Saturday, February 27, 2010

Democrats have a bad plan; Republicans have no plan

Sen. Lamar Alexander of Tennessee, chosen to be the Republican “point man” at President Obama’s health care summit presumably because he doesn’t come off like the meanest scold in the school the way Minority Leader Mitch McConnell of Kentucky does, told us afterwards that while his party supported almost nothing in the President’s health care proposal (including those aspects that they formerly championed) they had “better ideas”. This is a good thing, since they have no policy proposal. Those ideas being not on display at the meeting, where they spent their time sniping at the President’s proposal, I went to the Op-Ed in New York Times of February 22, 2010 where 5 prominent Republicans not currently in Congress discussed “How the G.O.P. Can Fix Health Care”.

Some of these are not bad ideas at all. Bill Frist, a heart transplant surgeon and former Senate Majority Leader (when the Republicans controlled both houses of Congress and the Presidency and did not do health care reform), although he cannot resist saying that the power to change is “…just not in the Democratic leaders’ DNA,” because they oppose markets, tells us that “Transforming health care to slow the growth of spending requires a radical restructuring of how health services are paid for. . The most powerful way to reduce costs (and make room to expand coverage) is to shift away from ‘volume-based’ reimbursement (the more you do, the more money you make) to 'value-based' reimbursement.” I agree and think I am on record as advocating that. “Reward value, not volume,” he says, “Medicare and private insurance companies should reimburse providers not for each discrete service they provide but for managing a patient’s condition over an entire episode of care… Health care providers could then compete on the basis of efficiency and success.” He also says, demonstrating more faith than evidence based on past performance, that at the local level waste would “most likely” be eliminated, and that “markets work”. It is a shame that Frist didn’t try to implement any of these changes when he had so much power. He also addresses not at all the other major issue of health reform, which is providing access to care for the poor, uninsured, and underinsured. Maybe not surprising from one who is not only a super-subspecialist doctor but a member of the family that created and owns Hospital Corporation of America (HCA), a huge for-profit chain that has never concerned itself about caring for the underserved.

Mark McClellan, the former head of the Center for Medicare and Medicaid Services (CMS) under President Bush, and now at the Brookings Institution, also has suggestions for saving money, though not as radical as Dr. Frist’s, and also completely avoids the coverage of those who are currently unable to access adequate health care. James Pinkerton, of the New America Foundation and a former advisor to Presidents Reagan and GHW Bush, does begin to address health care, not just money. He says Americans want more medical care but that they should also be able to get better health. I’m all for the better health part, but am not convinced by any evidence that more medical care overall is needed, though certainly some people need more than they are getting. Unfortunately, Pinkerton’s piece is entirely platitudes; while he doesn’t say he thinks we need more medical care, he offers no suggestions that would lead to better health, or (surprise!) even mention the problem of how to cover the uninsured. Another former policy advisor to President GHW Bush and president of the “nonpartisan” Committee for Economic Development, Charles Kolb, begins to get to the issue of coverage, saying both Medicare and the current private insurance market don’t work and we need a plan like the one for federal employees to compete with private insurance companies. He actually mentions the word “uninsured” and tells us that the way to fund coverage for them is to eliminate the tax deduction for employer based health care contributions. This might help but there would require a lot of other money. And this one will increase the costs to those already insured, as businesses will pass them on to their employees.

Finally, we have the distinguished Newt Gingrich, the former Speaker of the House whose caucus derailed President Clinton’s efforts at health care reform, as well as every other progressive idea that might help the American people, while posturing as a social conservative family-values guy and leaving his wife – who had cancer – for another woman. Not the first, but certainly not the last of incredible hypocrites wearing the Republican colors. And yes, I know about Eliot Spitzer, but you can’t beat the Republicans for sanctimonious words that are violated by their actions. (Kind of like all the GW Bush “hawks” from Cheney on down who never served in the military but were willing to paint as soft those who had, not only Al Gore but John Kerry and Max Cleland, who lost two legs and an arm in Vietnam, for goodness sakes!) Anyway, Newt is also against wasteful spending, and tells us that we can save $600 billion a year if we eliminate unnecessary care. This is presumably much of the same care that the majority of the people in the study cited by Charles Kolb want more of, but no matter. Gingrich is absolutely right on the need to control unnecessary care, most of it done by sub-sub-specialists (like Frist) and not primary care physicians, but how much is unclear; we do waste money, but most efforts to save Medicare from “fraud” seem to look like across-the-board witch hunts in which a set amount is to be recouped (e.g., we won’t pay for care that is a certain amount, like more than one or two standard deviations above the mean) rather than looking at the need for that care in that patient. And, of course, Gingrich doesn’t advocate using the savings for covering the uninsured, though at least he has “provided” the money. Again, something that he never did when in office, and his successors currently in office are not advocating.

