United Airlines, health care, and a system designed to privilege the powerful

The spectacle of Chicago Department of Aviation security officers beating and dragging a passenger off of a United Airlines flight was recorded by other passengers and quickly went viral on the Internet, generating outrage across the country (and internationally, particularly in China, where the fact that the passenger was Asian was a source of fury). A series of statements from United and its CEO, Oscar Muñoz escalated from tone-deaf explanation (essentially “well, we told him to get off first”) to most recently apparent contrition, saying it should never, ever, happen to anyone and that United would never, ever, have local police board its planes to take off a legitimate, paying customer.

It is unlikely that this too-little too-late response is going to appease anyone, and it is profoundly to be hoped that United suffers severe financial repercussions; the passenger, who suffered a broken nose and lost teeth, almost certainly will sue. It is not clear how to make this happen to the Chicago Aviation Department. The fury of the public is almost certainly increased by the personal experience of (coach) airline passengers. It also is not limited to either United or to airline travel, as Helaine Olen articulately describes in her NY Times op-ed “United Airlines is not alone”, on April 12, 2017. Ms. Olen goes through the list of issues that were raised by this incident, including not only the concerns about racism (would it have been worse if he were black?), but about the militarization of our police response to relatively minor issues. Although the officers involved were from Aviation Security and not the Police Department, it is understandable that a friend from Chicago posted the question “Was anyone surprised that the Chicago PD used such violence?” on Facebook, given that department’s history of “overreaction” and use of military-type tactics.

But Olen’s main point is that this event (if not necessarily the attendant violence) reflects the vast disparity in treatment provided, not only by United and other airlines but across our society, of people in different socioeconomic situations. She goes through the multiple enhancements to the first class cabins (sleepable seats with Saks 5^th Avenue bedding, better meals, etc.) and compares them to the growing level of discomforts and indignities inflicted on coach passengers, with no food, increased crowding, baggage fees, and the like. The crowding is worse than on a bus, and Greyhound doesn’t charge for baggage. Full-fare first class passengers are a big profit center, but most people in first class are not the 1%ers who can pay these fares, they are business travelers whose companies have bought coach tickets and upgraded to first based on miles earned through an airlines loyalty program. And airlines love that, because it means they will keep flying with them. The rest of us, tough. And don’t believe that they “need” to stay so lean; Olen notes that United made $2.3 Billion in profit last year.

Olen also makes the connection to health, observing that

In a study published in 2014, Martin Gilens at Princeton University and Benjamin Page at Northwestern University found government policy and actions rarely reflected majority sentiment, but instead favored corporate interests and the wealthiest Americans. When congressional Republicans offered up a health insurance reform package earlier this year that would have covered fewer people than the Affordable Care Act, Representative Jason Chaffetz, Republican of Utah, initially defended it by claiming Americans needed to choose between spending on necessary medical care or buying an iPhone. Meantime, the fabled 1 percent would have received an average tax cut totaling $37,000 if the legislation were fully enacted.

And if anyone doubts that this is how the health system functions (although I doubt that many readers of this blog do), I recommend the new book “An American Sickness: how healthcare became big business and how you can take it back”, by Elisabeth Rosenthal (Penguin Random House, 2017). Rosenthal, a former New York Times reporter whose fantastic series “Paying till it hurts” ran in the Times a couple of years ago, is now the editor-in-chief of Kaiser Health News. I have cited her reporting frequently in this blog and in my 2015 book “Health, Medicine and Justice: designing a fair and equitable healthcare system” (Copernicus Healthcare). Indeed, “An American Sickness” overlaps considerably with my book, but is by a much better-known figure, and hopefully will be widely read. Rosenthal, a physician, pulls few punches in this work, saying unequivocally that the US health system is designed and functions to maximize the income and profit of providers (especially hospitals), insurance companies, and pharmaceutical and device manufacturers. (An excellent review of the book by Jacob Hacker, Professor of Political Science at Yale, can be found here.) Rosenthal identifies the ten “Economic rules of the dysfunctional medical market” (which I have reproduced in the figure); all are important but #10, “Prices will rise to whatever the market will bear” is particularly critical, and reflects that the health system bears little or no relationship to a true market, and does not play by Adam Smith’s rules.

