I recently attended a conference where bloggers and print journalists talked about the pros and cons of their respective professions

I noted that as a blogger, I am never censored. As a print journalist I was told, on more than one occasion; “Maggie, you can’t say that!” (even though I had evidence to back up my facts.)  Usually, the editor was concerned that I would “scare the readers” or upset the publisher (and advertisers). 

Of course, the downside to not having an editor is that I’m working without a net. If I get something wrong, no one has my back. On the other hand, my readers are knowledgeable, and are likely to question anything that looks peculiar. I count on you to do that, and at the same time, know that if I make serious errors—or too many small mistakes—I would lose my credibility.

But not all bloggers have alert readers. And because of the lack of editing,   the blogosphere is clogged with posts that are silly, just plain nasty, and, all too often, simply not true.

Nevertheless, I think that the best blogs manage to keep the level of public discourse high, while enjoying first amendment freedoms that are difficult to achieve in mediums supported by advertising and owned by corporations.

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Forces calling for Healthcare Reform Now are gaining momentum. I share their sense of urgency—assuming that they are talking about the “reforms” needed to create an effective, affordable, patient-centered health care system.  But if they simply mean “universal coverage,” I have to disagree.

Giving every American a piece of paper labeled “health insurance” will bail out a health insurance industry desperate for customers. And it will help drug-makers, device-makers, and medical-equipment makers.  But it will not solve patients’ problems.  What Americans need is not health insurance, but rather effective health care.

A stunner of a story in yesterday’s Washington Post makes it clear that today we are pouring money into a health care system that does more for the health care industry than it does for patients.

“We're not getting what we pay for," Denis Cortese, president and chief executive of the Mayo Clinic, told the Post’s Ceci Connolly. "It's just that simple."

"Our health-care system is fraught with waste," added Gary Kaplan, chairman of Seattle's cutting-edge Virginia Mason Medical Center. According to Kaplan: “As much as half of the $2.3 trillion spent today does nothing to improve health.” 

“Not only is American health care inefficient and wasteful,” declared Kaiser Permanente chief executive George Halvorson, “much of it is dangerous.” 

This is a startling indictment, and one that health care reformers should heed.

“There is a broad consensus on what should be done,” writes Connolly, a health care journalist who knows her subject well. The system needs structural reforms which include  “realigning financial incentives, coordinating care, researching what treatments work best…and most daunting but perhaps most important, saying no to expensive, unproven therapies.”

Therapies that have not been fully tested harm tens of thousands of Americans each year. Consider this: 10 percent of all drugs approved by the FDA from 1975 to 1999 were later withdrawn from the market or “black-labeled” to warn of risks.

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Assume that you are a 40-year-old man. What do you think the chances are that you will die of a heart attack or stroke in the next 10 years? (Please forgive the morbidity of the question; there is a purpose to this pop-quiz.)  The answer: just 4 out of 10,000 according to Drs. Steve Woloshin and Lisa Schwartz, authors of Know Your Chances. The odds that you will die in an accident before reaching your 50th birthday are 50 percent higher: 6 out of 10,000. 

Nevertheless, many men remain convinced that they are at great risk of dying from vascular disease, particularly as they get older. In truth, even at age 60, the odds that a heart attack or stroke will end your life over the next decade are only 37 out of 10,000.  Over that span, you are three times as likely to die of another cause—with the chance of a fatal accident (5 out of 10,000 ) just as high as the chance of a stroke.

Moreover, for reasons we do not fully understand, the incidence of heart attacks is declining. “Fifty hears ago, heart attacks were a scourge. Everyone knew a working-age man who’d dropped dead from one,” writes Dr. Nortin Hadler in his new book, Worried Sick. Today “the decline in mortality from coronary artery disease is well documented.”

There is one exception:  If you are a 60-year-old smoker, the chance of a fatal heart attack or stroke in the next ten years climbs to 67 out of 10,000, and your chance of dying of lung disease rises to 59 out of 10,000.

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Below, a story and a poem from Pulse, a very special online magazine that uses stories and poems from patients and health care professionals to talk honestly about giving and receiving care.

Pulse was launched by the Department of Family and Social Medicine at Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx, New York, with help from colleagues and friends around the state and around the country. The magazine’s contributors are doctors, nurses, psychologists, social workers, patients, students, editors and writers.