So what do we have? Some reasonable ideas for saving money and controlling costs from Republicans who used to have power in government, but nothing concrete at all being offered up by those who are now in Congress. We have a virtually complete ignoring by these NY Times Op-Ed writers of the fact that there are 45 million uninsured and another 30 million underinsured in this country, a number that is growing , and that increasing large numbers of insured can’t afford it and can’t get the care that they need, while the insurance companies (see “Anthem Blue Cross of California”) are trying their best to seem as voracious and evil as the bankers and financiers who ruined the world’s economy for everyone. (And both, the financiers and the insurance companies, are making out like, well, the bandits that they are!) We have Republicans in Congress who can only oppose and snipe, and fear mainly that the Democrats, who have a large majority in both houses, may actually use it to pass a kind of (weak) health reform by using the budget reconciliation process. That part is ok; it still requires a majority and in contradiction to the conscious outright lying by the Republicans is the way most health legislation has been passed. For example, COBRA, that allows you to buy insurance coverage from your former employer when you lose your job, gets its name from the Consolidated Omnibus Budget and Reconciliation Act of 1986, SOBRA (Sixth OBRA of 1986), the State Children’s Health Insurance Program (S-CHIP) and the creation of Medicare Advantage plans (1991) – see Firedog Lake. Also both Bush tax cuts of 2001 and 2003 were implemented by Republican use of the budget reconciliation process.

And a terrible Democratic plan, that, in an apparent effort to garner either Republican or conservative Democratic support, is a huge giveaway to the insurance industry. See the great comments of Dr. Don McCanne, and the Reuters February 25, 2010 article by Drs. Steffie Woolhandler and David Himmelsten. But at least it will eliminate discrimination for pre-existing conditions and cover more people (maybe 30 million; why is covering only 30 million of the uninsured ok?). But given that the best Republican ideas don’t cover more than 3 million of the current uninsured, the answer to getting a better idea is never going to come from that side of the aisle.

A single-payer, Medicare for All, plan, would cover everyone, save a huge amount of money initially and provide the mechanism for future cost savings and controls, and is apparently off both the Democratic and Republican tables. It would “take” the money from the for-profit insurance companies who offer little value and run up our costs and wastes in an effort to make their profits. Call the President and your Senators and Congressman and demand single payer. Every day.

Thursday, February 18, 2010

Poverty, Primary Care and the Cost of Medical Care


On January 27, 2010 (Health is more than Medical Care) I discussed how the concept in the title of that piece is true. A society that does not provide for the basic needs of its citizens, such as the US, is going to have more sick poor people who end up requiring more health care services at much greater cost. The greater the income disparity in a country, the greater the negative impact of poor population health. Countries that have a national health system can mitigate some of these effects by, at least, providing access to care for those who, through the various negative effects of poverty, suffer the worst health, but they do not prevent it.

This point is illustrated in the latest (of many, over the years and decades) reports on health status in the United Kingdom, commissioned by the government and done by a panel headed by Sir Michael Marmot of the University College – London. The report, “Fair Society, Healthy Lives”, documents the cost to the National Health Service of the ill health of the poor. This is not, of course, news; Marmot’s famous Whitehall studies demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class; it shows that the problems have not been resolved. In countries with less disparity of wealth and income (class) than the UK, including most of Scandinavia, these disparities in health are less; in the US, where the disparities in wealth and income are greater, so are the disparities in health and their associated cost.

Since, in the US, poor people are more likely to be uninsured (or have Medicare, if they are over 65), their health care costs are largely borne by the public sector. In this sense, the costs of Medicare can, and have, been used as markers for the overall cost of medical care. This assumption has a great deal of validity, because Medicare recipients, the “aged, blind, and disabled”, are highly overrepresented in both the middle and high use segments of the population (see Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009). (It is, however, important to remember that the majority of the 5% of “highest cost” users are not seniors – they include NICU babies, multiple trauma victims, and cancer patients.) The publications of the Dartmouth Atlas of Health Care have demonstrated much geographic variation in cost, and these have been used by a large number of health economist and scholars, as well as the Obama administration, to suggest that a great deal of health spending could be avoided if the “high cost” regions utilized health resources at the same rate as the lower cost areas.

