Do Not Treat? Not Gonna Work....

Floyd Norris suggests a "do not treat" list as opposed to a health insurance mandate:

At least some members of the Supreme Court seem to be persuaded by the idea that the government does not have the power to force us to buy health insurance. The whole idea seems specious and anti-free-market to me: if the government could legally enact Medicare for all, and tax all of us to pay for it, why is mandatory insurance not legal? It accomplishes the same thing, while minimizing government control of the health system....

[As an alternative, a]nyone who chose not to have health insurance, and not to indicate how they would otherwise pay, would be put on a “Do Not Treat” list. Hospitals could simply refuse to offer any treatment, respecting the person’s wish to make his or her own decisions free of an intrusive government trying to keep them alive.

The problems with that? To start with,

1. Accident victims will still get emergency care. Why? Because when the ambulance brings them in, the priority will be on stabilizing their condition and getting them treatment, not figuring out what insurance they carry, who has guaranteed their bills, or if they (or their guarantor) can pass a credit check.

2. Assuming we could screen out "do not treat" patients, people simply won't be comfortable with the idea of going back to the pre-EMTALA days when ambulances might have to go to several ER's trying to get a patient admitted before the patient perhaps dies in transit. I'm pretty sure that ambulance drivers and EMT's don't want to go back to that era, either.

3. People will still game the system. Will we also disqualify somebody from treatment for a year, a number of years or indefinitely if they contract an acute or chronic illness and can't afford to pay out-of-pocket? If so, there will be a cost to society - lost productivity, disability payments and the like, plus a potential for much higher costs when they finally qualify for Medicaid or buy insurance. If not, it's pretty safe to be a free rider.

4. It is likely to be a younger, healthier population that opts out and, although in a sense it's not fair to ask younger, healthier people to in effect subsidize the system, when lower-cost patients aren't part of the pool the cost for everybody else goes up. That could reinforce the opting out effect, which in turn would continue to cause premiums to rise... where the cycle might stop, nobody knows.

5. There are serious potential public health consequences to having people contract communicable diseases, yet not get treatment for those diseases.

6. Informed non-participation may be great for some adults, but what about their children?

Other than being more up-front about the possible consequences of not being insured, mitigated only by the extent to which insurance subsidies reduce the number of uninsured who might otherwise opt out due to cost, the net effect of any effective implementation of this proposal would be to take us back to a pre-EMTALA era. That's what universality seeks to avoid.

Cancel the Backscatter Order

Due to a "calculation error" (i.e., incompetence), the radiation levels produced by backscatter X-ray body scanners was underestimated by a factor of ten. Back when the lower radiation level was being touted, we were being assured that the backscatter machine was no less safe than the millimeter-wave technology machines. Now we know that's false. So let's stick with millimeter-wave. Not only safer for passengers, but as millimeter-wave produces even better virtual strip search images it should provide for more accurate screening. And, of course, there's the issue of how well the backscatter machines will be maintained.

If we're going to pretend that the backscatter order is about anything other than handing billions of dollars to a well-connected company, it's time to cancel the order for new backscatter machines. But then....

I guess it's worth asking, have we confirmed that these machines actually would catch an "underwear bomber"? Because if they would not, what's their point again? (And yes, those questions are rhetorical, as if the machines actually would catch an "underwear bomber" their manufacturers and the TSA would be bragging up a storm rather than making nebulous statements about things being "unclear".)

Who Owns Governor Rick Scott?

Once you realize how common pill addiction has become in this nation - how many people are addicted to pills, how many pills they take, and how many pills are diverted from legitimate markets to illicit sales, it becomes pretty obvious that 'legitimate' industries are involved. Sure, there are problems with doctor shopping, forged prescriptions, individuals who sell the drugs they are prescribed to take... Sure, there are doctors who are nothing more than drug dealers with prescription pads. Tens of millions of pills are 'stolen' between the point of manufacture and the point of sale. But when you read about a state like Florida, it's reasonable to infer that there's a lot more to the picture:

Turns out that Florida medical practitioners bought 41.3 million oxycodone pills in the first half of 2010, almost 10 times more than their counterparts in all 49 other states combined. There is simply no legitimate explanation for that.

And there's no way that pharmaceutical companies aren't tracking those highly profitable sales, or that they don't know that Florida's doctors are purchasing far more pills than the population of the state could reasonably be expected to need. Under Jeb Bush, Florida had slowly started to take steps toward tracking prescriptions for controlled substances, a step that although far from perfect makes it much harder for doctors to engage in wholesale prescription fraud and drug dealing of the type recently seen in Florida.

Thirty-five states, including Virginia, and the District have found a way to manage the trade-off: prescription drug monitoring programs (PDMPs), paid for with both their own funds and federal grants. PDMPs generally require doctors and pharmacies to report dispensing of controlled substances to a central database, where the information is kept securely, available only to authorized persons - such as doctors and pharmacists - with a need to know if patients have a history of "doc-shopping." Studies by both the Government Accountability Office and a Justice Department-funded consulting firm have found that PDMPs deter overprescription and reduce the probability of drug abuse.

