Necessary Change

During the first one-hundred days of Obama's presidency there have been many debates about health care. Many democrats such as senators Max Baucus (Mont) and Ted Kennedy (Mass) have been eyeing health care reform down for a long time. But they aren't the only ones. Another notable democrat Peter Orszag, the new Director of the Office of Management and Budget, has a few ideas of his own.

Orszag's opinions have garnered a little bit of attention in the past few months. For one, he has asserted that without controlling health care costs we will persist to have an intractable budget and worsening debt. He's right, but that's old news. Most of those in the government know that we need to control health care costs, but few have proposed any ideas like his.

The traditional way those in government, especially republicans, have addressed controlling health care costs is by altering how it is paid for. Either through alterations in medicare or medicaid (to try and reduce the government's burden) or through increasing "market competition" (to lower rates on private plans). And yes, altering the way we pay for health care can help control costs and this should be thoroughly addressed -- you'll notice single payer insurance hasn't been realistically considered as an option.

However, Mr Orszag has brought to attention an important fact: the way health care is delivered also needs to be changed. As the Ney York Times reported, "to address the problem, he wants to do no less than change the way medicine is practiced, eliminating unnecessary tests and unproven treatments in favor of what he calls a higher-value approach that he says will actually improve health."

I touched on this a bit the other week in my post "Why Are Costs So High?". In it I comment on the fact that we tend to utilize expensive procedures and options much more often that other countries. However, we don't have any markers that show we get added health benefits above and beyond other countries. In fact, it is quite the opposite. With our higher infant mortality rates and lower life expectancy, we rank as one of the lowest developed countries in terms of health.

In his book Introduction to Health Policy, Dr Donald Barr M.D. also talks about excessive tests and unproven treatments especially when it comes to new technology. The history of treating high blood pressure is a useful example. Traditionally, physicians prescribed relatively cheap diuretic pills to patients for their high blood pressure. Then calcium-channel blockers became popular in the 1980's. Again, in the 90's a new category of drug called an ACE-Inhibitor became widely used. There was a problem though. To physicians, the efficacy of these treatments was inherent in the fact that these pills were new and not necessarily that they were any more effective.

Don't get me wrong. They obviously worked because patients were getting the results they needed. However, It took nearly two decades for clinical evidence to surface that showed the newer treatments were no more effective than the older diuretics. Plus when you take into account that these pills cost 10-15 times more than the $10 diuretic pills, you start to understand the usefulness of having a system of evidence-based medicine: practicing medicine that is put up against the scientific-method to assess the quality of evidence on a cost-effective basis.

And that is just one area in which we can change how health care is delivered. There are other ways in which we can save money and change the delivery of care. And that will be essential to fixing our health care problems. Focusing only on the financing of health care alone (ie. single-payer) isn't going to solve the problem of increasing health care expenditures. Only a comprehensive approach will.

- m.tsang

Aborting Appointments

One-hundred days. It's been nearly one-hundred days since Obama has taken office. A lot has been going on: countries have been visited, documents have been released, money has been spent and secretaries have been appointed. Well, all but one. As Carrie Brown from Politico Magazine expressed last Friday, "the Department of Health and Human Services holds a dubious distinction in the Obama administration: last on the list to install a secretary."

Who could have guessed HHS would be the last to appoint a secretary? Tom Daschle was practically one of the first cabinet members nominated by Obama immediately following the election. Daschle was anticipated to be a major impetus of change in health care. That was until he got held up on tax issues during congressional hearings. As ABC News explains, "Daschle failed to declare on his income taxes a chauffeur service that he used for years, as tax laws require. Though he corrected the violation during the vetting process, he was unable to overcome the political hurdles that came with the territory."

So on February 4th, Daschle removed his name from nomination. Less than a month later Obama nominated former Governor of Kansas Kathleen Sebelius to be the new Secretary of HHS. Sebelius, too, has been met with opposition in her appointment. Republicans blocked a vote last Thursday that would have most likely ended up in her appointment as secretary of HHS.