Not everyone agrees with the Dartmouth analysis. Probably their most prominent critic is Dr. Richard Cooper of the University of Pennsylvania’s Wharton School, whose positions I have previously discussed on several occasions (most recently January 7, 2010, Primary Care and Residency Expansion). On his blog, Physicians and Health Care Reform, and in venues such as the on-line public health discussion group “Spirit of 1848”, Dr. Cooper argues that it is poverty rather than “inappropriate” use of health services that drive the differences in Medicare spending in different regions. He illustrates this by maps showing the far greater density of poverty in “high cost” Los Angeles, Miami, and Birmingham, AL compared to “low cost” Rochester, MN, Grand Junction, CO, and Portland, OR.

Many others disagree with Dr. Cooper, not in the sense that they feel that poverty is not a (or the) major determinant of health status, but with his assertion that the cost variations the Dartmouth Atlas identifies are solely an artifact based on prevalence of poverty. Among the most prominent of these critics is Dr. Barbara Starfield, of the Johns Hopkins University, a major health services researcher whom I have also often cited. I believe that Cooper’s argument that the Upper Midwest is richer, and thus healthier, than the Southeast is relying on areas that are too large. His contrasts of the cities above in terms of their concentrations of poverty are accurate, but the argument misses the tremendous difference (cited by Dr. Atul Gawande in his piece “The Cost Conundrum” and its followup “The Cost Conundrum Redux” in the New Yorker) between cities such as McAllen and El Paso, TX. Or, for that matter, between Los Angeles and San Francisco, or Chicago, all of which have varying levels of health costs (i.e., Medicare spending).

The real issue is “what is the implication of either position, or any other, for what to do to address the health needs, and cost of medical care, for the US population?” From much of his previous writing, Dr. Cooper has disparaged the contribution of primary care prevalence to the quality of health care, seeing it as a confounder to the true cause of higher spending, because it is more prevalent in the Upper Midwest than in the high cost areas. The data, from many, many studies in many, many countries, not only those by Starfield and the Dartmouth folks, is that it is not a confounder. Where health systems are built on primary care costs are lower and, more important, quality is higher. This should not be a surprise to anyone who is concerned about the impact of poverty on health status – when poor people can access preventive services and treatment at an earlier stage, where intervention is both less costly and more effective, they will have better health status. Primary care reduces cost.

Hospitals and many subspecialist physicians are not happy about the potential for cuts in Medicare because they already think that Medicare spends too little. That is, it does not pay “enough” for the extraordinarily costly high-tech interventions that they make their profit on. I suggest that Medicare spends too much on this kind of care, rather than paying a lot more for the preventive and primary care services that would make this kind of tertiary intervention necessary less often. Medicare should not simply make revisions to its payment schedule, it should completely turn it on its head so that a day of managing multiple complex medical and social problems and doing preventive care by a primary care doctor generates more money than a day of doing procedures such as endoscopies, catheterizations, and the like. (Note that I am not suggesting we invert the incomes, just the amount that these doctors earn relative to each other; the net cost should be dramatically reduced.)

This would, of course, encourage more medical students to enter primary care, which would be a good thing for the health of us all. Simply increasing the number of funded-by-Medicare residency positions will not do that, but rather would just generate more hoping-for-high-income sub- and sub-subspecialists, whose overall effect on health status is, from a population perspective, small. (For example, I benefit, for sure, if my brain tumor is excised or my cerebral bleed drained, and I definitely want access to its benefit, for me and you and the poor; however, if there were no neurosurgery at all, the impact on the health status of populations would be minimal.)