ECONOMIC RULES OF THE DYSFUNCTIONAL MEDICAL MARKET

(E. Rosenthal, “An American Sickness”)

1.      More treatment is always better. Default to the most expensive option.

2.      A lifetime of treatment is preferable to a cure.

3.      Amenities and marketing matter more than good care.

4.      As technologies age, prices can rise rather than fall.

5.      There is no free choice. Patients are stuck. And they’re stuck with buying American.

6.      More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.

7.      Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.

8.      There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.

9.      There are no standards for billing. There’s money to be made in billing for anything and everything.

10.   Prices will rise to whatever the market will bear.

Rosenthal supports each of these rules with data and examples. Regarding rules #8 and #9, in an NPR interview with Terry Gross on “Fresh Air” ,she emphasizes the importance of getting an itemized bill from the hospital and going through it line by line, citing a person who found $70,000 in outpatient surgery charges for an inpatient hospitalization, and others billed for circumcisions their newborn sons did not have. But it is not always easy; in the book she tells of a person who demanded an itemized bill rather than the one she received, where the total of $45,000 was simply labeled “Miscellaneous”! The hospital never sent it, despite it being her legal right, but did send her to a collection agency! Rosenthal says we would never tolerate shopping at a supermarket with no prices where they just sent us a $2000 bill every week. We should not tolerate this in healthcare.  Every single service must have a listed, easily accessible public price. It may be fine to discount it for some insurers, and even more for some than for others, but the list price must be as clear as we expect it to be for anything else that we buy.

I learned some things from Rosenthal that had not even occurred to me; for example, the ACA’s 85% limit on “medical loss ratio” (i.e., the percent of premiums that insurers actually have to spend on medical care) ironically helps encourage them to be willing to pay higher prices to providers. Why would they pay $130,000 for a treatment that cost $19,000 only 15 blocks south (the opening example in the book)? Well, they get to keep 15%. And 15% of a bigger number is more in their pockets. And they just pass on the cost as higher premiums! Rosenthal discusses an important conservative health economist who is known for saying the high cost of US healthcare is overblown, but (amazingly) sings a very different tune when confronting the hospital bill for his father!

“Dysfunctional” is the wrong word for our health non-system. It functions just fine to make lots of money for the biggest corporate (including ostensibly “non-profit”) players. For the rest of us, it doesn’t always provide the best, or even adequate care, and it drains our individual and collective pockets, significantly contributing to individual bankruptcies and bad health outcomes when folks go without care. It also results in governments at federal, state, and local levels not having funds for other social programs that might actually improve health more.

Yes, we can change it but it will require resolve and a lot of work, because the opponents of change are rich, powerful, and entrenched. We cannot accept any excuses from our bought-off politicians or “pragmatists” who are the ones who suffer the least. We are least able to fight when we are sick and need care, just as we are least able to object to our conditions when we have a ticket and are on a plane bound for where we need to go. But just as we can fight the latter, we can fight the former; the social media response to United is an example of a good start.

But it is going to take more than a good start to get the thieves and profiteers out of healthcare, and get a system that benefits us all. It is going to take a long fight with a lot of hard work. Up for it?

