Sunday, October 19, 2014
There has been a lot written about Ebola lately, and lots of talk about it, and fear about it, in the halls of the hospital and clinics where I work, and I would guess lots of other places also. I don’t have any expertise in Ebola, and don’t claim to know what should have been done, or what “we” should be doing going forward, but it is clear that there have been mistakes, or at least major miscalculations, made by the WHO and the CDC and other government agencies. Some of this may be the result of cuts in funding over the last many years, some the result of emphasis on bioterrorism rather than the impact of infectious agents that get transmitted the regular way (“Failures of Competence”, Joe Nocera, October 18, 2014) but has been both sobering as well as a vehicle for administration opponents to attack it. Of course, the attacks may be justified, but there is no reason to think a previous administration would have done better.
First, it is critical to point out that the real problem, suffering, and crisis is in West Africa, in Liberia and Sierra Leone, and Guinea. In countries with little infrastructure and few resources and in the cases of the first two, relatively recent histories of devastating civil wars. The concern about Ebola in the US (so far two home-grown cases, both in nurses who cared for the Liberian man in Texas) needs to be seen in that context. Those countries that are severely affected need major resources, both human and financial, and need them fast. An excellent video analysis of the issues was recently done by Laurie Garrett on a webinar called “The Ebola crisis: the best and worst case scenarios from here”. Thankfully, there is some recognition of the need in these countries among those who are seeking to make political hay of this crisis; my own Senator Jerry Moran has joined others, particularly other Republicans, in calling for closing off flights from the affected countries, but proposes to exempt health workers. Of course, this misses the fact that it is easier to screen folks coming from those countries than people who first travel to other countries and then fly to the US.
What does interest me about the whole discussion in this country around Ebola is the degree to which it illustrates two common flaws in the way people think about problems. One, obviously at play in the case of Ebola, is the fear of the new, unfamiliar, and scary, especially when hyped up by the media. Thus, for example, the reluctance of both patients and staff (encouraged by their families) to come to work in our clinic during the period that a patient at our hospital was being ruled out for Ebola (he didn’t end up having it), even though it is in a separate building and the patient was three layers of isolation deep. This fear is stoked by events such as the revelation that the second nurse to come down with Ebola had been allowed to fly from Texas to Ohio and back on a commercial airliner (although it could just as well be cited as evidence that anyone, working in a hospital or not, might be at risk).
The second is that people often find it easier to worry about, to get worked up about, problems that they are at low risk for but that they cannot do anything about, even when they are not doing what they could do to prevent problems for which they are at much greater risk. I have written in the past about a prototypical patient obsessed by breast cancer, a condition for which she was in fact at no increased risk, who was not doing anything about problems she could act on such as uncontrolled hypertension, cigarette smoking, and unprotected sex with multiple partners. Indeed, my point was that if she was worried about those last three, people would expect her to do something about them since she could – she could take blood pressure medication, stop or cut down on her smoking, and use protection when having sex. But those might be hard. Worrying about breast cancer, something that there was nothing she herself could do to prevent (doctors could order mammograms, at too young an age and far too frequently, but she wouldn’t have to do anything) was, in this sense, easier. Both of these logical flaws were highlighted by comments from the chief medical officer of my hospital, early in the isolation of the possible Ebola patient: “If 20,000 people were dying of Ebola there would be riots in the streets. But every year an average of 22,000 Americans die of influenza, and people still don’t get their flu shots”.
This selective concern is a form of determinism, the topic addressed by Konika Banerjee and Paul Bloom in “Does everything happen for a reason?” in the NY Times, October 19, 2014. They discuss the idea of fate, that things happen that were destined to happen, that experiences of adversity which coincidentally lead to positive outcomes (the man hospitalized for injuries as a result of the 2013 Boston Marathon bombings who falls in love with and marries his nurse) are “meant to be”. They note that while this is most common in people who are religious and believe that God determines everything, it is still a very common belief among atheists. It is an attractive idea, but it is a mis-reading of chance. That is, people pay attention when things seem to fortuitously happen, or a coincidence facilitates something you wanted to happen. (E.g., yesterday morning I heard a part of a 1981 song on the oldies station but couldn’t remember its name; amazingly, when I turned the station back on in the evening, it was playing again! Fated? No, just Rick Springfield’s “Jesse’s Girl”.) We forget how often things do not happen, but remember when they do. Banerjee and Bloom write:
Not everyone would go as far as the atheist Richard Dawkins, who has written that the universe exhibits “precisely the properties we should expect if there is, at bottom, no design, no purpose, no evil, and no good, nothing but blind, pitiless indifference.”
Deists, like Thomas Jefferson I heard yesterday (also on the radio, but NPR this time), believed that the world was so ordered that there must be a creator, although they rejected the detailed instructions that many of their contemporaries took from the Bible or other religious texts. However, the random nature of events, as suggested by Dawkins or by Stephen Jay Gould (“Full House: The Spread of Excellence from Plato to Darwin”) accounts for these just as well.
The same issue of the Times contains a more medically related piece, “Why doctors need stories”, by Peter D. Kramer. I like stories, and I use them a lot (see above for a couple); they make things come alive, tie abstract events to actual lives, create examples in the experience of individual people of phenomena that are harder to understand when we look only at populations. But they can be misused; my story about the woman who was more worried about breast cancer than her smoking or high blood pressure is meant to be an example of how people can choose which facts they believe and which they ignore. It doesn’t prove anything, certainly not that most people act this way, or don’t. It does (I hope) get your attention. We have to be careful how stories are used; “I knew someone who had an abnormal Pap smear and she didn’t do anything and it went away”, while consistent with our most current knowledge about the early course of abnormal Pap smears in young women, is not a valid argument for you to not do anything. Stories tell what they tell; the lessons learned and conclusions reached are up to us.
Banerjee and Bloom end their piece:
If there is such a thing as divine justice or karmic retribution, the world we live in is not the place to find it. Instead, the events of human life unfold in a fair and just manner only when individuals and society work hard to make this happen. We should resist our natural urge to think otherwise.
And, no matter what we think about Ebola, we should get our flu shots.
Thursday, September 25, 2014
Ethics is a difficult area. Medical decision making is a difficult area. Both are fraught with ambiguities, conflicting priorities, differing values. Priorities shift with time, as our moral compass tacks back and forth, seeking to compensate for current problems and deficiencies, and sometimes overreaching, require new future shifts in direction. We will probably never get it exactly right, but need to keep working in the right direction.