Florida, not surprisingly, lags in this respect. In 2009, the state established a PDMP to be funded only through private donations; it has not yet gone into operation. Newly elected Gov. Rick Scott (R) wants to repeal even that weak measure, calling it an invasion of privacy.

Why am I skeptical that Rick Scott's concern is privacy. Florida's not alone in this regard:

Perhaps more surprising, Maryland has done less than Florida has. This is especially troubling given that medical practitioners in Maryland purchased 423,000 oxycodone pills in the first half of 2010, more than those of all but three states, including Florida, according to Drug Enforcement Administration (DEA) statistics. That is eight pills for every 1,000 residents, 10 times the rate of California and 53 times the rate of New York.

Did you catch that? California's doctors, who have a reputation for being quick to prescribe pain pills to their legitimate patients, prescribe them at a tenth the rate of doctors in Maryland. We're talking about hundreds of millions of dollars here, folks. When I read about the governors of states in which massive diversion is occurring blocking modest measures that could help reduce that problem in their states, I think it's more than fair to ask, "What's in it for them?"

I'm not suggesting that they're in the pocket of their states' drug cartels. But let's not forget that when this much money is at stake, and when we're talking about the diversion of millions of pills, the legitimate side of the industry has a huge financial interest in preserving the status quo. Here's where some transparency could be useful - I would like to hear Governors Scott and Maryland's former governor, Robert L. Ehrlich Jr., explain why they worked so hard to block PDMPs in their states - including the identities of the industries that lobbied against the PDMPs and the amounts those industries contributed to the governors' election campaigns.

Wash Your Hands After You Do That

Last year at a truck stop restroom a burly trucker type opened the restroom door with a paper towel and, almost apologetically, explained to me that it's necessary because so many people don't wash their hands. (Another little hygiene tip, the faucet handles on non-automatic restroom sinks, are even worse.) No need to apologize. (With about 2/3 of men washing their hands at the low end, frankly, I'm surprised the numbers of hand-washers was so high.)

On a related note, news from a few months back about "please wash your hands" signs in restroms:

"Female hand rinsing went down once the sign was placed, and their hand washing went up," Johnson said in an interview with Reuters Health.

But men, he added, "relatively stayed the same, regardless of the situation."

A small sample size, but still....

Taxing Soft Drinks

The New York Times endorses a tax on soft drinks to... magically affect current obesity rates. And I recognize the argument that such a tax could generate revenue. But I have yet to see anybody offer any evidence that it would actually affect obesity. For example,

• Is the consumption of soft drinks higher or lower in states with deposit laws?

• Is the consumption of soft drinks higher or lower in states that already tax them, such as in states that charge sales tax on soft drinks , or in Arkansas with its excise tax on soft drinks?

• Is there any evidence that overweight people, particularly overweight young people, drink more soft drinks than their peers?

Might it be more constructive to expand physical education in schools, and perhaps also nutrition education, rather than trying to blame a particular type of beverage for the manner in which we, as a society, have chosen to keep our kids sedentary and behind desks for the rest of the school day? Or by using pop machines in schools to subsidize school budgets?

Also, given that a lot of the soft drinks young people buy are purchased by the can or bottle out of machines - the most expensive way to buy soft drinks - why should we believe that a tax will appreciably affect their willingness to pay a premium for soft drinks? As much as they might want to do so, I have not seen that any vending machine company has successfully convinced a school to pull out its water fountains.

Finally, given that it's in no small part our nation's substantial subsidies for corn that allow the production of inexpensive sugary drinks and fast food, might it not make more sense to increase the cost of the end-product not by introducing a new tax, but by reducing or eliminating the corn subsidy?

Losing the Public Option

Having a healthcare bill pass without a public option inspires a valid question, what's the point? Or, in more detail, how do you inspire the changes and efficiencies you need in the current health insurance market without introducing a robust competitor whose focus is on providing care and not on profit? But perhaps losing the public option, at least the hobbled option that would pass under the current reform bill, isn't as bad as you think.

The number of compromises that were being injected into the public option to keep it from being effective, or even competing on a level playing field with for-profit competitors, were worrying. It may in fact be more productive to walk away from those demands and side deals, passing a cleaner version of a public plan in future years. The public plan was to be entirely separate from Medicare (why?), was to be forbidden from negotiating drug prices (why?).... Rhetorical questions - to make it less effective, more costly, and less able to price compete with private insurers who don't face similar restrictions.

I acknowledge the retort that if it doesn't happen now, we can't count on it happening in the future. True. But we can count on the trends in private insurance continuing - the dropping of high cost patients (sometimes in flagrant violation of contract), rapidly increasing premiums, employers finding themselves unable to offer quality plans or perhaps any plan at all, people being made more and more responsible for their own medical expenses - whether or not they can afford them. Stripping out the public option is meant by the insurance companies and their captive congressmen to maintain the status quo - but the status quo is not sustainable.