Risk, Primitive Reactions, and Human Health Behaviors

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NPR’s “All Things Considered” recently reviewed several scary events from 2010 (“The year in fear: fright or fallacy?”). Reporter Jon Hamilton spoke with Dr. David Ropiek, Director of Risk Communication at the Harvard Center for Risk, about what made these events (Toyota’s acceleration problems, the Deepwater Horizon oil spill and the use of chemical dispersants, etc.) particularly frightening. Dr. Ropiek said that people tend to make decisions, and react positively or negatively, based on very simplistic (and usually unconscious) criteria, rather than on careful critical analysis of the relative benefits of one course of action over another, with the most important criterion being “is there immediate danger?” The reason he gave was that our basic neurobiology was unchanged over human history while our culture and society was remarkably more complex than when quick decisions were mostly about achieving immediate results (fight or flee). “We use a risk-perception system that evolved in simpler times, when the risks were bad guys with clubs, and the dark, and wolves. It's quick. But quick isn't necessarily the best for the complicated stuff we face in modern society.” Thus, for example, even though the evidence would show that the human and environmental danger of the oil spill was in the oil much more than any risk from chemical dispersants, “Just the word chemicals in your listeners' minds is currently setting off a little organ in their brain called the amygdala, which is the 24/7 radar in our brain that says - is there danger in that data?”; that is, our fears are triggered by the word (chemicals) which we have come to associate with danger.

Similarly, people can grasp the specific, and feel the pain, for an individual more easily than for a large, amorphous population. Thus, the outpouring of concern for “Baby Jessica” falling down a well in 1987, or for the child dying of leukemia, is much stronger than that for thousands of people, especially those in other countries, dying of war, disease, or even more abstract, structural violence. It is not just the one versus the many; it is the suddenness of it. We feel for the trapped Chilean miners, or the victims of a bombing; Ropiek says “… a chronic risk doesn’t ring our alarm bells the way a catastrophic, all-at-once one does. Because it concentrates the mind to see a bunch of the tribe all whacked at once.” So a particularly gory battle or atrocity is horrifying, but when there are chronic, repeated bombings and battles (as in Iraq or Afghanistan), even though they lead to much more death, we feel less.

We can see a murderer as a bad person, but it is harder to identify the members of the “grifter class” (coined by Matt Taibbi, “Griftopia”[1] ) who are responsible for the financial system that has visited so much evil on all of us. When people hear about something they know little or nothing about, especially if it is very complex and hard to understand, they often deal with it by putting a “frame” around it, tying it to something that seems similar enough (at least in one dimension) that they feel they can hang their hat on the analogy and judge it. For example, “chemicals=bad” in the example above is such a frame; so is dealing with universal health insurance by framing it as “socialized medicine”=”socialism”=”bad”. Unfortunately, the world is far more complex than this, and more unfortunately unscrupulous politicians and opinion-makers (my frame = “selfish evil people”) take advantage of this to obscure complexity and buy into often nonsensical self contradictions (taxes=bad, deficits=bad; let’s not have either!)

When it comes to health and medicine, the same issues come into play. People perceive immediate distress with acute problems (e.g., cough, fever, and most especially pain!) and know how much they would appreciate relief. The impact of conditions that do not cause appreciable symptoms right now but will cause really bad outcomes (death, morbidity, poor quality of life) if untreated in the future, are much harder to get people to make high priorities. The doctor sees untreated hypertension in terms of a future outcome (stroke, kidney failure), but this is more difficult for the patient. Even when s/he believes and understands it intellectually, it is much less likely that the treatment of a largely asymptomatic condition will rise to the top of life’s many more urgent priorities (food, clothing, housing, childcare, work) than if it were, say, pain.

The problem is even greater for public health, as I discussed in Public Health and Changing People's Minds (Saturday, May 15, 2010) where populations are huge, timelines are long and risk is relative. Public health addresses risks for populations, not me, or my family; translating population risk into individual prior probability is fairly difficult. For most people, even the concept of risk – that a given event will not definitely have or definitely not have a particular result, but will be somewhere on the continuum between them – is something they are not accustomed to thinking about, although they use it all the time (deciding whether to cross on a red light, for example). Consciously comparing the relative risk of different actions is very difficult, especially when the results have very different timelines. A definite immediate benefit (have that tasty fried or sweet food; throw a wrapper out the window, get a big gas-guzzler, have unprotected sex) has a lot more weight than the possibility of a bad long-term outcome (besides, next time, in the future, I’m going to go on a diet, give up smoking, use condoms). Dr. Ropiek notes that because events that cause “a bunch of the tribe to be all whacked at once” happens relatively rarely, “…we tend to downplay chronic risks like car accidents, diabetes, heart disease and the flu.” Sometimes public health officials can create that fear and mobilize the attention of the populace, as with concern about the swine flu of 1976, but that is also an example of how, when predicted risk of bad outcomes doesn’t happen, it reinforces the tendency to downplay those chronic risks.