I count its editor-in-chief, Dr. Paul Gross, as a friend. Here Paul describes how Pulse was born:

“While leafing through a medical journal some years ago, it struck me that the scientific studies that filled its pages bore only a slight resemblance to my experience of the practice of medicine. For one thing, the patients in the studies seemed to enjoy swallowing pills. They remembered to take them and didn’t seem to mind their accompanying side effects…

“For another, the studies assumed that the pills were readily available—and affordable…

“These journals had glossy images of smiling patients who were now leading active lives thanks to antidepressants or anti-inflammatory agents. My experience with these same pills was a little different: many didn’t work nearly as well as advertised…

“The health center where I worked at the time wasn’t making things easier for patients, who complained about doctors (myself included) who made them wait and telephones that rang and rang unanswered.

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“Fat prejudice is the primary impediment to understanding—or wanting to understand what obesity is all about,” says a public health nurse who appears in “Fat: What No One Is Telling You,” a 2007 PBS home video documentary.

In the first installment of this post, I explained how little physicians know about what causes obesity—in part because, as this nurse points out, “blaming the victim has stood in the way of understanding.” Here, I am reminded of how, in the past, we blamed patients suffering from depression and other forms of mental illness. For centuries, this prejudice stood in the way of understanding that mood disorders are caused by a flaw in chemistry, not character

In “Fat,” patients describe how even some doctors treat them with contempt. “When I went to get a Pap smear, the doctor said, ‘You’re too fat; come back when you’ve lost weight,’” one woman recalls. 
The documentary also points out that “while everyone dies . . . it should perhaps come as no surprise that in our society, obese people are blamed for dying. If a thin patient comes into the hospital, has a heart attack, and dies, cause of death is labeled ‘heart disease’, a public health nurse who appears in the film tells the filmmakers. “If an obese patient has a heart attack and dies, cause of death is ‘obesity’.”

Nevertheless, despite the bias, today scientists have begun to look past the old-fashioned notion that obesity is merely a matter of gluttony, and have made real progress in beginning to understand a terribly complicated chronic disease.

Granted, obesity doesn’t look like “a subtle disease,” acknowledges Harvard’s Dr. Lee Kaplan, who heads the Weight Reduction Program at Mass General Hospital. Conventional wisdom says that if you put too much food in your mouth, and don’t exercise enough, you’ll wind up fat. Period.

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The film opens with a fetching red-head puffing away on a treadmill. She’s perspiring, but she’s smiling gamely into the camera. “It’s not an average work-out, but I wasn’t an average weight,” she explains. “I have to do above and beyond what any of you guys would have to do. I have to try twice as hard, sometimes three times as hard—just to maintain this level of…chubbiness.”

And she is right. She is chubby. By 21st century mainstream (and magazine) standards of beauty this young woman is probably 30 pounds overweight. The dimples, the pony-tail, the strawberries and cream complexion, and the undeniable on-camera charisma make her very appealing. But there is no doubt that most physicians would urge her to lose weight. 

Later in the film, we learn that she exercises three hours a day.  And when her mother was dying of cancer, this thirty-something nursed her and learned a great deal about nutrition. Dedicated and determined, she eats healthy meals and sticks to a strict exercise regime.  Why, then, is she “chubby?”

Doctors don’t know.  That is one of the first things you learn in “Fat: What No One is Telling You,” a 2007 documentary that is, by turns, entertaining, moving, and eye- opening. (The PBS home video, directed by Andrew Fredericks, can be rented on www.netflix.com or purchased on www.amazon.com).

The questions are endless, a narrator tells the audience. “Is it her genes, her childhood, a flaw in her character, stress, sadness, a lost love, processed food, television, seductive advertising, lack of sleep, a government that subsidizes corn, sugar and beef?”

All of the above may well contribute. But taken together, they still don’t constitute an answer. Doctors cannot help the vast majority of obese people lose weight–and keep it off—because doctors don’t know what causes obesity.

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Over at Colorado Insurance Insider, Louise hosts Health Wonk Review, highlighting some of the best healthcare post of the past two weeks.

Many focus on what the new administration will or won’t do about healthcare reform.  At the Covert Rationing Blog, Dr. Rich offers a particularly entertaining—and shrewd—assessment of the future of health insurance companies. 

Unlike many observers, Dr. Rich understands that the insurers are desperate to see universal coverage as soon as possible because they need new customers—Now. Insurers assume  that any reform plan will follow Obama’s model and include them, giving Americans a choice between public  sector insurance and private sector plans. With the government providing subsides for low-income Americans, this means that insurers could look forward to tapping that pool of 47 million Americans who are now uninsured.