Don't get me wrong. Killing the public option is cowardly and backward-thinking, the type of thing you would expect from a Member of Congress whose primary concern is the size of his campaign coffers. Those who stood in the way, or might stand in the way in the future, should be rewarded with primary challenges. But it may be more important to end the hysterics, let Obama move on to other parts of his agenda, and figure out how this issue can be more successfully addressed in the future.

If a public plan is postponed, the Democrats should evaluate what can be done through reconciliation. Can Medicare be expanded to let older workers buy in, at an unsubsidized rate, for a full or partial set of benefits? Could it be expanded to provide an administrative framework and national care provider network for insurance companies organized at the state level? Could it at least be rebranded with in-your-face tagline, such as "Medicare: Government Health Insurance That Works For You!"

Meanwhile, where's the Issa-Kingston "Federal Cafeteria Plan for Everyone" bill?

Where Did I Leave My Sack of Hammers

Oh, never mind. As it turns out, Bill O'Reilly's offering himself up as a reasonable substitute.

Don't Count On It....

In a lament for the lack of support for autistic adults, a parent writes,

Question: What coming social expenditure will cost more than a third of this year's budget for the Department of Health and Human Services and be larger than the entire current budget of the Energy Department?

Answer: The bill for the tide of autistic children entering adulthood over the next 15 years, an estimated $27 billion annually in current, non-inflation-adjusted dollars by the end of that period. The number of autistic children expected to need extensive adult services by 2023 - more than 380,000 people - is roughly equal to the population of Minneapolis.

It may, if the nation feels that it has the money and makes spending on disabled adults a priority. But I wouldn't count on that - I would be structuring a special needs trust and trying to provide for my own child, on the expectation that society will not.

I understand that no one wants to look at a child and imagine the clunky, in-your-face adult he or she will become or think about the stares he or she will induce. When I look at my pudgy 22-year-old son, Randy, still sweet-faced but so obviously disabled, I cannot locate the blond cherub he used to be, gripping his stuffed brown bear.

This perhaps explains in part the difference in the manner in which society treats developmental disability in childhood and adulthood. In childhood, there's lots of spending and support, individualized education plans, the sky's the limit. In adulthood there are... group homes, and perhaps a sheltered job. And arguably the former is an outgrowth of guilt, overcompensation for the early 20th century's approach of warehousing and writing off developmentally disabled kids (as well as many with physical disabilities).

At expected rates, we will need to find an additional million caregivers, people who must have the right personal qualities to work with autistic individuals but who are willing and able to work for low wages. This is no small challenge. We not only must train people but also show that we value this work by paying them better.

And it's not just autistic adults. The needs of other developmentally disabled people must also be addressed.

The status quo for adults has emerged within the context of a society that has the funding to do more, and has chosen to put that money elsewhere. I suspect that over time the focus may be on how to provide disabled minors with less, and possibly also applying means testing to benefits, as opposed to providing disabled adults with more. I say this not to be mean, or to begrudge the developmentally disabled of funding and support. But if the future turns out to be as I expect, parents will need to be more proactive in planning out their own kids' futures, as the state is likely to become an even less acceptable proxy.

Suicide

It can be difficult to mark the moment when self-confidence turns into gradiosity, or when a suspicious nature turns into paranoia, particularly in someone you see regularly. But when you speak with somebody only a few times a year, the progression is more marked.

When we lived in the same community, I knew somebody who would at times share theories of conspiracies which were, for the most part, plausible but unlikely. He was an intelligent professional, and he spun a lot of fact into his stories.

At some point, his theories became far more involved and personal. He became deeply wedded to the notion of a conspiracy reaching to the highest levels of government, in which he was the target of a range of efforts to discredit him or to have him killed, because the nation's most powerful people were afraid of what would happen if the world found out what he knew.

I wonder if there was more that could be done to help, but at the same time recognize that every effort to provide assistance was greeted with suspicion, and that the more aggressive efforts at intervention inspired new conspiracy theories, with those attempting to help transformed into villains trying to destroy him. There was no chance of getting court intervention, as he gave no evidence of being a danger to himself or others, and was quite rational when addressing issues other than his paranoid fantasies.

The most aggressive effort at intervention, which pressured him to seek voluntary, intensive psychiatric care or possibly lose his professional license, backfired. He put himself beyond the reach of everybody who wanted to help him, and was largely isolated for the past year. He contacted me every few months, and we even discussed on a few occasions how I might be able to help him, but unfortunately he didn't follow through. A couple of times I must have pressed too hard, as I received emails indicating that I was forgiven (for whatever it was that I had been perceived to have done), but that he knew that I was nonetheless "one of the good guys".)

I hadn't heard from him for quite a few months, then learned of is death through the proverbial grapevine. I can't say that I am surprised at this outcome, but I am saddened.

Addiction As A Public Health Problem

To one who has long argued that addiction should be viewed as a public health issue, and that we should remove the impediments to researching treatments and medications for addiction, this sounds like progress.