More important, it would free up a lot more money for addressing the overall social problems of poverty, while now the cost of medical care, exceeding 17.3% of the GDP (CMS report by Truffer CJ, et al, in Health Affairs, February 4, 2010) threatens to choke off any other social spending. As articulately stated by Bob Phillips of the Graham Center (personal communication), giving the “…poor the same access to excess that all of the rest of us have in order to lift them from disparity would only hurt them more. Economically, health care is starving the services that do help reduce disparities--education, social services, day care, Head Start, food stamps, etc. They are all suffering right now in state budgets because healthcare is devouring state budgets (health care consumed 1/3rd of all fed/state tax dollar s in 2008,[1] (and probably more now that tax revenue is down)”. This is demonstrated by the 2005 study by Boston University’s Sager and Socolar[2] and shown in the attached graphic, from the Graham Center’s presentation on the topic. Obviously, there would still need to be a decision by our society to spend the savings on social services (rather than, say, tax rebates to the wealthiest Americans, or war), but, other than war, there is hardly a less useful way to improve the health status of the poor than by spending it on more high cost tertiary and quarternary care medical centers staffed by more and more sub-sub-specialists.

[1] Sessions S and Lee PR,”Using Tax Reform to Drive Health Care Reform: Putting the Horse Before the Cart” JAMA. 2008;300(16):1929-1931
[2] Sager A, Socolar D, Health Costs Absorb One-Quarter of Economic Growth, 2000 – 2005 Recent Federal Report Unintentionally Obscures Massive Rise Physicians’ Decisions Key to Controlling Cost. Data Brief No. 8 - 9 February 2005.

Monday, February 15, 2010

Correction to the Meyers, et al paper on smoking bans

The paper by Meyers, et. al., cited in the February 6, 2010 blog, had a correction issued in the Journal of the American College of Cardiology, which had to do with a statistical calculation error. The association between smoking bans and decrease in AMI (heart attack) is still strong but less so; the rate goes down 14%, not 26%, per year after bans are in place

The formal correction published in JACC is:

Meyers DG, Neuberger JS, He J. Cardiovascular Effect of Bans on Smoking in Public Places: A Systematic Review and Meta-Analysis. J Am Coll Cardiol 2009;54:1249 –55.
In this article, the meta-analysis included data from Pueblo, Colorado, which the authors erroneously reported as incidence rate ratio (IRR): 0.30. Actually, the IRR is 0.66 (95% confidence interval [CI]: 0.58 to 0.75). This changes the meta-analysis summary IRR to 0.92 (95% CI: 0.86 to 0.99). The meta-regression of the effect of ban duration also changes. The coefficient of post-ban duration in the meta-regression model is -0.16 (95% CI: -0.20 to-0.11), meaning that the IRR decreases by 14% (95% CI: 11% to 18%) for each year of post-ban observation (e.g., IRR: 0.86 after 1 year, then 0.73, then 0.63 compared with pre-ban).
The authors regret this error.

Saturday, February 13, 2010

Insurance company greed: To know them is to not trust them

Anthem Blue Cross, a subsidiary of WellPoint of Indianapolis, has taken a lot of criticism for its proposed rate increases on its 800,000 individual policies in California (“Anthem Blue Cross dramatically raising rates for Californians with individual health policies”, Duke Helfand in the Los Angeles Times February 4, 2010,,0,3002094.story), to the extent that a follow-up article by Helfand on February 12 (“Anthem's parent company defends health insurance rate hike”,,0,3807841.story) calls them “beleaguered”. They deserve to be. Their action is not only outrageous, it points out the absolute absurdity of thinking that a solution to the nation’s health care access problems can involve for-profit insurance companies.

Anthem announced increases of up to 39% on individual policies, but the WellPoint announcement adds insult to injury when it says “…that less than a quarter of affected Anthem customers in California will see rate increases of 35% to 39%. The average will be about 25%, while some customers will see rates fall…” Whew! Only 25% on average! Only a quarter of those affected will see increases in the 35-39% range. I guess those folks – and the rest of us because, as I will keep saying, we are all in this together! – can now rest easy.

In addition to investigations by the California Insurance Commissioner and possibly the Attorney General of the state, this one outrageous act has been the target of increasing criticism from the administration and from Congress. Rep. Henry Waxman, Chair of the Energy and Commerce Committee, announced hearings into the rate increase (, and HHS Secretary Kathleen Sebelius is quoted by Helfand as saying “It remains difficult to understand how a company that made $2.7 billion in the last quarter of 2009 alone can justify massive increases that will leave consumers with nothing but bad options.” Sebelius, who is absolutely correct, has a history with Anthem. In 2002, as Kansas’ Insurance Commissioner, she blocked sale of Blue Cross/Blue Shield of Kansas to Anthem because it was ”not in the interest of Kansans”, an extremely popular position with both the medical and hospital societies and with the public, and played a significant role in her election as Governor later that year.