Their reasons? According to the Associated Press, RNC Chairman Michael Steele was quoted as saying, "Significant questions remain about Gov. Kathleen Sebelius' evolving relationship with a late-term abortion doctor as well as about her position on the practice of late-term abortions. If Gov. Sebelius and the Obama administration are unwilling to answer these questions, President Obama should withdraw her nomination." These inquiries are born by the fact that Sebelius received over $35K in campaign contribution from a Dr Tiller who owns an abortion clinic in Kansas.

It doesn't matter to Republicans that "Sebelius told the Finance Committee that she personally opposes abortion" according to the AP. However, they apparently think there is something sinister lurking behind the prose of this woman who respects the rights of those who want the choice to have an abortion. As Governor, Sebelius repeatedly vetoed legislation redacted by anti-abortion groups who tried to take away a women's right to choose.

If I'm not mistaken that should be the type of person congress is looking for: one who upholds the right of choice. During the election polls showed that most people were actually in favor of abortion by some 13%. But by and large I think it is safe to say that the majority of people are split down the middle regarding this issue. So why not have a woman as secretary of HHS that inherently sees this division? As one who personally opposes abortion, but also upholds the right for women to choose.

- m.tsang

Smoking = World War III

What costs five dollars and can catalyze World War III? Cigarettes! Alright, you got me. In the U.S. cigarettes on average cost less than five dollars with tax. Ok, and they won't cause World War III. I was just attempting to utilize what advertisers and marketers call "somatic markers". In the book Buy-ology Martin Lindstrom explains that "somatic markers are typically associations between two incompatible elements".

In the brain they work as shortcuts to create a linear, succinct train of thought. That way we can "connect an experience or emotion with a specific, required reaction" states Lindstrom.

Earlier this month, there was an advertisement that incited a lot of contention for depicting a kid at the train station without his mother. The kicker? It was an anti-smoking advertisement that intimates, “this is how your child feels after losing you for a minute...just imagine if they lost you for life.” Unfortunately, the debate isn't centered around whether the message is effective or valid. People seem to be more concerned about the crying child in the video: whether he was truly acting or not. (I really don't wish to debate that aspect of it. But I will say this, I have seen an elephant instructed to paint another elephant. I'm sure someone can get a kid to cry on command.)

What I do wish to comment on is that this video makes use of the somatic marker in a very pointed way. It connects the experience of losing your child, or your child losing you, through smoking. As I recounted above, somatic markers are used to link two elements that aren't traditionally associated, and that association is supposed to elicit specific responses. In a way, the ad links two things that are conceivably associated. People do die from smoking, and they inevitably will be survived by some family or friends. Yet at the same time that association is about the largest tangible stretch one could propose.

I wonder, how effective is this message?

Lets take a look at the typical associations anti-smoking campaigns utilize: disclaimers on cigarette boxes. We've all seen them. The black and white letters advising you that smoking will cause: birth defects, lung cancer, and emphysema among other things. This association is much more straightforward, thus you might not think there is an inherent difference in these two ad techniques I've mentioned. But I do.

In his book, Lindstrom notes one particular study in which brain activity was recorded using fMRI while test subjects were shown anti-smoking ads. The results? The most activity in the brain was recorded in the Nucleus Accumbens. Don't worry, it meant nothing to me when I first read it either. That's a region of the brain strongly associated with pleasure and addiction. Thus, what Lindstrom was arguing is that those ads are actually counterproductive and "encourage smokers to light up".

How is this so? The hypothesis lies in the existence of Mirror Neurons. These neurons have been shown to exist in primates and are thought to exist in humans. In primates, mirror neurons have been shown to fire while both participating in an action, such as picking up a nut, or just watching that action take place.

Therefore, it seems as though when smokers see or read traditional anti-smoking ads their mirror neurons fire and activate their nucleus accumbens. You can imagine this through the envisioning the thought process step-by-step. You see the warning of emphysema, telling you it is caused by smoking; you think of the smoke in your lungs; you imagine having to physically take a drag in order to get the smoke in your lungs; and by this time your mirror neurons have already started freaking out. Done. Over. You want to smoke.