In making decisions about medical care, this sort of perception can cut either way, depending on how a person looks at it based on personal and familial experience, cultural beliefs, and the way they “frame” medical interventions, as well as how urgent or important a solution is. Some people do not trust doctors or medicines, based on these criteria, and prefer to not take medicines or advice, even when an analysis of the relative risk shows the treatment to be definitely beneficial. Others have unrealistic expectations of what medicine can do (fueled, of course, by both doctors and direct-to-consumer drug advertising), and are angry when the doctor cannot cure their viral illness, make their back pain disappear, or compensate for all of the other parts of life that are bad and make them happy. At times of serious illness, where both treatment and non-treatment have real risks, or at end of life when people are not ready to accept that it is the end of life, even a professional evaluation of relative risk/benefit is difficult, so it is hardly surprising that people return to simpler methods of decision making (will I be able to live another day? Will it end my/his/her pain?).

Hamilton ends the interview segment with: “So Ropiek says we need to acquire a new fear - the fear of getting risk wrong.” I wish us luck on that.


[1] Taibbi, M. Griftopia: Bubble Machines, Vampire Squids, and the Long Con That Is Breaking America. Random House. New York. 2010
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Drugs, Tobacco, Doctors and the Health of the Public

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Drugs (the legal prescription type) and drug safety seems to continually return to the news, most recently with reports of serious side effects from a new oral contraceptive pill (OCP), featured on NPR’s "Morning Edition”. With regard to OCPs, it is important to note that virtually all the side effects of oral contraceptives, including the serious ones, are the same as the ones women are at greater risk for from being pregnant. The fact that pregnancy is a “natural” event does not make it risk free; complications such as clots in the veins of the legs (deep venous thrombosis, DVT) do occur, associated with the higher levels of estrogen in pregnancy, and occur more frequently than they do for women taking oral contraceptives. Whatever one’s level of risk for OCPs, a risk that increases with increasing age and dramatically if one smokes, that risk is greater from being pregnant.

However, because the probability of getting pregnant (and thus having serious “side effects” from it) decreases with increasing age while the risk of serious side effects from OCPs goes up, it makes sense for older women who are still fertile to use alternative types of contraception – but, unless they are actively trying to get pregnant, to use contraception. The fact that OCPs can have significant benefits (mainly: preventing unwanted pregnancy) does not make them benign, but neither is pregnancy itself.

The choice to use or not use drugs for any condition (or for prevention of a condition), whether they are prescribed by a health care provider or, in the case of many nonprescription drugs, chosen by the person him/herself, is influenced by number of factors. The best one is that a person has a condition that puts them at risk for bad health outcomes (the “patient important outcomes” of premature death or decreased quality of life; see Calcium, Heart Attack and Osteoporosis, August 2, 2010; Rosiglitazone and the "Holy Grail" July 16, 2010; Statins and scientific integrity, July 6, 2010), and the probability that a drug will decrease that risk is significantly greater than the probability that the drug’s effects will cause a problem. There are sometimes other reasons; a person (patient) will hear from a friend that a drug worked for them, or see on it advertised on television or elsewhere, and decide to try it (if non-prescription) or ask their doctor for it (as so often urged on TV commercials). Depending on a number of factors (whether the drug is in fact useful or potentially useful for something the person has, whether it might create increased risk for the patient, how persistent, or even demanding, the person is) the doctor might in fact prescribe it.

