depressio

phenomenal stuff from timothy noah on the public option, why its necessary, and (the worst part) why reform in the absence of a public option just puts more power and money in the hands of insurers. noah eloquently refutes paul krugman's assertion that the current version of reform is similar to that of switzerland's, and in doing so, makes me incredibly depressed about the prospect of true reform:

At the broadest possible level, the public option is necessary simply because it's impossible to identify a successful health system anywhere in the world based on a for-profit insurance model. If profit-driven health insurance could be made to work, then surely somebody would have figured it out by now. Paul Krugman, in an Aug. 17 New York Times column, likens health reform to the reforms Switzerland instituted in 1994: "[E]veryone is required to buy insurance, insurers can't discriminate based on medical history or pre-existing conditions, and lower-income citizens get government help in paying for their policies." But there's a significant difference. In Switzerland, private insurers are required to provide basic health coverage on a nonprofit basis. Under Obamacare, private insurers will continue to seek profits, and it's quite possible that the new regulatory restraints imposed on them (take all comers, don't punish the sick with higher premiums, don't seek out fine-print reasons to cancel policies after policyholders get sick, etc.) will inspire them to find ever-more-ingenious ways to avoid payouts. President Obama often says that a public option will help keep the private insurers honest. What he doesn't say, but surely knows, is that private insurers' duties to their shareholders may be irreconcilable with their duties to their customers. Should that prove true, a public option would provide a necessary refuge.

i don't care, i'll say it. don't pass 6 band-aid bills, mr. president. spend some of your political capital to get one thing done properly.

on a non-policy, but still health care note, here's a wacky article on sirtuin activators, which may mimic caloric restriction and slow aging. but count me out as a believer for a number of reasons. first, it definitely looks like an artifact of using mice that are on high caloric diets - clearly, they aren't able to get nearly the same results with wild mice or other species. second, and more importantly, i simply don't believe that the slow buildup of DNA damage over time is ultimately reversible, and I think that manipulations that try and overcome DNA damage (like messing with telomerases) are as likely to be carcinogenic as they are to be life-extending. Basically, I agree with the evolutionary biologists:

In the view of evolutionary biologists, the life span of each species is adapted to the nature of its environment. Mice live at most a year in the wild because owls, cats and freezing to death are such frequent hazards. Mice with genes that allow longer life can rarely be favored by natural selection. Rather, the mice that leave the most progeny are those that devote resources to breeding at as early an age as possible.

So call me a skeptic. Although, I do like that these drugs are present in low concentrations in red wine. Drink up, folks!

health care

I agree that its sad that time is being wasted on this insane euthanasia/death panel nonsense. But what's even more upsetting is the other part of the opposition's rationale in fighting health care -- "People love the health care that they have!" Uh, yeah. People also like credit cards with unlimited credit. This is what I don't understand about the White House's approach. Why aren't they just stating the plain fact - the health care you have is not financially sustainable. We need a new business plan for health care, because its hemorrhaging money. The way I see it, there are 4 major ideas that are being proposed to cut costs:

1. Increased efficiency - I think everyone is on board with things like electronic medical records and things of that nature, but there is a legitimate argument over insuring the 45 million uninsured. But again, here, the argument over the moral imperative (is health care a 'right') is spurious - society has already determined that health care is a right. Public hospitals don't turn away people with no insurance. So what's the best way to insure people who can't pay? Thinking in terms of efficiency would suggest that broad government coverage be focused on 1) catastrophic coverage, and 2) preventative care. Shouldn't a public plan be based predominantly around those tenets?

2. Rationing - This issue was addressed by Peter Singer a few weeks ago in the NYT Magazine, where he asked a simple question:

The way we regard rationing in health care seems to rest on a similar assumption, that it’s immoral to apply monetary considerations to saving lives — but is that stance tenable?

Probably not. Some estimates suggest that up to 80% of health care costs are spent on the terminally ill. This is where the outcries of 'euthanasia' come from, but its a realistic question. Is it sustainable, or efficient, to spend most of our money in this way? Correct me if I'm wrong, but convincing a terminally ill patient that a DNR is the right decision is more likely humane than murder, or so most hospitalists believe. Or am I wrong? What's really wrong is that the cries of death panels drown out the need for legitimate discussion on rationing.