Why is this different than the video ad's technique above? Because the association is remote. There are too many reasons why a child and a parent could become separated. It should be hard for the brain to linearly connect smoking with losing your child. That just isn't a known association, and maybe it won't set off any mirror neurons.

However, the point being is that this remote association has been forged and it is very memorable. Now, possibly, not only are no mirror neurons firing, but you might have some furtive apprehensions about wanting to light that cigarette. Advertisers use this technique relentlessly. Ever watched a commercial and said "what? how is that related?". It doesn't matter. The ad now created an alliance between two disparate trains of thought, and next time you look for toilet paper you might think "yeah, guys with double comb overs are funny...I'll buy that toilet paper".

So if you take away anything from this lot of information remember this: smoking isn't exactly what is considered healthy. Every eight seconds someone dies from smoking; twelve times more British citizens have died from smoking than in WWII; smoking kills one in ten adults globally; and smoking related diseases caused more than $150 billion dollars in health care expenses in the U.S. Oh, and cigarettes will kill your pets.

- m.tsang

Poor Health, Literally

On Monday, I came across the Union Tribune's article that stated San Diego County Health Officials now claim that the number one cause of mortality in the county is cancer. Historically, cardiovascular disease was the number one killer in the county. That is consistent with the national trend where cardiovascular disease is the country's top killer -- cancer and stroke follow as the second and third leading causes of death in the nation respectively.

But for a number of reasons, in many areas cancer has supplanted cardiovascular disease's spot as the nation's largest health threat.  San Diego County joins the ranks of other areas in the U.S. that are faced with similar statistics. States such as Minnesota, Washington, North Carolina and Colorado all list cancer as the number one cause of death among its residents.

After reading the article I was able to peruse through some of the other reader's comments, and I came across this opinion: "...disease effects the rich and the poor. It has no preference." Well, honestly it does seem to be that way doesn't it? I can't imagine rogue cancer cells, infectious bacteria or menacing viruses deny applications based on a person's gross income the year before. However, there are many well-designed studies that have demonstrated that the poor and less-opulent bear a disproportionate amount of the world's health woes.

Last December, Medical News Today reported on a study out of Colorado called "Cancer and Poverty in Colorado: 1995 - 2006". The study analyzed the rates and incidence of multiple cancer types across the state of Colorado. Overall, the report noted that poorer residents of the state had a greater disadvantage in battling cancer. The authors of the report note that, "for most cancers, Coloradans who lived in poorer neighborhoods were more likely to die within the first five years following cancer diagnosis". 

They went on further to state, "the inequities of the health care system put poor people at a tremendous disadvantage in the fight against cancer. Poor people are less likely to get properly screened for cancer, although early detection is a crucial component in fighting its development. Poor people also are likely to have poorer health insurance coverage or no coverage, and coverage plays a crucial role in an individual's [health]."

For instance, lets look at Medicare coverage. Patients on Medicare coverage often have less aggressive treatment and are not given the same amount of care than those with private insurance are provided. This has been shown to be especially true for patients with kidney disease. Even though under Medicare a patient is covered for kidney treatment. Shockingly, medicare patients are consistently referred less often than those with private insurance to undergo kidney transplantation.

Moreover, as Donald Barr MD says in his book Health Disparities in the U.S., "the relationship between social class and health is a continuous relationship that spans all levels of the social hierarchy from the very lowest to the very highest". Health tends to get better proportionally as one's socioeconomic status increases.

This has been demonstrated in the Whitehall study. This study tracked the health, morbidity and mortality of workers in the British Civil Service for more than twenty years. Within the U.K. all citizens are all guaranteed the same health coverage and access to care. Thus one might assume that health of their workers would be less stratified. Surprisingly enough, the study demonstrated that, starting from the lowest, less-prestigious job positions chances of mortality steadily declined as you traveled to the ranks of CEO's. 