In general, it is fine if you ask your doctor about a medication that you have reason to think might benefit you, but probably not such a good idea to persist/insist if s/he suggests it would not be advisable to take it. A few cautions and things to think about, some of which I have previously discussed (“Conservative” Drug Prescribing March 11 2009):

• Not everything is effectively treatable with a drug. Taking a pill may be easier than changing your diet or exercising or doing other hard or proactive things, but without those other activities it may not work or work as well, and may well be worse;

• Not all drugs are “bad”. Some are really helpful for the right people with the conditions that they are effective in treating, and the potential side effects are far less than the benefits.

• Because some drugs do not require a prescription this does not make them “safe”. They should still only be used when the same criteria are fulfilled: scientific evidence demonstrates that the probability of benefit significantly exceeds the probability of harm. The same applies to any “nutritional supplement”. Because it is not called a “drug” doesn’t make it safe. Everything has potential for harm in the wrong people, the wrong circumstances or the wrong dose (Dietary Supplements can be Dangerous for your Health, October 31,2009)

• If a little is good, more is not necessarily better. Nor is less necessarily better. The right amount is: the right amount!

• Despite our culture’s fascination for the “NEW!!”, new is not necessarily better. Frequently it is worse. Drugs are not cars or cell phones. Newer drugs may have side effects that have not become apparent in the necessarily limited testing that is done before they are marketed, but do manifest when many times more people take them. They sometimes have therapeutic benefit for some people that is greater than old drugs, but often they do not. The only reason to even consider a drug that is new on the market is if your old drug, and the other available old (=”well established”) drugs don’t work adequately or have intolerable side effects, and there is reason (=”evidence”) that the new one will (work better), or won’t (have those side effects).

• Advertising drugs, whether to physicians or to patients, is pretty much a bad thing. As in all advertising, the goal is to sell stuff; it is not (despite pharmaceutical company slogans) improving people’s health. This is highly tied to “NEW!!” because it is the new drugs that are the ones that are advertised. This is because they are the ones that cost the most, that have the highest profit margin, and that the companies need to develop a market for. They also have to amortize their research and development costs, as they will often point out. This would be a less offensive claim if most of the drugs that came out and are heavily marketed were not “me too” drugs – modifications (often quite minor) of existing drugs that are no longer under patent and are being sold generically. Drugs that the doctor may have in his/her “sample closet” will always be these same drugs – the newest, highest cost (and highest profit) options. In health care, if something is being advertised, whether a drug or a procedure available at a local hospital, the meaning is “we would like it if you would buy this because we will make money” and not at all necessarily “this will be good for your health”. By the way, in the case of advertised procedures that you may see on billboards for a hospital or clinic, it means also “if you have insurance”.

The issue of advertising to physicians is addressed in an excellent editorial by Matthew Anderson in the current issue of Social Medicine. It examines the historic and current collaboration by medical organizations with big corporations. In addition to the AAFP/Coca-Cola alliance that I have recently written about, it examines the relationship between the American Academy of Pediatrics (AAP) and infant formula manufacturers and the tight involvement of the AMA with pharmaceutical companies. It is eye opening. In addition, the journal contains a powerful piece by Alan Blum introducing two classic articles about physician activism around tobacco written by the same Dr. Blum when he was, 20 years ago, editor of the New York State Journal of Medicine: “Cigarette smoking and its promotion: Editorials are not enough” and When “More doctors smoked Camels”: Cigarette advertising in the Journal” . The introductory quotation to the first article, from Ira Gershwin of all people, cannot be repeated often enough “One man's death is another man's living”.

And, for those who doubt that, given the current shameful practices, sometimes, given enough time pressure and public awareness, progress is possible, it is worth just looking at the Social Medicine’s cover to see how far we have come, in at least the relationships between doctors and tobacco.
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