Barron Lerner makes an excellent start in his NY Times Op-Ed from September 18, 2014,”When Medicine is Futile”. He talks about his father, who was a physician leader in “The medical futility movement, which argued that doctors should be able to withhold interventions that they believed would merely prolong the dying process...”. The father was an infectious disease specialist, whose early career was marked by the miracle of penicillin and drugs to treat tuberculosis. However, later his practice, as that of most infectious disease physicians in the US, was being called to consult on infections occurring in hospitalized patients who were otherwise severely ill, often in intensive care units, with terminal diseases and frequently advanced dementia, “…connected to machines and tubes he knew would not help them.”
The younger Dr. Lerner, author of this piece and a professor of medicine at a major medical school, notes that his father “..placed some of the blame for the situation at the feet of bioethics and patients’ rights, two movements that I, as a young physician, had fiercely advocated,” which put them in conflict. And yet, from a longer perspective, he can see a great deal of his father’s concerns. As he point out, the patient’s rights movement and to a lesser extent bioethics
…did not account for one thing: Patients often demanded interventions that had little or no chance of succeeding. And physicians, with ethicists and lawyers looking over their shoulders, and, at times, with substantial money to be made, provided them.
The stimulus for this article is a recent report by the Institute of Medicine (IOM) of the National Academy of Sciences, “Dying in America,” “…that argues that we subject dying patients to too many treatments, denying them a peaceful death.” This report begins the process of reconciling the physician’s responsibility to at least provide accurate information on treatments and the likelihood of their success with the autonomy of patients to make their own decisions about the treatment that they want. This is a welcome effort at reconciliation of these two apparently or potentially conflicted ethical principles, especially given, as Dr. Lerner points out, that “Physicians declaring things to be ‘futile’ sounded too much like the old system of medical paternalism, in which doctors had made life-and-death decisions for patients by themselves.” But any meaningful discussion of this requires consideration of four powerful issues that always impact upon it.
First, there is trust. Can patients and their families trust the doctors to be advising them in their best interests? This is particularly true for many disenfranchised people who are not like the majority of doctors in background, ethnicity, and certainly income. For the poor and members of minority groups that have in fact in the past been victims of outrageous abuses, there may remain a suspicion of any effort to suggest that further interventions would be futile. People may think “you are only saying this because I (or my family member) is …” and would recommend intervention for a member of your own family, or someone more like you.
Second is the issue touched on above about the “likelihood of success”. Success at what? For patients and/or their families to make intelligent decisions, the parameters of success, or similar words like “help”, “improve”, “make better”, need to be clearly defined in words and concepts that lay people can understand and that physicians are willing to use. I have written in the past about a woman whose daughter worked with me who was dying in the intensive care unit (ICU) of the hospital I worked at. I came to visit and met her 5 children trying to decide whether to approve the use of an intervention in their unconscious, uncomprehending, and terminally ill mother that they were told “would help”. As I was not the treating physician, I went to the ICU doctor and inquired, on their behalf, what the intervention was and how it was expected that it might help. I then cautiously returned to the family to feel them out regarding their understanding of “help”. They thought it meant it would make her “better”. What, I asked, did “better” mean to them? When they appeared confused, I went further, asking if it meant that she would wake up, be able to talk to them, be able to go home, perhaps be able to say goodbye? Yes, they said, that is what it meant to them. I tried to gently say that this would not happen, that this intervention would, perhaps, correct a laboratory value, but would not have any of the outcomes they hoped for. They opted to not have it.
These are not easy discussions, and lead to the third issue. Most people do not have the training and background to understand the ramifications of the decisions that they are asked to make under the rubric of “patient autonomy”. I feel that I am knowledgeable about many areas, particularly medical ones, but it would be ridiculous to ask me how a bridge should be built. You wouldn’t want to drive over it, and I wouldn’t either. Simply citing “patient autonomy” and presenting incomprehensible data and decisions about whether to do something that even the words for make no sense to a regular person is not ethical; it is equivalent to abandonment. Sometimes a doctor or nurse or other health professional with patience can spend the time and effort necessary to help a patient or their family really understand what is going on, what likely outcomes of any intervention or –equally validly – non-interventions might be, so that they can make an informed decision based upon that information and on their own values and priorities. Most of the time the healthcare providers are too busy, and do not have the time and may not have the inclination, and are not paid well, or at all, for that time.
Which leads to the final issue, money. In a quote from Dr. Lerner above regarding procedures that will not be effective, I include “the substantial money to be made from them”. The money to be made by providing them is a profoundly important issue, potentially corrupting any discussion of ethic versus futility. Dr. Lerner notes that the IOM report “…advocates that Medicare and other insurers pay physicians to talk to their patients about end-of-life care”. This is a great idea, but it doesn’t currently happen often, and even the proposal that physicians do it (not to mention be paid for it) was grossly misrepresented as “death panels” when included in the Affordable Care Act (ACA). Even if this time is paid for, it would never approach the amount of money that would come from doing the procedure, or certainly not the money a busy surgeon, for example, might make from operating on someone else.
All people know, intellectually, that everyone dies. What may be harder for many to accept is that they must die, particularly when their time comes. It may be even harder for family members, who are not the actual patient, to accept, and to demand that “everything” be done. For Dr. Barron the elder, as described by his son, “Infections were the way that such frail individuals were supposed to die, the ‘final straw’ in the deterioration of so many of the body’s vital organs and functions.” Yet somehow they had become things that needed to be treated.”
Everyone dies; what we can only hope for is a death unaccompanied by pain and unpleasantness. Infections like pneumonia which should be treated in an otherwise healthy person in whom a return to health is likely probably should not be in a person who is terminally ill, bed bound, demented. They are nature’s exit door. The same could be said for starvation, a relatively benign way to go, and almost always better than the alternatives of feeding tubes or intravenous nutrition, which carry high risks of complications of aspiration and infection and discomfort.
Everyone dies; what we can only hope for is a death unaccompanied by pain and unpleasantness. Infections like pneumonia which should be treated in an otherwise healthy person in whom a return to health is likely probably should not be in a person who is terminally ill, bed bound, demented. They are nature’s exit door. The same could be said for starvation, a relatively benign way to go, and almost always better than the alternatives of feeding tubes or intravenous nutrition, which carry high risks of complications of aspiration and infection and discomfort.
There must be a real understanding that patient autonomy does not include the right to demand any treatment. We would not assume a person could request a Corvette or a lifetime pension, and yet the latter would probably do more to improve health than any medical intervention, and the former would cost less than many.