However, why relationships between being poor, having lower socioeconomic status and health exist have not fully been made aware yet. Similarly to what Jillian Jacobellis said in Medical News Today, I am not arguing that being poor is the ultimate cause of acquiring a disease. It is clear that there are many factors that guide the health of any one individual or any one society: health behaviors, lifestyle, income, place of residence. 

Although it is clear that being poor significantly compounds ones chances of acquiring disease and succumbing to its pernicious effects. It is unfortunate that where one lives might make them more susceptible to, say, cancer, or that how much money one makes might make them more susceptible to high-blood pressure. But it does. Sadly, it seems as though disease has an inherent propensity. A propensity for the poor(er).

- m.tsang

Because Its Socially Accepted

Non-scientific claims. Warped sense of logic. Need for immediate gratification. Mixed with a little stubbornness and perhaps credulity. Out comes the drive to begin the "Master Cleanse" detox diet. Also known to detox connoisseurs as the "Lemonade Diet" or "Cayenne Pepper Diet".

This so-called diet is actually a concoction of maple syrup, lemonade, and cayenne pepper. That’s it. Mix that in a cup and drink it a few times a day. The individual is supposed to be on the diet for about ten days. Although some people take it to the extreme and have reported being on it for upwards of 40 days!

The basic tenants of this diet were born by Stanley Burroughs*. As a self-proclaimed natural healer focusing on the practices of alternative medicine, Stanley claimed he could cure many ailments and diseases through reflexology massage sessions, exposure to colored lights and lemonade concoctions. Don't worry. It its not as specious of a treatment as it sounds. There is a completely cogent explanation for his treatments: Mr Burroughs actually found and translated the lost tablet of Joseph Smith.

The diet has been further perpetuated by Peter Glickman. Glickman basically took Burroughs' lemonade diet, added the syrup and pepper and wrote a book about it in 2004. He again advocated that this diet can magically do many things like rid the body of toxins, cure ulcers and break one free from habits like smoking. I say magically because these claims by the likes of Glickman and Burroughs have no backing by science based medicine. There has never been any evidence submitted to a peer-reviewed journal showing empirically that any of these claims are true.

Actually, there is one outcome that is typical of this diet: weight loss. It’s no surprise. Of course you will lose weight if you are only ingesting syrup and lemonade daily. Given a few hundred calories a day, your body is going to need to get extra energy from somewhere. Mainly from fat and muscle. Your muscle and bone will start to rarefy due to the lack of nutrients in the diet such as protein and calcium. In fact, prolonged fasting such as this can elevate compounds called Ketone Bodies that lower the pH throughout the body and can have damaging effects on cells, tissues and organs.

I have come to think that the people who take on this diet inherently understand that it probably isn't as good for them as it sounds. They see the smoke and mirrors of "detox" but choose to embrace the gimmick anyway for what it really does: helps you lose weight by starving yourself. I was having a hard time understanding this, until a friend proposed an idea to me. She said simply, "it is socially accepted anorexia". I kind of thought "yeah yeah yeah, but what about the ketone bodies do you think they heard me say that"?

However, the more I thought about it the more it became clear that this is a completely viable theory. Its a common way of life: immediate gratification. People want the results but don't want to put in the work. Not only that, but our society puts a high price on being thin, especially for women. An idealized image can be hard for people to obtain with their regular routine. It can be difficult to go join a gym or start running regularly.

So why not? Why not starve yourself for ten days to lose the weight you want like Peter the Gimmick Clickman have proposed? Why not lose weight with the Lemonade Diet like Beyonce did for her role in Dreamgirls? Because you can eat breakfast, lunch and dinner and still lose weight. Because your body doesn't need to be starved to detoxify itself. Because a gimmick is a gimmick, and if you understand that from the get-go than there is a greater problem you need to deal with even if it is socially acceptable.

- m.tsang

[*Mr Burroughs' treatments actually ended up killing one of his quote, un-quote patiends]

Hold The Sugar

Are you one of the lucky television viewers who has witnessed the horrible High Fructose Corn Syrup (HFCS) commercials? I'm sorry. Well, beyond the absurd script and the clear bias of the Corn Refiners Association there is a real debate at hand: how bad is HFCS for us? Does HFCS cause obesity? Will HFCS steal your car stereo in the middle of the night?