3. Driving down drug costs - One of the other big controversies in health care reform is the sketchy dealings between the White House and pharmaceutical trade representatives. One of the big potential cost-saving measures was thought to be by having Medicare (and by extension, the government), which serves as a huge buyer of drugs, use that leverage to drive down drug prices - which is basically letting market forces set drug prices. It's not entirely clear what is going on, but it appears that the White House has ceded that negotiating capacity in exchange for a guaranteed price reduction that does not exceed $80 billion over 10 years, plus about $150 million spent on advertising to get health care reform passed. Frankly, $80 billion is a drop in the bucket compared to a $1.5 trillion health care expansion, so this is pretty much a lost cause in terms of savings. Now, so I don't seem hyperpartisan, there are plenty of arguments (some presented here) that suggest that hard line Medicare negotiations would set price ceilings that would hamper drug and health care technology development.

Perhaps. But isn't there a more measured answer to this? Is Medicare always really in the market for 1st line, newly patented state-of-the-art drugs? Can't Medicare negotiate cheap prices on generic, broadly issued drugs while still allowing high prices on the newest drugs to drive more research and development? It's another argument for stratifying health care, which leads us to:

4. Driving down insurance costs - As opposed to Big Pharma, insurance companies appear to be the main target of health care reform (to the extent that its now being called 'health insurance reform' on whitehouse.gov and in Barack Obama's op-ed in NYT today). To quote:

[R]eform will provide every American with some basic consumer protections that will finally hold insurance companies accountable. [W]e will require insurance companies to cover routine checkups, preventive care and screening tests like mammograms and colonoscopies. There’s no reason that we shouldn’t be catching diseases like breast cancer and prostate cancer on the front end. It makes sense, it saves lives and it can also save money.

OK, fine. That appears to fulfill the moral imperative but almost completely ignores how exactly this is going to pay for itself (in the editorial, he offers cutting 'hundreds of billions of dollars' in Medicare/Medicaid inefficiencies and preventative screening has his two cost-saving breakthroughs - not exactly enough to knock my socks off). And in fact, there are alternate, free market proposals out there. One long-winded perspective comes from David Goldhill, who in this month's Atlantic offers a businessman's perspective on how to reform health care. His idea: a combination of government-funded catastrophic health insurance, vouchers for some preventative care, and out-of-pocket payment for everything else:

First, we should replace our current web of employer- and government-based insurance with a single program of catastrophic insurance open to all Americans—indeed, all Americans should be required to buy it—with fixed premiums based solely on age. This program would be best run as a single national pool, without underwriting for specific risk factors, and would ultimately replace Medicare, Medicaid, and private insurance. All Americans would be insured against catastrophic illness, throughout their lives. How would we pay for most of our health care? The same way we pay for everything else—out of our income and savings. Medicare itself is, in a sense, a form of forced savings, as is commercial insurance. In place of these programs and the premiums we now contribute to them, and along with catastrophic insurance, the government should create a new form of health savings account—a vehicle that has existed, though in imperfect form, since 2003. Every American should be required to maintain an HSA, and contribute a minimum percentage of post-tax income, subject to a floor and a cap in total dollar contributions. The income percentage required should rise over a working life, as wages and wealth typically do.

He then suggests that the elimination of comprehensive private insurance might lead to people being more efficient with how they spend money on health care - might they be more likely to turn to walk-in clinics, for example? But whether through out-of-pocket expenditures or through insurance plans, I happen to think that this idea of stratifying coverage - providing basic coverage for everyone and increasing coverage through increasing cost - is a good one. The benefit of a public 'option' (or government funded catastrophic insurance, whatever) is that it provides a competitive model for people to actually decide whether the extra cost of private insurance is worth it - forcing insurance companies to also be more efficient. I happen to think that insurance-based systems still provide alot of benefits - they spread risk around broadly and offer more continuity of care - but merely subsidizing people with vouchers to be able to pay for coverage does nothing to pressure insurance companies to lower costs. On the other hand, I totally agree with the potential to use cheap, efficient walk-in clinics at places like Wal-Mart as efficient triage sites. But ultimately, pretending that some kind of reform, including increased efficiency, thoughtful rationing of exorbitant health care expenditures, and competition to reduce pharmaceutical and insurance profit margins, is unnecessary, is patently ridiculous, and one need only look at spectacles like what happened in California this week to know that the system is broken, and getting worse.

the discussion on health care we should all be having

sorry todd, i think the daily show beats colbert on this one.