It would be a mistake, however, to see the WellPoint/Anthem action as an isolated case of stupendous greed by one insurance company. It is an example of the widespread stupendous greed of all of the health insurance companies. The New York Times’ Katharine Q. Seeley (“Administration Rejects Health Insurer’s Defense of Huge Rate Increases”, also quotes Sebelius, but also notes that the top 5 health insurance companies, WellPoint, Cigna, UnitedHealth Group Inc., Aetna Inc. and Humana Inc., “…had an average profit last year of 5.2 percent — for a combined total of $12.2 billion. This was an increase of $4.4 billion, or 56 percent, compared with 2008…” The data comes from Security and Exchange Commission filings, and is contained in a report by “Health Care for American Now” ( The report, at, also notes that the “medical loss ratio” for these companies is incredibly low. As a reminder for regular people, the ones who pay the bills, the “medical loss ratio” is the percent of the premiums insurance companies collect that they actually have to spend on providing health care, that is, that they do not get to keep!

The medical loss ratios for these companies for 2009, notes Don McCanne in his wonderful “Quote of the Day” for February 12, were:

· WellPoint - 82.6%
· UnitedHealth - 82.3%
· Humana - 82.8%
· Cigna - 81.2%
· Aetna - 85.2%

Or, “…of the estimated $809 billion spent on private health insurance in 2009, the five biggest for-profit companies... captured $232 billion.”

In case you had any illusions that these insurance companies might have made a mistake, or be embarrassed, or in any way could be thought to be serving the public, the statements of WellPoint’s spokesman, Bart Sassi, should change your minds.
"We welcome the scrutiny and are confident that our rates reflect anticipated medical costs and are established consistent with actuarial principles and state law.". That means he thinks it is legal, not that folks can afford it. He adds that Anthem's insurance policies "remain very competitively priced when compared with the dozens of other plans competing in the California individual market." Competitive with the other huge rapacious insurance companies, that is. Oligopolies don’t compete.

Helfand (Feb 11) also reports that “Anthem is not the only health insurer imposing double-digit rate increases. Competitors such as Blue Shield of California and Aetna also have raised premiums significantly in recent years, insurance brokers said. But they said the impending Anthem increases are the largest they have seen.” But at least we know that they have a human side, and are empathic. "We care deeply about our California customers and community,"Sassi said, "Clearly, we understand that these increases create a challenge for many of our members." Not that they are going to do anything about it except raise rates. Words are cheap.

The real message here is that health care reform must happen, and that to include for-profit insurance companies as the centerpiece, or as any meaningful component, is absurd and will guarantee failure in both of its goals: meeting the health access needs of the American people and controlling costs so that medical care does not bankrupt us and prevent the society from implementing the other necessary programs essential to health. If not a government-run single payer plan (the best choice), any health reform plan that does involve insurance companies must require them to be non-profit, or at least closely regulated by the government regarding the services that they must provide and the prices that they can charge. One of these methods is used by every other developed country, all of which have better outcomes for lower cost than we do.

The physician and ethicist Howard Brody has written an important article, “Medicine’s ethical responsibility for health care reform – the top 5 list”, New England Journal of Medicine, Jan 10 2010;362(4):283-5, in which he calls on physicians to take a strong and concrete role in cost control by limiting the tests and procedures that they order to those which are evidence based. He suggests that each specialty, through its specialty societies, identify the “Top 5” procedures that are commonly done their field that are both costly and not evidence-based, and exert pressure on their members to refrain from doing them. Indeed, to keep. Brody’s ethical justification for calling on doctors to do this is that “Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests.” He adds that, while insurance companies, along with pharmaceutical companies, have promised the President to cut their costs as a “contribution” to health reform, “None of the for-profit health care industries that have promised cost savings have taken such an oath.”

You can say that again. This latest round of premium increases to bolster their obscene profits also shows how false their promises were. From the Obama administration and its Congressional allies who have been trying to steer an impossible “middle course”, to the Republican who have united in obstructionism and whose only offering is more give-aways to the insurance industry, to the “teabagger” populists who fear big government but should fear the private insurers rapacity more, it should be clear: To know this is to not trust them.