First, let's brake it down in context of the contentious debate regarding HFCS versus Table Sugar (Sucrose). In this country, over the last 50 years HFCS has edged its way onto our tables and into our food. Traditionally, Sucrose was used as sweeteners in soft drinks, juices and other foods. Then, HFCS was developed in the 1950's, but it wasn't initially heavily used in foods. However, tariffs on imported table sugar plus subsidies to corn farming (which is the source of HFCS) made it cheaper to use HFCS in products in the U.S. than to use Sucrose -- thats why you can buy Coca-Cola in Mexico made with Sugar and not HFCS. Currently, HFCS receives equal usage in food products as does sucrose.

Now let's look at these two chemically. Sucrose is a compound of two individual sugar molecules: one Glucose and one Fructose. These two are connected to one another through a hydrogen bond. So whenever you ingest Sucrose you get exactly 50% Glucose and 50% Fructose. HFCS is also made of Glucose and Fructose, however there is no bond holding them together. Thus, depending on the product, you could be ingesting either 42% fructose, 55% fructose or even 95% Fructose (rarely used).

Metabolically speaking, these two substances haven't proved to be much different either. While its true that Sucrose absorption is technically limited by the amount of enzyme sucrase available (which breaks the bond between glucose and fructose), studies haven't shown that there is any real difference in blood glucose levels from ingesting one or the other.

So, what HFCS proponents enthusiastically point out is that these two substances are virtually the same, and they are both "natural". Also, Fructose is the sweetest of all the sugars which makes it attractive for food processing. Thus, why not use HFCS? 

As Kathleen J Melanson et al state in their December 2008 article, " although Fructose is present in fruit, honey, and some other carbohydrate sources, the quantities consumed from these sources are not as large as is found in foods and beverages sweetened by HFCS".

In contrast, the most common sugar in nature is Glucose. Glucose comes in the form of starch (in plants) and glycogen (in animals). Glucose and Fructose have inherent differences in their chemical properties. Within the stomach, they use different transport channels to enter the body. Glucose can activate insulin release, but fructose can't. Also, Fructose can bypass a critical step in fat synthesis that Glucose cannot. 

The current research also suggests Fructose plays a much more noxious role than was previously assumed. For example, many studies have demonstrated that Fructose effectively inhibits the feeling of fullness while eating. "Stimulation of the AMPK/malonyl-CoA signaling pathway from fructose leads to more eating, while glucose intake leads to less eating, as glucose levels rise in the brain" states Kathleen Blanchard RN reflecting on recent research out of Johns Hopkins University.

Increased Fructose consumption has also been shown to decrease Leptin concentrations. Leptin is a hormone that regulates appetite throughout the day and is associated with energy expenditure. Therefore, as Kimber L Stanhope and Peter J Havel suggest prolonged Fructose consumption could be "contributing to weight gain and obesity as a result of reduced insulin and leptin signaling in the brain".

As George A. Bray, MD, stated, "it is interesting to note that nature did not select fructose to circulate in the blood." "Human milk has essentially no fructose, nor do the foods that comprise most traditional diets."

Some companies have tried to shake this bad press and are now advertising that their products contain only natural sugar and no HFCS. Hopefully this whole time your intuitive mind has been screaming "but Sucrose contains Fructose too!".  And it does, as I clearly stated above. Yet, until clear, definitive data arises on these subjects we will still be left with increased sugar levels in our food -- in the form of Sucrose, HFCS or some other sweetener. 

The average person in the U.S. has steadily increased the amount of calories they eat over the past half century. And there is strong reason to believe added HFCS or even Sucrose in processed foods and beverages abets this trend. "Between 1991 and 2000 there was a 120% increase in calories from HFCS" argues Kiyah J Duffey and Barry M Popkin. Multiple studies have also shown clear evidence that drinking beverages with added sugar amounts to increase weight gain.