Dealing with and overcoming the barriers presented by the first three issues will be difficult but can be done. To really do so means eliminating the fourth issue, the perverse economic conflict of interest that can cloud judgment, decrease trust, and pollute the entire process.
Wednesday, September 17, 2014
Recently, SASS-MoKan, our local suicide survivors’ support group, held its annual Remembrance Walk. I have written about these in the past, and have included the fact that my personal interest in the issue of suicide is the fact that my older son, Matt, committed suicide in 2002, just after he turned 24. At the time, everything seemed to be going fine in his life, and it came as a real surprise to his family, his close friends, everyone.
The Remembrance Walk is a lovely ceremony. Following a lap around a good-sized park, there is a ceremony. All the survivors stand on the grass in a circle, and the names of all those they have lost are read; at the end, a flight of doves is released. It is caring, and it is supportive. Of course, the ceremony also brings out the pain and sadness of our losses.
Matt died nearly 12 years ago, but I know others who have lost children very recently. I can tell them that the acute agonizing pain that feels as if it will never ease does, but they cannot and should not believe. It becomes less acute, less sharp, less all-consuming every minute, but it never goes away.
Recently, an Op-Ed in the New York Times by Pranay Sinha discussed “Why do doctors commit suicide?”. Because I am a doctor, and one who many of my colleagues know had a suicide in my family, several people shared this with me, although I’d already seen it. The article provides the perhaps shocking information that the suicide rate among physicians is twice the national average. Beyond this, however, it focuses on residents, doctors in training, and the enormous stresses that they are under, not further discussing the reasons why doctors in general have such high suicide rates. This is not surprising, as Dr. Sinha himself is a first-year resident (at Yale) and is obviously acutely aware of the stresses and strains of residents.
I know that this is true; I was a resident (a long time ago, in the last millennium) and I work every day with residents. It is a hard job; although these people will become, in a few years, full-fledged physicians who will range from very well-paid to extremely well-paid, they are, as residents, working for about the US average wage, but up to 80 hours a week, often with life and death in their hands. That this is fewer hours than residents used to work is good, but is of limited comfort to them. The point is that the residency is a big stress, and it occurs at an age when many people, especially males, are already at risk. The important issues that are addressed in this piece, and in several of the letters written in response to it, are the idea that doctors are supposed to be all-knowing, infallible, unwilling to admit mistakes or weakness. The op-ed and the letters make clear how obviously unreasonable and burdensome that this is, for all doctors and possibly even more for these young doctors who are even more aware, inside, of what they don’t know and are terrified of showing it.
This is National Suicide Prevention Month, which is why the remembrance walk is in September, and why there are such articles appearing. NPR recently ran a program on the increase in the number of suicides in middle-aged men has increased by 50% since 1999; older men have always had the highest suicide rate, followed by adolescents and young men, but this increase in men aged 45-65 is new. Some suggestion is that it is the economic downturn, which hit poor people well before the “official” recession; it is lower-income men who had the highest rates in this age group. Robin Williams’ recent suicide was widely covered; I doubt that National Suicide Prevention Month entered into his decision. Interestingly to me, many of the commentators focused on the “how surprising, he was so funny, he made us laugh, who would have guessed” angle, while others have discussed how he, like many comedians, needed the public attention but was lost when alone. I suspect Williams was bipolar; certainly many of his activities have suggested an ongoing depression while his outer persona was so often manic.
What many of the articles, including the Op-Ed, do not discuss, however, is the fact that most suicides in the US are caused by depression, a disease. It may be unipolar (“just” depression) or bipolar (“manic depression”), but it is potentially fatal. The stresses of being a doctor, or being a resident, are tremendous and cause people who are depressed to go “over the edge” and commit suicide, but it is important to remember that most people undergoing the same stresses do not. The underlying condition usually needs to be present for the precipitating cause to be fatal. I have previously cited what I consider to be one of the best discussions of this issue, “The trap of meaning: a public health tragedy” by CG Lyketsos and MS Chisolm in JAMA.
National Suicide Prevention Month, and the activities associated with it, are critically important for raising awareness about a condition that kills 40,000 Americans a year, but is often kept secret, through shame. When I became a member of the club no one wants to be in, what are called suicide survivors (although the meaning is family and friends of someone who has completed suicide, rather than those who have personally survived a suicide attempt), I found out lots of people I knew were also members. They had parents, children, siblings, close friends who had committed suicide, but I didn’t know. We often don’t talk about our pain, but the sadness of losing a child seems to many to be more ok to talk about if it was a medical disease, or car accident, or homicide, than if it was suicide. But the loss is the loss; the pain is the pain.
I don’t have the optimism that some do about being able to prevent suicide in specific cases. I do believe that early diagnosis and treatment helps; I believe that being aware of the warning signs is important, and I will never know how many times having those who loved him around might have prevented my son from killing himself before he finally did. I can only hope that more awareness and discussion about this condition will make a difference for some, and perhaps many.
Sunday, September 7, 2014
My friend Allen Perkins received a text from his college-student daughter asking if she should be worried about the Ebola virus. His reply, discussed in “Ebola virus and the dread factor” in his excellent blog, “Training Family Doctors” was “Are you considering moving to west Africa?” This was wise and profound fatherly advice, based upon an understanding of the epidemiology of disease. While is it obviously a serious problem in West Africa (particularly Liberia, Sierra Leone, and Guinea), it is not in the United States. Many other things are much more of a threat in the US, including, as Allen points out, “death from bee stings” (100 per year in the US).
Ebola might someday become a significant problem in the US, but it is unlikely and is not now. Many other health problems are. College students like Allen’s daughter should be sure that they have all their recommended immunizations for diseases that can be prevented by vaccine, including HPV and meningococcus, a very serious and often deadly cause of meningitis that can become epidemic where young people live together in close quarters, like college dormitories (and army bases). Yet, many do not receive these immunizations for reasons that range from passively not getting it done (less of a problem in schools where it is required) to having beliefs, or having parents who have beliefs, that vaccines are dangerous and should be avoided (in some cases this can trump school requirements). They are, by the way, wrong. The net benefit far outstrips the risk. Having your child get meningococcal meningitis and die or have serious brain damage, or get cervical cancer, is not something you want.