Saturday, February 6, 2010

The Public’s Health: Smoking and Salt

People pretty much know that smoking is bad for you. You, the smoker, and you, the person exposed to secondhand smoke. Smoking accounts for over 450,000 deaths a year in the US, more than alcohol, accidents, homicides, suicides, and illegal drugs. It is good for people’s health – both the smokers and those who are exposed to that smoke in their homes, workplaces and places of recreation – that people are smoking less; fewer people are smoking and those who do are, on average, smoking fewer cigarettes. Most of the people who have quit have done it on their own, rarely the first time that they tried (“Quitting smoking is easy,” said Mark Twain, “I’ve done it hundreds of times.”) Others have had help – from support groups, physicians, therapists, drugs.

But more important than individual efforts to change individual behavior is the positive impact public policy can have on public health. Mandatory immunizations for school, seat-belt laws, laws governing the safety of manufactured automobiles, helmet laws etc., have all had measurable and significant impact on our health. The two most common and important public policy initiatives regarding smoking are taxing tobacco and banning smoking in public places. In the January 27, 2010 JAMA, Mohammed K. Ali and Jeffrey P. Koplan look at “Promoting health through tobacco taxation”.[1] They show that increasing tobacco taxes decreases tobacco use, especially in young people, and thus the morbidity and mortality that comes from tobacco.

The beneficial effect of smoking bans is so enormous it suprises even tobacco control advocates. “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, published by David G. Meyers, John S. Neuberger, and Jianghua He in the Journal of the American College of Cardiology, September 29, 2009,[2] examined 11 studies of smoking bans done in 10 different locations and found that there was a 17% overall reduction in acute myocardial infarction (AMI = heart attack) when these bans were implemented, and that the risk incrementally decreased 26% for each year that the ban was in place. In Helena, MT a smoking ban instituted in June 2002 and resulted in a 40% decrease in AMI by the time the ban was suspended by a court order in December. After the ban was lifted, the AMI rate returned to baseline within 6 months. The impact on AMI is in addition to any effect on other diseases, such as cancers, which were not examined in this study (and would take many more years to have an effect). While much of this improvement in the public’s health comes from reducing the impact from second hand smoke on non-smokers, such bans also unquestionably encourage smokers, especially younger ones, to stop smoking. This is particularly true when quitting is something that the smoker had wanted and planned to do, with the smoking ban or increase in the tobacco tax acting as the “final straw”.

Ronald Bayer and Matthew Kelly, in the New England Journal of Medicine January 28, 2010 discuss “Tobacco control and free speech[3] and look at how the courts are likely to decide on cases brought to them on tobacco control. While not, so far, opposing tobacco bans, the American Civil Liberties Union is supporting objections to limits on tobacco advertising on the basis of their restriction of free speech: “Burt Neuborne of the New York Civil Liberties Union told Congress that the proposed bans represented ‘a vote of no confidence in the capacity of ordinary Americans to judge for themselves how to react to tobacco advertising”. Bayer and Kelly cite the Posadas decision, written by former Chief Justice Rehnquist in 1986, that limited the advertising for a casino. The quote his opinion “It would surely…be a strange constitutional doctrine which would concede to the legislature the authority to totally ban a product or activity [such as gambling] but deny to the legislature the authority to forbid the stimulation of demand for the product or activity [advertising]”. I would argue that it is unreasonable to suggest that we can outlaw products (such as heroin, marijuana) or activities (gambling) but not restrict others (e.g., smoking in public places) and thus most often bans have been supported.

However, the Supreme Court is moving away from the Posadas position, Bayer and Kelly tell us, in the 2001 case of Lorillard Tobacco Company v. Reilly, and given the 2010 Citizens United decision in which the Court has made the bizarre declaration that corporations have First Amendment rights to give money directly to political candidates, it is far from certain that they would support tobacco bans, taxes, or restrictions on advertising in the future. Clearly, these justices who have previously styled themselves as “strict constructionists” looking at original intent”, have clearly demonstrated that they have no such belief, radically making new law and reading their own beliefs into the Constitution. But what is certain is that all these restrictions, without directly forbidding any adult from smoking, have a dramatic positive impact on the public’s health.