The Daily Show With Jon Stewart	Mon - Thurs 11p / 10c
Healther Skelter - Obama Death Panel Debate
www.thedailyshow.com
Daily Show Full Episodes Political Humor Spinal Tap Performance

health care potential

paul krugman weighs in with good news on health care policy. maybe everyone is getting on the same page? (other than john boehner).

AMAZING

McSweeney's, on universal health care according to Dr. Mario. I'll just quote part of the awesomeness:

MYTH THREE: A government-run plan sounds
a lot like what Bowser wants

The king of all Koopas would love to take over every hospital in Mushroom Kingdom, to use them to extract Peach's DNA or create a horrific suit that looks like me to trick the princess. But government-funded doesn't mean government-run. I propose that we set up an oversight committee that would reside on Star World, a place linked to all of our lands. This committee would keep watch over the providers. It would see that free Megavitamins were distributed. Finally, it would research new health innovations, such as the powers of the rare Super Mushrooms.

And, just for fun, more McSweeney's!

Blocking Care for Women

is the title of a scintillating Op-Ed by Hillary Clinton. Everyone should read it in full, so I'll just post a few quotes and be done with it. READ THIS. The Bush administration is proposing a new rule that would require any health care entity receiving federal funding to certify that none of its employees are required to assist in ANY MEDICAL SERVICES THEY FIND OBJECTIONABLE.

The new rule would go further, ensuring that all employees and volunteers for health care entities can refuse to aid in providing any treatment they object to, which could include not only abortion and sterilization but also contraception. Astonishingly, the department does not even address the real cost to patients who might be refused access to these critical services. Women patients, who look to their health care providers as an unbiased source of medical information, might not even know they were being deprived of advice about their options or denied access to care.

This is an abomination. Does anyone know how to participate in the 30-day comment period? People at NYU, could we somehow get a comment from higher-ups or something?

health care: both camps fall short

The policy journal Health Affairs has released profiles on both the Republican and Democratic health care plans. The bad news: both fall short of universal coverage. The worse news: one falls short of increasing coverage at all, and i'll bet you can guess which one.

Yep. The McCain health plan would increase the number of uninsured by 5 million within 5 years. The Obama plan would decrease the number of uninsured by 18 million in 1 year and 34 million in 10 years, an improvement but still short of the 45 million total uninsured.

health affairs article here, new york times article here.

antiprobiotics.

Probiotics are stupid. The premise, ostensibly, is that eating a bunch of bacteria might help the digestion of people with IBS (Irritable Bowel Syndrome). This is awfully convenient, because IBS cannot be assessed quantifiably (the readout is generally based on patient symptoms) making this type of "therapy" succeptible to a whopping placebo effect. Who says that these bacteria can out-compete your endogenous flora? And even if it did, how do we know that is a good thing? Commensal bacteria constitute a vital presence in your gut, serving many functions other than digestion. They help prevent infection by more dangerous bacteria. They make sure your immune system doesn't respond inappropriately to harmless bacteria. In fact, one of the more popular models for inflammatory bowel disease involves a damaged immune response to your gut flora. Plus, as Lauren Sandler points out, the marketing techniques essentially imply that you can use 'probiotic' therapy to lose weight. Its even more egregious overseas. So, don't pay a premium for something that is in no way scientifically validated to be helpful.

On the other hand, using worms to treat allergies - that may actually work, and interestingly, in a way that commensals might also act - by serving to dampen your immune response so it doesn't respond to inappropriate things, like pollen. This is summed up in the hygiene hypothesis.