But focusing on conditions over which we have little or no control, rather than the ones we do, is fairly epidemic in this country (and likely others). Dr. Perkins focuses on the “dread factor”, about how news reports (not to mention thriller movies) whip up fear about these diseases. On the other hand, mostly what we can do is fear them, while the diseases which we individually might be able to have an impact on would require us to have to maybe do something hard: change our diet, start exercising, stop smoking, not drink so much or at the wrong times. I have written in the past about a patient who had a terror of breast cancer, a disease for which she was not at an increased risk based both on her youth and lack of family history. On the other hand, she did not seem particularly worried about the health risks of her uncontrolled high blood pressure, smoking two packs of cigarettes a day, or having unprotected sex with several different men.
Most of us can see that this is not logical, and maybe even snicker a little about her poor decision making. But it is only a little extreme. Many, perhaps most, of us, could do a better job of eating right, of exercising, of not smoking or drinking excessively (which for many people is “at all”). If not Allen’s daughter, many of her classmates are at much greater risk from going out and getting drunk on a weekend night, increasing their risk of motor vehicle accidents, sexual assault, poor judgment in choosing voluntary sexual encounters, and long term habituation for those with a predilection for or family history of alcoholism, just for starters. But taking action to prevent such bad outcomes is hard, requires effort, and often means not doing things we like in the short term, such as eating tasty-but-unhealthful foods, drinking with friends, smoking when we are addicted to nicotine, driving when we (or the driver) is only a “little drunk”, or having to do unpleasant exercise. Or it can conflict with our self-image: wearing a bicycle or motorcycle helmet, eschewing doing things that our friends are doing. Worrying about things that we can do nothing about, like breast cancer or Ebola, may be a little irrational, but it is in some way comforting because if the bad thing happens we are an innocent victim.
In addition, there are actions a society can take, that could make even more of a difference from a public health, population health, point of view, saving more lives, but these require political will. Sadly, this is often more lacking than individual will. Guns are the prime example; many state legislatures and legislators make it a point of personal pride to advocate for there being no restrictions at all on what kind of guns (e.g., automatic weapons) and ammunition (e.g., armor piercing bullets) people can have or where they can carry them (everywhere, open or concealed). Helmets and alcohol regulation are other areas where opportunity for prevention is often missed. Car safety has been increased by car and highway redesign and tobacco has been increasingly regulated (against the opposition of the industry, it should be noted, in both cases) for the benefit of public health, but many opportunities remain.
Indeed, expanding health coverage to all those below 133% of poverty by Medicaid expansion continues to be opposed by those who want to be seen as against Obamacare. This may be irrational from a public health point of view, but in many states it is rational, if offensive, for being re-elected. The most unjust and inequitable part of it all is how the effects of poor public health policies most affect the most vulnerable, poorest, least empowered people in our society, or indeed any society. Public health education campaigns tend to focus on diseases that have well-funded advocacy groups and affect the majority population; a recent qualitative study of African-American women found that they were very aware of the threat of breast cancer, but hardly at all of stroke – a disease statistically more likely to affect them.
Speaking of public health, it is gratifying to see some newspaper coverage of Ebola that is not sensationalist or scary. “U.S. Colleges See Little Risk From Ebola, but Depend on Students to Speak Up”, by Richard Pérez-Peña in the NY Times, August 30, 2014, addresses the small but real risk that may affect colleges from students who have (unlike Allen’s daughter) actually traveled to West Africa. Even better is “Leadership and Calm Are Urged in Ebola Outbreak” by Donald G. McNeil, Jr., which presents a rational, thoughtful, public health approach, and discusses public health strategies which have been used in the past in major crises and are beginning to be implemented in West Africa. These strategies center around the use of local, respected experts who can effectively communicate with the people in their countries, rather than international aid agencies. The goal is to help people to utilize appropriate prevention and protection measures rather than panic. Again, as in the case of the other personal behaviors described above, this can be hard for people, especially when it contradicts cultural and religious values (such as how the dead are buried). But having voices who are local, who understand the culture, and have both medical/public health credentials and individual credibility, is extremely important. Of course, unlike the Ebola “scare” articles, these were both on page 8 of the newspaper, but have a more prominent position on that day’s Times homepage.
So what are the lessons? Understanding risk is not always easy, especially when an epidemic with a hugely high mortality rate threatens. Doing something is harder than not doing anything, and it can thus be tempting to worry more about the things that we can’t do anything about rather than those we could reasonably take action on. The same is true for public health issues that need to be addressed at a societal level.
And, of course, it is always the most vulnerable who suffer the most.
Saturday, August 30, 2014
The New York Times of August 23, 2014, contains a front-page story by Matthew L. Wald with good news. The use of blood in the US has gone down, because the need has gone down significantly: a decline of almost one-third over the last five years. One big reason is that new surgical techniques, such as laparoscopy and other “minimally-invasive” methods, have replaced many of the traditional “cut someone open” surgeries, so there is thus less blood loss and less need for transfusion. The other reason is that guidelines for blood transfusion have been more standardized and made more stringent, so that only people who really need blood get it rather than it being administered “routinely” to people after certain kinds of surgery. Certainly, in my institution, the physician who is director of our blood bank keeps a close eye on transfusions being ordered for people whose blood counts are above the generally-recommended cut-offs (provided of course, that they are not actively hemorrhaging). Since blood transfusion, like any other treatment, can have negative effects (the transmission of viral diseases like Hepatitis B and C, and HIV are not very significant any more now that we can test for them, but transfusion reactions still occur, especially in those who have multiple transfusions), it is obviously a good idea to limit them to only when they are really needed. Wald notes other reasons:
…new guidelines emphasize treating patients for anemia [my note: not with transfusions but with treatments that encourage the body to make more of its own blood, such as iron] in the weeks before surgery to minimize the need for transfusions. Cancer therapies have also changed in a way that reduces transfusion needs. So has surgery: In a total hip replacement, loss of 750 milliliters of blood, about 1.5 pints, was considered standard; now it is just 200 milliliters.
So it is a little surprising that the title of the article is in the negative: “Blood industry hurt by surplus” in the print edition (a little less negative, “Blood industry shrinks as transfusions decline” in the on-line version), and much of its thrust is about how this decreased need for blood and associated pressure from its purchasers (mostly hospitals) for lower prices is leading to decreased profits, industry consolidation, and worker layoffs. I assume that (based on the fact that the on-line version is part of “Business Day”) that this is in part because it is a business article and that Mr. Wald is a business reporter, not a health reporter. I guess it is indeed too bad for the owners of the for-profit blood banks (as opposed to the non-profit American Red Cross), and it is really bad for the workers, many of whom seem to be represented by the Communication Workers of America, who are losing their jobs. But from a health point of view, the fact that people are only getting blood transfusions when they really need them, and that the frequency of that need is declining, is a very positive development.