So what is one to do?. Try curbing your consumption of foods with added caloric sweeteners altogether. Stay away from sugary beverages. Drink water instead. However, in a processed food haven like the U.S. you might be trying to find yourself a needle in a haystack.

- m.tsang

If the Price Is Right

Over the last few posts I discussed a few reasons as to why our health care costs are so high in this country and also how the control in health care expenditures has become intractable. Even with this large and uncontrollable health care spending there are over 46 million citizens uninsured in this country. An increase in the number of uninsured is partly due to the lack of employer-based health insurance. Since the start of the recession, roughly 500,000 working aged Californians have lost their jobs. This, and the fact that some employers find themselves struggling to insure their current employees, is going to significantly contribute to the amount of uninsured people.

That's when public coverage comes in. Programs such as SCHIP have actually curbed the amount of uninsured in this country by covering children whose families meet certain income requirements. Also, the American Recovery and Reinvestment Act of 2009 (ARRA) will allocate a large sum of money into other public programs such as Medicare. The ARRA designates $150 billion for health care-- with $86.6 billion of that going straight to Medicare.

However, what good is it to give out health insurance if doctors won't accept it? According to Julie Connelly of the New York Times, many more doctors have been turning down Medicare and Medicaid payments. Connelly notes that some doctors have "opted out of the insurance system" altogether, or "they are not accepting new patients with Medicare coverage." Most of these doctors are internists and primary care physicians, but specialists such as gynecologists and psychiatrists have also been rejecting the plans. The reasons why aren't new or unusual: "reimbursement rates are too low and paperwork too much of a hassle" states Connelly.

Reimbursement rates are too low they say. It is true that physicians aren't reimbursed the full amount charged for an office visit or procedure through Medicare and Medicaid. The typical reimbursement to the physician is 80% of the actual fee charged. That doesn't seem that unreasonable. Especially in light of the fact that, as I said last Tuesday, the fees that physicians in the U.S. charge for general lab tests, procedures and office visits are typically 30% higher than what their counterparts in Canada are charging.

I can see their frustration to an extent. A doctor will complete a certain amount of work and charge the system accordingly. Thus, they expect to see that money. They've most likely calculated their budgets according to that pay scale. And above all, they earned it. So, when they aren't getting the remuneration they expect it is probably very discontenting.

However, there seems to be more to it that just that. For starters, not all doctors are opting out of the Medicare system. As Connelly notes, "a 2008 survey by the Texas Medical Association found that while 58% of the state’s doctors took new Medicare patients." This is very similar to the percentage of physicians who support single-payer national health insurance in this country. A 2008 report showed that 59% of physicians support this idea while 32% reprove it.

I believe the two polls express opinions concerning one underlying concept: autonomy. Both the Medicare situation and opinions regarding single-payer national health insurance deal with physicians having to relinquish a certain amount of autonomy in their practice. That autonomy is the freedom to charge what they wish.

I am going to take two excerpts from Dr Donald Barr's (MD, PhD) book Introduction to U.S. Health Policy that shows two disparate positions regarding this autonomy in more detail. The first is from Dr R. M. Sade and was published in the New England Journal of Medicine in 1971:

"Medical care is neither a right nor a privilege: it is a service that is provided by doctors and others to people who wish to purchase it".

On the other hand, we have the position of Dr. John Bowman who released this statement in 1918:

"As a people we are accustomed to hospital service; we look upon that service no longer as a luxury which we may buy, but rather as an inherent right...we regard the right to health today as we regard the right to life".

In the former view, either you have the money to pay what a doctor will charge or you don't. These are the doctors who feel they shouldn't have to comply with a system that won't let them freely charge what they wish. The latter view suggested that we should all be able to receive care when necessary. If that means accepting a discounted rate on services or supporting a single-payer national insurance system than so be it.