Other Science thoughts, courtesy of Nature News:
1. SIDS - Excellent work from Cornelius Gross's group. They engineered a mouse with excess levels of the serotonin 1A receptor, which acts as a negative regulator of serotonin levels, based on prior associations of serotonin with SIDS (sudden infant death syndrome). The resulting mice experienced sudden drops in heart rates and sudden death at early ages, mimicking SIDS phenotypes. Nature News article here, Science paper here.

2. Schroedinger's Cat, alive! - Someone explain this to the nerd in me who owns A Cartoon History of Time and wants to understand shit like the Copenhagen Interpretation!

The notion is exemplified by the paradox of Schrödinger's cat, a thought experiment in which a cat is locked in a box with a vial of poisonous gas that would be broken if a quantum particle was in one state, and remain intact if the particle was in another. While the box is closed, the particle exists in a superposition of both states simultaneously, so the poison must also simultaneously be both released and contained, and, in turn, the cat must be both alive and dead. When the box is opened, the quantum superposition collapses, and the cat is either killed or saved, in an instant.

Now, Nadav Katz at the University of California, Santa Barbara, and his colleagues have performed an experiment in which they pull a quantum state back from the brink of collapse, 'uncollapsing' it and returning it to its unobserved state. Effectively, they have peeked at Schrodinger's cat in its box, but saved it from near-certain death (N. Katz et al. http://arxiv.org/abs/0806.3547).

To physicists raised on the textbook Copenhagen interpretation, any notion of uncollapsing a quantum state seems “astonishing”, says Markus Büttiker, a quantum physicist at the University of Geneva in Switzerland. “On opening the box, Schrödinger's cat is either dead or alive — there is no in between.”

Help!!!!

Other, Other Thoughts:
1. Nadal triumphs at Wimbledon - Now, I'm a huge Federer fan. I think he's a true surgeon on the court, hitting impossible angles and exhibiting that 'sixth sense' where he sees 5 shots ahead. But Nadal bested him honestly this time, and he did so with an almost inhuman defensive consistency, hitting precision groundstrokes, forcing Federer to come to the net, and then hitting passing shot after passing shot. It was pretty phenomenal. I'll just say 2 things. First, I really hope this inspires Federer to raise his game. He's got about 4-5 years left, so hopefully he's still got some great tennis in him. I think he's been stagnant for lack of a true challenger in the past few years, so this is exciting. And 2) I didn't really appreciate the Nadal homerism by the commentators. It goes back to the desire to see a champion torn down, to see him (or her) exposed as mortal. Why not appreciate the dominant run that we've seen for the last 4 years (12 of the last 13 grand slam finals, 13 grand slam titles including 5 wimbeldon, 4 us open, 4 australian open titles) instead of being so eager to anoint a successor? It's kind of a shame.

2. Destruction of the Indian Embassy in Afghanistan - The attack clearly appears to be a response to the growing threat of Indian influence in Afghanistan. To quote:

Pakistani intelligence has long supported militant groups fighting in Kashmir and Afghanistan as a means to influence regions on its borders and, according to some Western diplomats and military officials, it maintains those links today, including with some elements of the Taliban.
Pakistani intelligence, which regards Afghanistan as its backyard, fiercely resents India’s growing influence here, Afghan officials said. The Afghan Interior Ministry said it believed that the attack was carried out in collaboration with “an active intelligence service in the region.”

The US has for a long time been allied with Pakistan, which included use of Pakistani airspace for attacks on Afghanistan shortly after 9/11. One would assume, however, that the recent pattern of behavior would demand a shift in policy.

3. This American Life: By Proxy: This week's This American Life is fantastic. It speaks of people who have had to act as proxies for others in many facets. The most interesting, and gut-wrenching, is the story of an Iraqi translator who gets caught in the crossfire between American soldiers, for whom he works and considers noble until the events of Abu Ghraib, and Iraqi civilians growing increasingly resentful of American occupation. By the way, on the Wikipedia page for the events of Abu Ghraib (which everyone should flip through just to be fully aware of what happened), I just want to highlight a couple of responses.