One of the more interesting points that Wald makes is the cost of blood products:
Nonprofit organizations collect whole blood from unpaid donors, but hospitals may pay $225 to $240 a unit, according to executives in the business, which covers a variety of costs, including testing. If the unit is billed to the patient, the price can be $1,000 or more.
That’s quite the markup. The markup from unpaid donors to the cost to hospitals is in part explained by the cost “…for storage, management and inventory losses; around a million units a year are discarded, mostly because they are not used soon enough.” Fair enough; these are real costs that must be covered, and the blood banks are bearing them, and hospitals want to pay less for the blood. Less justifiable is the markup by the hospitals, from less than $250 to over $1,000 per unit of blood, although as I have often discussed, this is not atypical for hospital charges. Once again, this is an example of business interest (maximizing profit, even in non-profit hospitals) diverges from the health interest of people (to get their care at a reasonable cost).
The treatment of positive health developments as negative business developments is not new, or unique to blood banking. If more care can be safely and effectively delivered in the outpatient setting, so that hospital admissions decrease, it may be bad for hospital business but it is good for people. If cheap drugs are effective for preventing or treating serious medical conditions (like aspirin to prevent heart attack in men or stroke in women, or folic acid – a vitamin – given to pregnant women to prevent neurologic defects in babies), it may be bad for companies making more expensive drugs to do the same thing, but it is good for people. Conversely, when a previously generic and cheap drug is allowed by a glitch in federal law to be patented, it is good for business but bad for patients (this actually happened in the case of the anti-gout drug colchicine; see the April 16, 2010 guest blog by R. Steven Griffith, VISA and colchicine: maybe the banks and Pharma really ARE in it for the money!). If we have duplication (or triplication, or quadruplication, or whatever) of expensive health care services so that there are more cancer centers, or MRI machines, or transplant centers than a community needs, it may be perceived as necessary for that individual hospital to “compete” but it costs our health system (that is, us all) more money.
What is interesting about this article is the difference in how the cost of health care services are treated by a business reporter (good or bad for business) and how they are treated by a health reporter such as Elisabeth Rosenthal, whose series of NY Times articles (e.g., “The $2.7 Trillion medical bill”) extensively document the high costs and markups in health care. The question for the rest of us is what we feel is more important, business profits or quality cost-effective health care, without unnecessary markups or excessive redundancy in capacity. It is sad when jobs are eliminated because certainly our people need jobs, but that is another question.
I think I am pretty clear on where I stand.
Saturday, August 23, 2014
“Second chance med school”, by Anemona Harticollis in the New York Times July 31, 2014, is the most recent treatment of the topic of for-profit Caribbean medical schools that train American students who, in most cases, were unable to gain admission to traditional US-based schools. This is not the first time Ms. Harticollis has covered the story; they are also the subject of her article in the Times from December 22, 2010, “Medical schools in region fight Caribbean flow”, which focused on the fear of US schools that these Caribbean schools are willing to pay for the use of clinical teaching spots in hospitals that these US-based schools have been using for free. This most recent piece focuses on St. George’s University in Grenada, one of the more established and better-regarded Caribbean schools. It was briefly famous when protection of its students was one of the justifications for President Ronald Reagan’s invasion of that country in 1983. The article also mentions the other three schools that have been approved for US loans by the Department of Education. However, beyond this, and despite Harticollis’ efforts, the discussion gets murky on two counts: which Caribbean schools are under discussion, and what are the issues of concern.
Harticollis notes that
There are more than 70 medical schools across the Caribbean, about half of them catering to Americans. A handful — including St. George’s, Saba University, Ross University in Dominica and American University of the Caribbean in St. Maarten, all of which are for-profit — have qualified for federal financial aid programs by demonstrating that their standards are comparable to those in the United States. And they report that high numbers of their test-takers — 95 percent or more — pass the United States Medical Licensing Exam Step 1, a basic science test.
But quality is all over the map in the Caribbean. A 2008 study in the journal Academic Medicine looked at 14 schools and found that the first-time pass rate on the exam ranged from 19 percent to 84 percent. Countries whose schools performed lowest were the Cayman Islands, Haiti, Cuba, Aruba, Dominican Republic, Antigua and Barbuda and, the lowest, St. Lucia, which hosted four medical schools at the time. High performers were in Jamaica, Barbados, Dominica and, the highest, Grenada.
It is irrelevant to the discussion of American medical students going to the Caribbean to look at the national medical schools in Caribbean (or any other) countries; it is only relevant to look at those which were created to educate Americans, and for the purpose of this discussion to limit it to the four that have Department of Education approval. The next thing is to understand that what is “good” or “bad” about any of these schools, or whether they should exist altogether, depends on who is looking and what their interests are. From the point of view of the individuals or companies that own these schools, the motivation is profit, but having a high-quality product increases their enrollment. From the point of view of students enrolling, the motivation is a chance to become physicians and practice in the US. From the point of view of those who are responsible for the academics of the schools themselves, it is to support students, provide a good education, and help them to be successful. From the point of view of many American medical schools, it may be to limit competition, whether that is for clinical teaching spots in hospitals such as those of the New York City public hospitals or for good students.
Most US allopathic medical schools, and their trade association, the Association of American Medical Colleges (AAMC), disparage the Caribbean medical schools in terms of quality of the students that they accept, since the majority of those attending such schools have failed to gain admission to AAMC member schools. However, since most of these AAMC schools have recently or are in the process of expanding their own classes, they must believe that there are well-qualified students who are not currently being admitted, and many of these have ended up in Caribbean schools. When AAMC campaigns to disparage the Caribbean schools, they tend to lump them all together, rather than looking at individual schools or only the 4 listed above. Unquestionably, students even at these four schools have, on average, lower grade-point averages (GPAs) and Medical College Admissions Test (MCAT) scores, and may, on average, not do as well on the USMLE exams as those from US allopathic schools, but there is great overlap. On the other hand, what is perhaps the most concerning part of education at the Caribbean schools is their clinical training – where they learn clinical medicine in the last two years of school. Are the doctors teaching them and the institutions in which they practice of high quality? Is there a well-defined curriculum? Is there standardization of the curriculum so that they can be confident that students are learning what they need to whether they are doing, say, a surgery clerkship in a NYC public hospital or a community hospital in Michigan? However, when AAMC schools are fighting with them about whether they should be able to have spots at the same places US medical schools use – say, NYC public hospitals – this point is also moot.