Of course, if the reform plan regulates insurers (as it must), they won’t be able to “cherry-pick” their customers. Nevertheless, Dr. Rich speculates (and this is the part that is, I think, particularly shrewd) that insurers were looking forward to “one last, huge windfall, in the form of government-provided premiums for some significant chunk of millions of uninsured Americans. Then, a couple of years later and having realized their final gains, they would get out of the health insurance business altogether and let the feds have the whole mess.”

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While some argue that we must have health care reform “Now,” others (including HealthBeat) have argued that “doing it right” will take time.

In the white paper released today Senate Finance Committee chairman  Max Baucus seems to take both sides of the argument. On the one hand: “Congressional leaders and the public must be realistic about the timeframe in which the fiscal success of reform is measured. “

On the other hand:  “If we fail to act  we will double our current national expenditure on health care from $2 trillion to $4 trillion, continue to witness the plight of tens of millions of our citizens without health insurance cost shifting to those who do, continue to tolerate poor quality . . .  We must choose to invest now."

Is this simply political double-talk of the “Look Before You Leap”/“He Who Hesitates Is Lost” variety?

Not at all. Baucus’ multi-part plan would unroll over time “hopefully . . . in about three years.” (You can hear him offer this time-frame in his press conference on C-Span).  Over this period, he would create a Health Insurance Exchange that would insure that “affordable, high quality and meaningful health insurance options are available to all Americans.” The insurance offered through the exchange “would need to meet certain requirements established by a new Independent Health Coverage Council,” Baucus explains.

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Today, Senate Finance Chairman Max Baucus issued a “Call to Action” for Health Care Reform. And it is shockingly honest.

The bombshell in the plan is that it would require every American to purchase health insurance. There would be sliding subsidies for everyone under four times the Federal poverty level ($70,400 for a family of 3), but there would be no exemptions.

The individual mandate is necessary because Baucus is barring insurers from charging higher premiums or denying coverage outright to people with pre-existing conditions. (Today, in the vast majority of states, insurers can shun the sick–or charge them whatever it chooses).

As HealthBeat has explained here, if you insist that insurers must cover everyone, old or young, sick or healthy, at the same price, you must have the individual mandate. Otherwise, many young, healthy people would wait until they became sick to join a pool—safe in the knowledge that an insurer could not charge them more—and expect people who had been paying premiums into that program for years to now pick up their medical bills. If that happened, ultimately only the sick and the elderly would buy insurance—and prices would levitate to a point that virtually no one could afford it. 

What Baucus doesn’t mention is that community ratings are likely to hike premiums in many states because suddenly, the very sick will be included in the insurance pool. As Time magazine reported in 1994: In 1993, [when] New York State tried community ratings, “thirty- year-old males watched their premiums soar 170%, according to the Council for Affordable Health Insurance, while men aged 60 enjoyed a 45% cut. The rate hike for 30-year-old women was 82%, and women twice their age saw rates slashed by a quarter.”

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Here we go again.   If you haven’t yet heard the news from the American Heart Association meeting that was held in New Orleans yesterday, here is Bloomberg’s report on a medical breakthrough that, some say, will “change the way we practice medicine.”

Bloomberg, Nov. 9: “AstraZeneca Plc’s Crestor [a cholesterol-lowering medication] slashed the risk of heart attack, stroke and death by nearly half in people with normal or low cholesterol in a study, potentially opening a way to save the lives of thousands of seemingly healthy people.”

I like that last phrase: “seemingly healthy people.”  As we all know, there are no truly healthy people. Even if you think you might be healthy—you’re worried. You know there is probably something wrong with you.

Here, I can’t help but think of “The Last Well Person.” This was the title of an “Occasional Note” that Tennessee physician Clifton Meader wrote for The New England Journal of Medicine in 1994. His fiction was set in the not-too-distant future, and focuses on a 53-year-old professor of freshman algebra at a small college somewhere in the Midwest. He is…you guessed it, the very last healthy American.  Using advanced medical screening, physicians have found something wrong with everyone else. 

Now medical science is catching up with Meader’s science fiction.  It’s beginning to look as if all of should be taking Crestor, or some other cholesterol-lowering drug (a.k.a. a statin) even if we don’t have high cholesterol.

The trial of Crestor  reported at the AHA conference yesterday, showed the effect of the drug on patients who did not suffer from high levels of “bad” cholesterol—but did show high levels of a protein called CRP.  It turns out that CRP is a marker for inflammation. It is tied to heart risk even in “well” people with no additional symptoms. At the moment, Crestor is approved by U.S. regulators only to lower bad cholesterol. Now, it appears that it also reduces inflammation, and other statins may have the same effect.

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