Rush Limbaugh: "This is no different than what happens at the Skull and Bones initiation and we're going to ruin people's lives over it and we're going to hamper our military effort, and then we are going to really hammer them because they had a good time. You know, these people are being fired at every day. I'm talking about people having a good time, these people, you ever heard of emotional release? You ever heard of emotional release?"

Senator James Inhofe: "I'm probably not the only one up at this table that is more outraged by the outrage than we are by the treatment [...] [They] are not there for traffic violations. [...] If they're in cell block 1A or 1B, these prisoners — they're murderers, they're terrorists, they're insurgents. [...] Many of them probably have American blood on their hands. And here we're so concerned about the treatment of those individuals." (It's been estimated that at least 90% of detainees were innocent)

Yes, I know this was a million years ago. But please. Don't listen to Rush Limbaugh or any program on which he appears. And please, for the love of God, don't ever vote for James Inhofe.

4. Should abortion procedures be taught in medical school? (Obviously, yes). E.J. Graff at Slate had an interesting perspective on this, as he noted that in a recent poll, 80% of people believe that abortion should be allowed in at least some cases. Isn't this enough that ob-gyns should be formally trained in this procedure? Thoughts?

transatlantic boserk health care discussion, sort of transcribed

robin argues from india:
"Large employers are far more likely to provide some health care coverage; small ones do not, because health care premiums are very high and because they don't have the bargaining power of the larger firms who can provide volume to health insurance companies in return for lower premiums. So your plan doesn't address the crux of the problem, and it will also drive premiums up even further, since cost of coverage is linked to how much coverage is purchased."

USA Today article on above: http://www.usatoday.com/money/smallbusiness/2006-10-08-employ-usat_x.htm

santosh: mandate large business, government subsidize small businesses. exemptions provide loopholes.

robin: "I feel very strongly, on the other hand, that the 40 million Americans who are unemployed, or are employed but without health insurance, should recieve coverage, mandated by the federal government. I assume there is no daylight between us on that aspect. Our difference comes in WHAT is covered. If ALL procedures are covered for ALL illnesses for ALL people who have no incentive to take care of themselves, people will keep coming into point-of-care with late-stage problems, and either the taxpayer or corporations have to foot the bill. There isn't enough money for that."

santosh: obviously rather than the above i support a single payer system, but im thinking realistically. expanding coverage doesn't mean providing coverage for anything. in fact, covering more people may mean not covering more elective procedures for anyone, but that's a good tradeoff.

robin: if you favor expanded coverage, then why are you hating on things like MinuteClinics in CVS and Walmart type stores for screening, and on online doctors?

santosh: the issue here is quality of health care. internet doctor guy doesnt take insurance so he's just exploiting rich people in a hurry. those people would be better off if they saw a doctor in person, and we shouldnt enable people to get riskier healthcare if they can get less risky healthcare. i have no problem with things like minuteclinics for large-scale screenings, ESPECIALLY for people with no insurance. the issue is for people who do have insurance, is this a time-saving strategy? Again, that makes these people take on a risk by not seeing an actual doctor, and currently i dont think its difficult enough to see a doctor (if you DO have insurance) to validate that. i would much MUCH rather just pay for the uninsured to have insurance so everyone can have healthcare without some people that have less time or money shouldering increased risk.

robin, you rock dude.

health care!

finally. i was almost starting to like mccain. thank god he unveiled his new health care plan. give consumers a tax break to purchase insurance? 5000 whole dollars? without putting pressure on insurance companies to offer affordable coverage to lower middle class families with chronic disease? sa-weet!

2 salient quotes:
"Democrats had said that his market-driven plan, by not compelling insurance companies to cover people with health problems, would ignore the plight of people who have trouble getting coverage."

"Unlike Mr. McCain, of Arizona, Senators Barack Obama of Illinois and Hillary Rodham Clinton of New York would make it illegal for health insurance companies to deny an applicant because of health status."

honestly. just expand the public health care plan and make larger business cover employees, and eliminate health-status based discrimination. seriously.

duh. other thoughts for this morning:
- facebook scandal implicates a prominent new york school. what do we really think about public vs private education?
- the new yorker takes on the hills???!!!
- will the red sox ever hit well and pitch well at the same time? come on!