The most important perspective, of course, is not that of the students, the owners or faculty of the Caribbean schools, or that of the US schools and the AAMC. It is that of the American people and whether they will have access to physicians who will provide excellent care for them. The measures that are usually used for assessing the “quality” of applicants and students – MCAT and GPA and USMLE Step 1 scores – are at best peripheral, since, as I have often argued, they are scarcely relevant to being a good doctor. Does it matter that a doctor didn’t focus when they were a freshman in college and so got C’s, and so even after doing well for 3 years had a lower GPA than another? Should the chance to become a doctor be a reward for having your nose to the academic grindstone your whole life without surcease, or an opportunity for those with skill, passion, and commitment? I have often argued that the way to judge a medical school is by what its graduates do with their lives, and that the percent that enter primary care and practice in underserved areas is a major criterion. It is fine to have some of your graduates doing laboratory research or entering narrow subspecialties, but a school should be judged on its overall output and how well it provides for the needs of our nation.
There is some concern that because of recent agreements between the Accreditation Council for Graduate Medical Education (ACGME), which accredits allopathic (MD) residencies and the American Osteopathic Association (AOA), which accredits DO residencies, that osteopathic graduates will be more welcome in allopathic residencies, tending to crowd out Caribbean graduates. I would doubt that this will be an issue in the Midwest, where osteopathy is strong and most residencies already tend to prefer DOs to Caribbean grads, but it might have an impact in the East, where osteopathy is less present, and where I hear that information pre-med students get from peers (and perhaps sometimes pre-med advisors) is that Caribbean schools are preferable to US-based osteopathic schools.
Like osteopathic schools, Caribbean medical schools, including the 4 DOE-certified schools, place a much higher percentage of their graduates into primary care than do US-based allopathic schools. Is this just a result of the fact that primary care residencies are less competitive than many other specialties, so easier for students from Caribbean schools to get into? Unquestionably, this is part of the explanation, but there is also more encouragement for primary care in these schools, which do not boast a huge research enterprise or maintain tertiary-care hospitals. It also doesn’t change the fact that graduates of these schools, like many international graduates who were not US citizens, are serving the needs of our country because the US schools are not stepping up to the plate. US medical schools are very selective about taking students with high grades, and putting most of them into oversupplied specialties.
The education at Caribbean schools varies, and it would be a mistake to say that they are doing a better job than US allopathic schools. However, US schools are doing a poor job of training the doctors America needs, of ensuring that all people have equal access to quality health care, and the students graduating from Caribbean schools are often filling the holes that they leave.
Those who live in glass houses…
Saturday, August 16, 2014
The social determinants of health are those factors that affect people’s health status that are the result of the social situation in which they find themselves. Thus, in the well-known graphic from Healthy People 2010 (dropped, for some reason, from Healthy People 2020), which I have reproduced several times, they complement the other determinants such as the biological (genetics), but are represented in most of the other areas. Physical environment and socioeconomic environment, certainly, but even “behaviors” are affected by the circumstances into which one is born and lives. So is biology, actually, as we learn more about genetic coding predisposing some people to addictive behaviors. Certainly it is not all volitional or evidence of weak character.
The social determinants of health can be partially enumerated, and include adequate housing (including sufficient heat in the winter), adequate food, education, and also a reasonable amount of nurturingand support from your family. In short, they are “the rest of life”, outside and often ignored by the healthcare system. Camara Phyllis Jones, in her wonderful “cliff analogy” (which I have also reproduced before) creates a metaphor in which medical care services are provided for those who need them (or “fall into them”) along a cliff face, while the social determinants of health are represented by how far a person, or a group of people, lives from that cliff face. As such, it illustrates the degree of protection that we all have from falling off that cliff, more for some and less for others.
One of the clearest ways to show the impact of these determinants is by a technique called “geo-mapping” in which certain characteristics (income, educational level, gang violence, drug use, number of grocery stores or liquor stores, public transportation routes, whatever you can think of) are laid over maps of a city, town, or region. We have seen these portrayed on TV or in the newspapers as national and state maps for political events (such as what areas voted for who), but they can also be very useful for understanding the different challenges faces by people living in different areas. The work of Steven Woolf and his colleagues at Virginia Commonwealth University has greatly contributed to this work; in addition to their incredibly useful County Health Calculator, has produced graphs that can be found on the Robert Wood Johnson Commission for a Healthier America site that show how life expectancy can vary dramatically in different neighborhoods, as in the map displayed of the Washington, DC area, mapped along Metro lines for greater effect, or the one of my area, Kansas City, Missouri (which doesn’t have a Metro!)
A recent contribution to this field has been made by Melody S. Goodman and Keon L. Gilbert, of Washington University in St. Louis, who mapped the dramatic differences across Delmar Boulevard in that city, in “Divided cities lead to differences in health”. Their graphic shows the disparities in education, income, and housing value, and, unsurprising, racial composition, on either side of Delmar. This work was covered in a BBC documentary. Dr. Goodman, speaking to a symposium from her alma mater, the Harvard School of Public Health, is quoted as saying “Your zip code is a better predictor of your health than your genetic code.”
This is a pretty sad commentary, given not only the incredible amount of money that has been spent on unraveling the genetic code but the amount of faith and expectation that we have been convinced to have in how this new genetic knowledge will facilitate our health. By knowing what we are at risk for, genetically, the argument goes, science can work on “cures” that target the specific genes. This is a topic for a different discussion, but in brief one problem is that the most common diseases we suffer from are not the result of a single gene abnormality. It is probable that, at least in the short-to-medium term, knowledge of our genetics will be more likely to lead to higher life insurance rates than cures of our diseases. The more profound issue, however, is that there is evidence from the social determinants of health, from the work of Woolf and Goodman and many others, that we do not address the causes of ill health even when we know what they are.
Why is this so? Why is there such great resistance to understanding, believing, that investment in housing, education, jobs, and opportunities will have a much greater impact on people’s health than more and more money spent on high-tech medical care (and, of course, profit for not only the providers, but the drug and device companies and middleman insurance companies)? It is in part because we hope (and, when we are more privileged, expect) that we will be the beneficiaries. And it is also because we choose to believe that those who do not have the benefits we have (of money, education, family) somehow “deserve” it because of character flaws.
The issue of “fault” is articulately addressed by Nicholas Kristof in a New York Times Op-Ed on August 10, 2014, “Is a hard life inherited?” Kristof argues that it is, not genetically but because the circumstances to which one is born and in which one grows up, the presence of caring parents who read to you rather than beat you, who take care of you instead of abusing drugs, as well as adequate food and housing make a tremendous difference in how you turn out.