I interpret the former view as one that flirts with selfishness. And being a doctor requires a bit of something quite the opposite: selflessness. The motivation to be a doctor seems that it should stem from wanting to help others even when the price isn't right. Although I understand, not everyone can walk around wielding their services for free. No one can live off of that, and certainly no one expects their doctor to work for free.

The main point is: doctors do and will still get paid if they accept Medicare payments. The same goes for a single-payer insurance plan. Also, a doctor still has complete autonomy over how, when and in what manner they wish to wield their services. They are no-less a physician because of these systems. So which price are physicians willing to pay in this country? The price of fiscal autonomy? Or the price of health for their fellow citizens?

- m.tsang

"Why Are Costs So High?" for 2.2 Trillion

I ended last week with a post that pointed out something most of us already know: we can't afford our current health care system! Literally. I'm not just saying we can't afford it now, or we couldn't afford it in the 90's. For the last fourty years the cost of health care has been out-pacing inflation and the growth of GDP almost two to one. That means tax revenues are increasing only half as fast as health care costs. Think about it in terms of government spending: 46% of all health care costs are paid by local, state and federal government funds, and if tax revenues are outpaced by spending than you increase your debt. If you notice that something is absurdly inept with this situation then you win the daily double. New category, "Why are costs so high?" for 2.2 trillion dollars.

Taking a look to our neighbors in the the North can help us figure out part of this problem. Overall, Canada's health care expenditures as a percentage of GDP were 9.9% in 2003 as opposed to 15% in the U.S. Whats more is they only have to shell out half the amount of money per person to cover everyone in their country with health coverage while we have over 46 million uninsured. So how is it that we spend on average twice as much or more on health care compared to most other industrialized countries yet we can't afford to insure all our citizens?

As the Organization for Economic Co-operation and Development stated in their recent report Health Care Reform in the United States, "it is difficult to judge whether the high level of health expenditures in the United States mainly reflects a high volume of health care services or high relative prices for health care." Alright, lets hypothesize for a moment: maybe all the smog and fast food is giving us health problems and we see the doctor much more often than other countries? The answer is frankly we do not! Donald Barr, M.D. points out in his book An Introduction to U.S. Health Policy that "people in the U.S. go to the doctor 28% less often than people in Canada and are admitted to the hospital 9% less often than Canadians."

Are you as nonplussed as I am? Lets recap as I am in disbelief: Canadians spend less money per person for their health coverage, the go to see the doctor more often and they are admitted to hospitals more frequently, yet we spend more and have 46 million uninsured. Unbelievable, truly unbelievable.

If we aren't using health care services as often than we may quite possibly be paying more per service rendered. Dr. Barr notes that "resources such as laboratory tests, medications, and supplies used in providing care in physicians' offices cost 30% more in the United States than comparable resources in Canada." He also points out that U.S. physicians charge more than two and a half times more for services rendered to their patients.

Moreover, when we do go to the doctor we receive some of the best and most advanced treatment in the world while utilizing some of the newest and most expensive procedures available. And we as patients put an extremely high value on these services. Often we equate new and expensive with better and effective. We want to see x-rays; we want MRI's. We want CT scans and new drugs. According to the OECD, the U.S. has the second highest number of MRI machines and CT scanners per million individuals. (Trailing only to that of Japan whom spend the second lowest share of GDP that is put towards health care, 7.9%).

In the U.S. most of us expect nothing but alacrity in a physicians' use of new or advanced services, and much of the times physicians themselves eagerly await the chance to wield them too. This can be seen as a reflection in the amount of specialists there are in this country. Over the last 30 years, the number of specialists has nearly doubled while the number of primary care doctors has only increased by about half. Close to 70% of physicians are specialists in the U.S. states Dr Barr. That is in stark contrast to Canada where they have a 50/50 ratio of primary care to specialist ratio.

The United Kingdom, under a universal health care system might I add, has a similar ratio of doctors like the United States, yet their national health expednitures are the lowest in terms of GDP! Again, this can be at least partially explained by the lack of celerity in which they utilize specialist services and expensive technology. Before a patient can be seen by a specialist they must first be checked out and referred by a general practitioner. This "gate-keeper" method is virtually unknown in our country whereby we are able to go visit our cardiologist today if we impulsively wanted to do so.

