnitude better. And the first place where that dumb-dumberry starts, that willful ignorance of even the most basic concepts that centuries of very bright people have toiled to make accessible to the masses, is with the mainstream media. Let me explain.

Let’s take just two examples from the mass media—one extremely well-publicized but not directly related to medicine, and one less well known but that bears directly on the state of medicine. Both stories hinge on a willful misrepresentation of the facts, and at least in the former case an entire brouhaha has resulted because very few pundits have understood the simple mathematical misconception that has formed the basis of the misunderstanding. In the latter case, which I will discuss in a separate entry in the days to come, the same mathematical twit-headedness is used in a different way, but one much loved by the mainstream media.

By now, anyone with a pulse who has been following “real” news (read: not Jon and Kate Plus 8) will be aware that President Obama has nominated Judge Sonia Sotomayor to the Supreme Court of the United States. Sotomayor, a New Yorker of Puerto Rican heritage, has had one of those heartwarming, kid-from-the-neighborhood-makes-good stories that undoubtedly must have played a major consideration in Obama’s choice to nominate her. I am not a lawyer but from all the reports I have read, it appears that she is not an especially highly-charged ideologue as a nominee, less like Judge Robert Bork (one of Reagan’s failed SCOTUS nominees) or Anthony Scalia (one of Reagan’s successful SCOTUS nominees) and more like, say, John Roberts—which is not to say that Sotomayor and Roberts have the same judicial philosophy or temperament, only that they aren’t or weren’t obvious ideological firebrands as nominees. If anything, and despite the loud farts that I have smelled from the right-wing about her being a virtual communist in disguise, I have concluded that the word that best describes her is “establishment.” (And, for what that’s worth, I don’t mean that as a glowing compliment.)

Conservatives have had a hard time deciding their line of attack against Sotomayor. It is theoretically clear that on a variety of constitutional issues she is more likely to side with the court’s so-called “liberal” wing than its “conservative” one (though one should take the example of the very justice she is replacing, Justice David Souter, appointed by the senior Bush, as a warning about making confident predictions of future decisions on the court), and as a consequence the conservatives have drawn battle lines against the President on this. The problem is: how to attack a woman whose hard-work-reaps-benefits feelgood story resonates with so many Americans—and in particular the much sought after Hispanic population, who have been leaving Republicans in droves despite a fairly progressive policy adopted by the Bush administration?

The answer is that conservatives—many of whom all but in name “run” the Republican party—have decided that Sotomayor—a Latina woman from decidedly humble beginnings—is...a racist. No, I am not making this stuff up. Assuming that the readership of this blog is already familiar with this, let us zero in on the smoking gun: the words that the right-wing talking heads have used to make their case. Sotomayor, in a speech in 2001, said the following:

I would hope that a wise Latina woman with the richness of her experiences would more often than not reach a better conclusion than a white male who hasn't lived that life.

It is this quote, this single quote—along with her single decision in a case involving the City of New Haven in which she sided with a district court judge in ruling against a group of white plaintiffs alleging reverse-discrimination (see here)—that has formed the basis of charges of racism. After discovering this ammunition, the blowhards on Fox News, Newt Gingrich on his blog, and of course the right-wing’s leading pundit, Rush Limbaugh, began to beat the drum of Sotomayor’s racism (covered nicely by Dana Milbank here).

But this is absurd—and it’s absurd not because Sotomayor represents Light and Truth or because Limbaugh represents the forces of Darkness. No matter the relative truth of at least the latter half of that equation, the political positions of Sotomayor’s proponents and opponents are totally irrelevant. The key point here is that, as a judge, Sotomayor has generated thousands and thousands of words in hundreds of decisions. Going bananas over one brief quip, or even one decision (one unsigned decision!), reveals the naked contempt that these commentators have for their audience. You cannot make particularly good judgments about anything when you have a sample size of one.

But wait!—you say. Isn’t what Sotomayor said above racist? Doesn’t the logic of this sentence imply that, simply by virtue of being a Latina woman, that one has an inherently richer life experience than a white male, and that as a consequence she reaches better conclusions? And how can’t that be racist?

I don’t know. It is true that this small clip of Sotomayor’s speech leaves an unfortunate taste in the mouth—assuming that she said precisely what she meant. It may have been that you nudge a few words in a different direction, and you have something perfectly reasonable that a kum-ba-ya doc such as me would welcome with open arms: “I would hope that a wise Latina woman…would at least as often reach as good a conclusion than a white male…” Or she might have been trying to say something else entirely, or she might have just not realized the implications of what she was saying. I don’t mean to imply that she gets a free pass on the statement—it will require explanation, and it is entirely fair game to come up in the hearings. But this statement has to be viewed in the context of all of her decisions and speeches, or for that matter even the rest of her speech, which can be found here.

After careful consideration of that large volume of material, should one wish to make the case that Sotomayor is some crazed Hispanic nationalist legislating hatred of the white man from the bench, then by all means one should do so. But my guess is that no such ideology is to be found in her public or judicial statements, and that absence explains the level of volume in the criticism of her. When they ain’t got nothing good, they just shout louder.

Lest anyone mistake this entry for a cheer-on-the-liberals, boo-the-bad-conservatives piece, thus missing that the key point here is that you can’t have thoughtful political dialogue of any kind when you trot out sample sizes of one to make a point, Bob Somersby at The Daily Howler (one of Billy’s very favorite blogs) discusses the Sotomayor kerfuffle here and here in a way that may make some liberals unsettled. Money quote:

As the Cult of the Offhand Comment advances, are journalists and liberals even capable of shaping intelligent discourse? […When taking quotes out of context to attack opponents,] we ourselves have shown an occasional tendency to sign up with this dim-witted cult. John McCain said he wants a hundred-year war! We had some fun with that gong-show claim until we learned an unfortunate fact: When we talk sh*t about Saint McCain, the mainstream press corps won’t go along! But we’ve already seen some liberals on TV explaining what Sotomayor meant; their explanations aren’t necessarily all that convincing, however dogmatic they’re willing to be.

Remember: whenever you hear a political discussion about anything, and the entirety of said discussion rotates around sample sizes of one (which in the biz is referred to as “n=1,” whence the title of this entry), you can elevate the level of dialogue just by inquiring how much you can conclude from one single fact without context.

Later this week, I’m going to demonstrate a different way in which an “n of 1” is used and abused, this time about something closer to Billy’s heart…the scariness of the generic medicine industry. Boo.