Indeed, another major study by Johns Hopkins sociologist Karl Alexander, to be published in his “life’s work”, “The Long Shadow: Family Background, Disadvantaged Urban Youth, and Transition to Adulthood”, and covered on NPR, confirms this. Alexander and his colleagues tracked nearly 800 children for more than 20 years, and found that those from less privileged backgrounds with lower incomes and less supportive families did worse. Only 33 of the children moved from the low income to the high income bracket. Problems with drugs and alcohol were more prevalent among white males than other groups, but they did better financially anyway. Some people, rarely, overcome the deck being stacked against them, but most of those who do well after being born with relative privilege would likely not be among them had they been in the same situation. Kristof writes:
ONE delusion common among America’s successful people is that they triumphed just because of hard work and intelligence. In fact, their big break came when they were conceived in middle-class American families who loved them, read them stories, and nurtured them with Little League sports, library cards and music lessons. They were programmed for success by the time they were zygotes. Yet many are oblivious of their own advantages, and of other people’s disadvantages. The result is a meanspiritedness in the political world or, at best, a lack of empathy toward those struggling…
That lack of empathy leads to a lack of action; we are willing to accept people living in conditions that we would never accept for our family and neighbors, not only across the globe but across town, or even across a street. From the point of view of health, our priorities and investments are misplaced when we do not address the social determinants of health as well as cures for disease. When we do not try to change the known factors of zip code that impact our health as we investigate those of the genetic code.
If there are to be “cures” that come from our understanding of genetics, there is every reason to expect that they will be one more thing that is available to the people on the south side of Delmar Boulevard in St. Louis long before they are to those on the north side of the street.
 Jones CP, Jones CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228
Saturday, August 9, 2014
The title of Alan Bavley’s article, “Kansas is only state to see an increase in its uninsured rate, survey says”, (Kansas City Star, August 5, 2014) kind of says it all. It could be seen as a victory by some. Four years after the passage of the Affordable Care Act (ACA), aimed at expanding health coverage to more Americans by a combination of strategies including the creation of both state-run and federally-run (for those states that chose not to run their own) insurance exchanges to match people seeking coverage with insurance companies and subsidizing premiums for the moderately low-income, and expanding Medicaid for the very low-income, Kansas has succeeded in actually reducing the number of people covered!
The adult uninsured rate in Kansas rose from 12.5 percent last year to 17.6 percent during the first half of this year, giving the state the seventh-highest rate in the nation, according to data collected as part of the Gallup-Healthways Well-Being Index…. in other states uninsured rates declined or remained unchanged. Kansas was the only state with a statistically significant increase in the percentage of uninsured residents.
One could construct a fantasy out of whole cloth demonstrating how this proves why the opponents of the ACA were right all along; that it is not increasing health care coverage because it is evil and socialist, and that the increased costs for some people, along with cuts in the number of employed folks because of policies that do not always support “job creators” (read: very rich people) have decreased our employer-based insured group. Of course, that would be incorrect, but I expect to see it anyway.
In fact, those governing my state have worked very hard to make this happen. Governor Brownback and most of the state legislature are strong opponents of Obamacare, and have done what they could to make it not succeed. When the Supreme Court ruling allowed states to opt out of expanding Medicaid, Kansas did so, eliminating the very poor (under 133% of poverty) from the method the law intended for them to receive coverage. Kansas also chose not to develop a state-run insurance exchange and pu up as many obstacles as it could to the federally-run one. One of two Court of Appeals decisions (discussed in this blog in ACA: Where are we? And where should we go?, July 27, 2014) ruled that subsidies could be available only to enrollees in state-run exchanges (which Kansas doesn’t have); it hasn’t gone into effect yet, because another district’s Court ruled the other way, so we will have to wait for the Supreme Court to decide, but if it is upheld would bolster the number of Kansans not getting insurance.
But a decrease in the number of insured? The only one? Surely that is a notable accomplishment. How did we pull that off? “’It’s eye-popping. Kansas really sticks out,’ said Dan Witters, research director for the Well-Being Index, an ongoing national poll that surveys people’s health, relationships and finances.” For starters, it could, possibly, not be exactly true, but a data anomaly of the survey somehow. This is basically the position of the state’s Insurance Commissioner, Sandy Praeger, who said
…the number “appears to be an anomaly that needs more review. To have the uninsured jump that much in one year would be unprecedented.” The uninsured numbers in Kansas have hovered around 12 to 13 percent for many years, Praeger said, adding, “We will try to find out where the discrepancy is.”
This is worth noting, as Praeger is one of the few honest, trustworthy, and non-ideological members of state government in Kansas. Note that she does not claim that it is a liberal lie, or that it is a good thing, but just that it is inconsistent with previous data and she will try to find out why there is a discrepancy. If that is the reason, I’m sure she will.
But there are reasons to think that the numbers may not be inaccurate, even if they turn out not to be quite as bad as this survey indicates. Since the election of Governor Brownback in 2010, and with the support of the legislature, taxes in Kansas have been slashed, particularly income tax rates on high-income people and corporations and business taxes. The motivation was a profound belief in supply-side economics, that tax cuts would stimulate job growth. Unfortunately, it has not. Job growth in Kansas has been more sluggish than in the country as a whole, and the state is facing enormous deficits. Cuts in spending have been dramatic, but the problem is, in fact, on the supply side – not enough tax revenue. People don’t have jobs, and thus often don’t have enough income to qualify themselves for the exchanges, even if subsidies are allowed by SCOTUS to continue. The state has a very large number of undocumented workers (and most are indeed working, or in families of people working) who would not be eligible for coverage by any part of ACA, and can only get it if their employers pay for it. Which many do not.
While many states with Republican governors have pursued many of the same tacks as Kansas, including limiting the impact of ACA and cutting taxes, Kansas has been in many ways a test case for these strategies, even more than Wisconsin, because of its strong Republican tradition. Americans for Prosperity has a very strong political and financial influence in the state, and it is heavily financed by the Koch brothers whose Koch Industries is based in Wichita, Kansas (where Charles Koch still lives). Cutting taxes for the wealthy and corporations, and blocking any opposition to fossil fuel expansion, is the cornerstone of state politics, not ensuring the health or well-being of its residents.
In a larger sense, however, this is more than a story about Kansas. It may be the only state with a statistically significant increase in uninsured in the last year, but it is far from the state with the largest percentage of uninsured. Many other states that have not expanded Medicaid, and cut social services, have similar situations. Sadly, of course, many of these states (particularly in the southeast) started pretty far down, much worse than Kansas did, and have dug themselves deeper in the hole. The real story, I think, is in the states that, despite being southern and conservative, have chosen to expand Medicaid, and have seen real benefit for their people.