Alright, we now realize medical services tend to cost more in this country; we utilize a higher volume of expensive services; and doctors are payed more in the U.S. So we must be doing it for some good reason, right? We should be pretty damn healthy at this point. Surprisingly we aren't saliently any healthier than other industrialized nations, in fact in some ways we have poorer health. For example, the OECD reports that out of the top 27 industrialized nations the United States ranks 23rd in terms of life expectancy. This poor ranking has much to do with the fact that we also have the second highest rate of infant mortality of those 27 nations - trailing only to that of Slovak Republic.

But don't get me wrong. Lowering physicians pay in this country, lowering the prices of medical services or trying to limit the use of expensive technology isn't going to solve all problems associated with health care expendituers. The technology is beneficial to many people, and the specialists are needed. But maybe not everyone needs an MRI when they go see their doctor for a hurt knee or the newest drug for their hypertension, which will cost more. Those are actions that can help the problem at least a bit. Although, that will take effort and a shift in our proclivities. A shift away from "a system that provides the most expensive care in the world while also excluding the largest number of people from care" (Dr. Barr).

- m.tsang

Playing Catch-Up

By now we are all well-aware of the infelicitous turn our economy has taken since the later half of 2007. The housing bubble, job losses, bank bailouts, investment firm collapses and accumulation of debt have all turned us upside down. And here, in California, we are clearly no exception. In just one year California has jumped up 4.3% in unemployment to a total of 10.5%. More than 481,000 homes were relegated to foreclosure in 2007. And we have a projected 14 billion dollar deficit to boot.

What this actually means is that we have no money to spare. So how can we afford to pay for all the things we need? Like health care? Technically we can't. As Donald Barr, MD notes in his book Introduction to Health Policy, "state and local governments typically are forbidden by law from engaging in deficit spending." Therefore, there are realistically only two ways to get funds for services like health care:

a) Through increasing taxes, or b) Taking funds from other programs

Programs and services will have to be dropped in order to stay afloat fiscally. "Likely targets for deeper budget cuts include higher education, public schools, transportation, the prisons and health care" notes Eric Bailey of the LA Times. (If you are scratching your head also because you are unsure what else the government is spending our money on, you are not the only one)

That is exactly what is on the upcoming special election ballot on May 19th. Propositions 1D and 1E deal with such issues. According to the California Healthline,

"Proposition 1D would temporarily shift $608 million from First 5 programs to fund services for children, including programs for foster children and kids with developmental disabilities. First 5 was created in 1998 when voters approved Proposition 10 to increase the state tobacco tax to fund early childhood health care and education programs. Proposition 1E would shift $226.7 million from mental health care programs funded by Proposition 63 to the existing Early Periodic Screening, Diagnosis and Treatment Program for low-income children for two years."

Along with 4 other ballot initiatives, Governor Schwarzenegger needs these all to pass in order for our state's budget to stop drowning in debt. But these piecemeal measures aren't going to pull us out of the water. Nationally, health care costs occupy close to 16% of the total GDP in the United States. Barr also notes that "governments at all levels - federal, state and local - are responsible for a combined 46% of all health care expenditures".

The 140 Billion that will go towards health care from the stimulus package is a nice gesture, but its not going to cut it. As Arnold Relman, MD exclaims in his book A Second Opinion, "the average rate of increase in health expenditures since the late 1960's has been between nine and ten percent per year, which is more than twice the rate of general price inflation". 

Do you see the problem yet? Government obtains the money it needs for health care through acquisition of taxes, and taxes generally rise at the same rate as GDP growth. But Barr sagaciously points out "health care expenditures rise faster than GDP". Thus, the government and all purchasers of health care have historically been playing an unachievable game of catch-up. Unless major reform is considered in the financing, organization and delivery of health care we are only going to be running into short sighted dead ends. That is the challenge we face - as patients, doctors, health care practitioners, politions and citizens.

- m.tsang