Another article in the New England Journal of Medcine, published on-line January 20, 2010, by Kristen Bibbins-Domingo, et. al., looks at the “Projected effect of dietary salt reductions on future cardiovascular disease”, and notes that reducing dietary salt by 3g per day (or about 1/3) would reduce the annual number of deaths from all causes by 44,000 to 92,000, and new cases of coronary heart disease by 60,000 to 120,000, stroke by 32,000 to 66,000 and AMI by 54,000 to 99,000. This is important, because in recent years the emphasis on salt reduction as a method of treating hypertension (high blood pressure), one of the big vehicles for these bad outcomes, has diminished with the marketing of large numbers of anti-hypertensive drugs. We, as physicians and the public, need reminders of the dramatic efficacy of this sort of dietary change.

The article does not address how that reduction might be accomplished; clearly, as with smoking, the effect could occur if people as individuals just reduce their salt intake. But the probability of this happening is again low. Programs such as labeling the salt/sodium content on foods in both grocery stores and restaurants, especially “fast-food” restaurants, have been implemented in a number of cities. Further regulation, actually requiring lowering of the amount of salt in these foods, would have an even greater impact. Unlike smoking bans, which have a great part of their effect through elimination of exposure of non-smokers to secondhand smoke, the benefit of salt restriction is mostly to the individual consumer. However, this does not mean that societal impetus for this change is not a critical part of changing people’s behavior. Indeed, as noted by Mark Doescher, Director of the Rural Health Research Center and the Center for Health Workforce Studies at the University of Washington in his comments on the important new textbook Community Based Health Interventions [4], “…environmental factors, such as safe streets, healthy food choices, and smoke-free establishments govern individual behavior.”

Experts in occupational safety have long recognized that changing individual behavior is the least effective way of increasing safety. If we want to prevent people from slipping on a factory floor and going through a plate glass window, the first choice is architectural (don’t put a plate glass window next to a shop floor where substances may be spilled that people can slip on). The second choice is engineering, or retrofitting (put a steel mesh over the window). The least effective choice is changing human behavior (telling people to be careful!). The dramatic reduction in deaths from car accidents over the last 30 years has had virtually nothing to do with people driving more safely, and everything to do with car manufacture (engines that collapse down instead of into your lap, air bags, etc., all of which were resisted by the automobile industry) and safer road construction. With regard to the health of the public, the same rules apply. Tobacco bans, tobacco taxes, and efforts to reduce salt intake by honest labeling are much more likely to have a salubrious impact than efforts to get people to change their behavior individual by individual. We need to encourage the latter, but because Doescher is correct, we must also implement the policy changes. We must no longer allow the economic benefit to special interests to continue to endanger the public’s health.

[1] Ali MK, Koplan JP, “Promoting health through tobacco taxation”, JAMA 27Jan10;303(4)357-8.
[2] Meyers DG, Neuberger JS, He J, “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, J Amer Coll Card 29Sep09;54(14):1249-55.
[3] Bayer R, Kelly M, “Tobacco control and free speech”, NEJM 28Jan10; 262(4):281-3.
[4] Guttmacher S, Kelly PJ, Ruiz-Janecko Y, eds., Community-based health interventions, Jossey-Bass, San Francisco, 2010.

Monday, February 1, 2010

Haiti and Health Reform: We need real leadership

There is a lot bad in the world, and compared to people in many places, people in the US are doing OK. The most obvious and well-covered venue of desperation is Haiti, where the earthquake smashed a country that had been set up for failure, figuratively raped and pillaged by wealthy nations, including the United State, for two centuries. Less publicized is the horrific situation in the Congo, characterized by literal rape and pillage as painfully described by Nicholas Kristof in his New York Times Op-Ed January 31, 2010, “Orphaned, Raped and Ignored”. I won’t repeat the details – it is a must-read – but he leads with “Sometimes I wish eastern Congo could suffer an earthquake or a tsunami, so that it might finally get the attention it needs. The barbaric civil war being waged here is the most lethal conflict since World War II and has claimed at least 30 times as many lives as the Haiti earthquake.” And, worse, provides details that almost make one hope that with him.

The American people have responded in a truly humanitarian way to the crisis in Haiti, and it gives me new faith in the American people, if not their leaders. Many of us who have money have written checks and made pledges, but so have those without. People on fixed incomes have sent their last $5 or $10. Writing about her volunteer work with Heart to Heart in the Kansas City suburbs a week or so ago, my friend Pat Kelly writes:

The number and type of people donating goods to the Heart to Heart trailer this afternoon was moving in itself. The live broadcaster from 1540 AM, a local Hispanic radio station wound up hauling boxes with two members of his family who decided to stay and help. Hispanic families, clearly not wealthy, driving very minimal cars, opened their trunks which were full of bottled water, canned goods, toilet paper. Cars with three infant seats in the back seat pulled out bags and bags just purchased from Target and Walmart with soaps, alcohol, hygienic products. Three different guys in lawn service pick-up trucks stopped by with checks or cash. African-American couples, mostly older, had full back seats of donations. There were at least three times as many Blacks and Hispanic donating as Whites--and this was on Shawnee Mission Parkway at Roe, not in the urban core.”

Yes. These people understand what hard times are. Understand how important it is to share and to help and to give. It is a wonderful response, the only comprehensibly human response, people giving all that they have to give. It is also something the bankers, and too many of the privileged in our national leadership either do not understand or reject. In their selfish cruelty they may disparage such giving as weakness, but of course they are wrong; generosity and caring and social consciousness are strength.

And so what will this mean for health care reform bill, I have no idea. Despite being made fun of by everyone from Barack Obama to Jon Stewart, the Republicans are going to continue to revel in being the “party of no”, of sitting on their hands and glowering at the State of the Union, of being completely uncivil when the President walks into their den, and hoping (no, believing) that acting in this way is going to get them “street cred” with the American people. They are, as identified by Frank Rich (“The State of the Union Is Comatose”, NY Times January 31, 2010), the “unpatriotic opposition”.

May it will; maybe the majority of the American people are attracted to mean looking white guys with their arms folded, responding to controversy in a manner that suggests they haven’t had a thought in a long time, but I don’t think so. Because so many of us are, as our response to the crisis in Haiti demonstrates, a caring people. On the other hand, it could be their only available strategy, since every time they trot out “facts” they are completely wrong, and a lot of folks seem to have the bad taste to want to point this out. So, at this point, I will wait and see what happens. There is a better solution – Medicare for all, pass it, let it happen, let the Republicans and insurance companies choke on their bile, and let us move forward. Obama gave a good speech; it is time for him to follow it up.

Health care is only the start. Dealing with the financial industry, in a firm and decisive manner, is also on the agenda. There have been many references to the administration of Franklin Roosevelt, and in particular the aggressive investigations led by Ferdinand Pecora. Citing the actions of a more recent president, Frank Rich’s January 24, 2010 column “After the Massachusetts Massacre”, describes John Kennedy’s dressing down of Richard Reeves, the president of US Steel, in 1962. I look, however, to an even earlier president, Theodore Roosevelt, who broke up the Standard Oil monopoly. If we have banks that are “too big to fail”, the obvious solution is: let’s not have them; break them up. I think that the fact that the one thing that everyone from every sector can agree on is that the banks and financial sector is comprised of heartless, evil people whose greed plunged our nation and world into the worst financial crisis since 1929, it is time to take strong action. Who will oppose it save the Geithners and Summers’? Here is another opportunity for the Republicans, who have been playing populist like they were George W. Bush paintball warriors; they can rush to the defense of Goldman Sachs and Citigroup and see if the American people support them. I don’t think so.

President Obama said many good things in his State of the Union speech (and some not so good ones), but he needs to follow these statements up. Rich (Jan 31) suggests “Obama should turn up the heat on both the G.O.P’s record of fiscal recklessness and its mad-dog obstructionism. He should stop paying lip service to the fantasy that his Congressional opposition has serious ideas to contribute to the cleanup. Better still, he should publicize exactly what those ‘ideas’ are.” His budget proposal is not encouraging, emphasizing increases in defense spending and decreases in domestic services.

There is a lot to do, and there are leaders who get it. As an underlying assumption, I believe that the best statement was: “In these difficult times, the government believes it is important to continue working toward a society in which people feel a sense of togetherness, respect one another and share responsibility.” Absolutely.

Of course, that was not President Obama, but Queen Beatrix of the Netherlands in her Speech from the Throne (NY Times, January 27, 2010). But I keep hoping that the US can also have leaders who can get it, and can act on it. What would be really wonderful is if they could act as nobly as the plain folks in Kansas City.

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