The Gallup poll found that the 10 states with the largest reductions in uninsured rates this year had all expanded their Medicaid programs and had either created their own exchanges or partnered with the federal government on an exchange. Arkansas saw the steepest decline, from 22.5 percent uninsured in 2013 to 12.4 percent this year. Kentucky was second with a decline from 20.4 percent uninsured to 11.9 percent.
Good policies can actually help. The state with the actual highest rate of uninsured people is Texas. “Look out, Texas,” Governor Brownback stated in announcing his original tax cuts, “here comes Kansas!” He was talking about job growth, which we haven’t achieved, but we are making much more progress on denying people access to healthcare coverage.
Sunday, July 27, 2014
I am finished writing the book, as yet untitled, that I have been working on during my sabbatical, which accounts for the sparse number of blog posts. This is not to say that the book is anywhere near ready to be published; I am sure it will need more revisions.
However, it does mean that I am likely to be posting to the blog more frequently, as I find things that inspire me to write.
Thanks for your patience!
The Affordable Care Act (ACA) has been law since 2010, and was supposed to have been fully implemented this year in 2014, although as is clear many of its provisions have not yet been. The most important has been the failure of about half our states to implement the expansion of Medicaid, which was the mechanism through which the law intended to cover all those poor (incomes under 133% of the federal poverty level) who are currently ineligible for Medicaid (most of those now receiving it are poor children and their mothers, although the majority of dollars are spent on nursing home care). This is legal as a result of the Supreme Court decision that was important because it made the rest of the law legal; this is, I think, of faint solace to those poor people who live in my state of Kansas and the others who have failed to expand Medicaid despite the fact that the federal government would have paid 100% of the cost for 4 years, then 90%.
The newest court actions that affect ACA are two Court of Appeals decisions which say, basically, opposite things about the subsidies that support the premiums of people making above 133% of poverty but less than allows them to pay the full amount. One court decided that people living in states that ran their own exchanges were eligible for the subsidies, but that those who were in federally-administered exchanges were not. The other appeals court decided that both were. Of course, those states that have federally-administered exchanges are those with governors and legislatures who oppose ACA completely; they include all those who did not expand Medicaid plus many more (about 36 altogether). This suggests some political agenda; the interpretation of Congressional intent rather than parsing the words, has historically been the basis for such court decisions. It also will mean that the cases will go to the Supreme Court, sometimes known as SCOTUS, but now appropriately called COCUHL (Court of Citizens United and Hobby Lobby), where it will be amazing if a conscious, careful, legal approach supersedes politics. The decision to basically gut the Hobby Lobby decisions one remaining protection only a day after it was announced bodes ill. The Republicans in Congress have decided to sue President Obama for not implementing portions of the ACA, which, as Timothy Egan of the NY Times points out, “…they have tried to repeal more than 50 times.”
What has the Republicans so flustered that they have taken to self-contradictory actions is, in fact, the success of the ACA at achieving many of its goals. These are summarized in another NY Times op-ed, by Paul Krugman, titled “Obamacare fails to fail”. There has been a huge surge in enrollment, and while indeed some people are paying more (largely healthy young people who are low risk for high-cost illness, thus previously had lower premiums), most people (including 74% of Republicans) are happy with their current premiums. In addition to the early wins (preventing insurance companies from not covering those with pre-existing conditions, allowing young people to stay on their parents’ insurance until they are 26), we now add over 6 million people who are newly covered, and can access health care. Despite decisions such as Hobby Lobby, most women will now get contraceptive coverage without a copayment. It is a good thing. This is why opponents (mainly ideological) are trying any trick that they can to limit its effectiveness, including the two biggest addressed above—not expanding Medicare and trying to block subsidies for those on the federal exchanges. That is to say, trying to limit health insurance coverage to our less-affluent citizens.
But ACA, even if it came through all the court decisions unscathed, is not a solution. It doesn’t cover those who are not citizens, even though they live here. It is a gift to insurance companies, who still get to charge high rates and make enormous profits, but now have the federal government paying the premiums. Therefore, it will not really save cost. Don’t get me wrong – I am not advocating that we provide less of the health care people need to save money (although I do advocating not providing “health care” that will not help or even harm people just because someone can make money on it). I am saying that the huge profits guaranteed for insurers, and other components of our system who make profit, make it excessively costly. It costs us way more per capita, for poorer health outcomes, than do the healthcare systems of other developed countries. The latest edition of “Mirror, Mirror on the Wall”, published in 2014 by the Commonwealth Fund demonstrates this clearly; in comparing 11 wealthy countries the US ranks #11 overall, and #11 in 3 of the 5 areas examined (Efficiency, Equity), and Healthy Lives), #5 in Quality, and #9 in Access. It achieves this less-than-mediocre performance by spending (2011) $8508 per capita, while the other 10 countries spent from $3182 (New Zealand) to $5669 (Norway).
The problem is not that our system is not working, but that it is. Paul Batalden is famous for saying “every system is perfectly designed to get the results that it gets”, and ours is. The results that we get are relatively poor health outcomes on a population basis, large numbers of people excluded from health care coverage (even after ACA), many people getting unnecessary care because someone can make a profit on it, and the bizarre concept that there are not only people who are preferable to provide care for (because of their wealth or insurance status) but even diseases that it is preferable to provide care for (because the profit margin is better). Our system is not designed for people’s health; it is designed so that some (providers, insurers, drug companies, etc.) can make profit. It gets the results it is designed to get.
But that is unacceptable. We need a health system designed to maximize the health of our people. All our people. And we need it yesterday.
 Goodnough A, Ruling on Health Care Subsidies Puts Coverage at Risk, NY Times 7/23/14, http://www.nytimes.com/2014/07/24/us/politics/court-ruling-on-health-care-subsidies-risks-loss-of-coverage.html
 Egan, T, “Ambulance Chaser in the House”, NY Times, 7/26/14, http://www.nytimes.com/2014/07/26/opinion/timothy-egan-Congresss-Next-Big-Idea-Sue-Obama.html
 Krugman P, “Obamacare fails to fail”, NY Times, 7/13/14. http://www.nytimes.com/2014/07/14/opinion/paul-krugman-obamacare-fails-to-fail.html
 Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2014 Update, The Commonwealth Fund, June 2014. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror