Author Archives: The Century Foundation

Glenn Beck Gives Birth to a New Health Care Myth

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Over on CNN.com, I came across one of the most wrong-headed arguments against health care reform that I’ve ever seen in my life. Here’s the gist of it: we can’t reform the health care system until doctors are nicer to their patients. Perhaps unsurprisingly, this gem comes from a TV pundit.

The talking head in question this time is the lamentable Glenn Beck, CNN’s go-to ‘irreverent conservative’ voice. In an online Op-Ed, Beck details his miserable experience with doctors after getting surgery and works very hard to turn his displeasure into an argument against health care reform—with little success.

Long story short, Beck had surgery on his butt, things went horribly awry, and he was seriously medicated in order to dull the pain. The combination of drugs Beck received “took [him] to an incredibly dark place…Every time I closed my eyes…I would see horrific, unimaginable images of death and after two and a half days…I was literally suicidal. It felt like there was no hope…”

Beck’s despair went more or less ignored by doctors, who he says "treated [me] more like a number than a patient. At times, staff members literally turned their back on my cries of pain and pleas for help. In one case a nurse even stood by tapping his fingers as if he was bored while my tiny wife struggled to lift me off a waiting room couch."

This is unsettling stuff that I wouldn’t wish even on Glenn Beck. Predictably, but not unjustly, Beck uses his experience as a launching pad to assert the importance of compassion and bedside manner in medical professionals. Here here! But then Beck really, really jumps the tracks:

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Health Care and—Not or—the Economy

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Yesterday Maggie posted on how economic insecurity and health care are in fact related issues. I agree 100 percent, and wanted to take the opportunity to show that the American people concur. Health care costs and economic insecurity aren’t in competition for public mindshare—according to poll responses at least, the two are coupled.

Every year Gallup asks voters “Are you generally satisfied or dissatisfied with the total cost of health care in this country?” Check out the results from 2001 through 2007 below.

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The trend toward being more worried about price of health care is clear. And inherently, cost worries are economic issues.

But the connection between economics and health care goes well beyond this logical argument—you can actually see the two linked in polls. Take a look at the graphs below (click both to enlarge them), from a Kaiser Family Foundation report published last month. Since 2004, Kaiser has been asking respondents how worried they are about a set of potential problems. The first set of bars shows that flagging incomes and high health care costs are the two major concerns that people say they are “very worried” about. This makes sense: the less confident you are about your purchasing power, the more worried you’ll be about buying essentials like health coverage.

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The Newest Last-Place Finish for U.S. Health Care

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Many people—okay, mostly conservative politicos—like to say that the U.S. has the best health care system in the world. Time and again, those of us in the reality-based community offer a legion of evidence as to why this isn’t true; the ethno-centrists wag their fingers and repeat their refrain; and so the cycle continues.

But recent numbers from the Commonwealth Fund should put a stop to this cycle: the U.S. health care system places last in the world when it comes to stopping preventable deaths.  In other words, we spend more but accomplish less—does that sound like success to you?

The new study, funded by Commonwealth and appearing in the Jan/Feb ’08 issue of Health Affairs, looks at “deaths from certain causes before age 75 that are potentially preventable with timely and effective health care.” Relevant causes of death include diabetes mellitus, intestinal infectious diseases, whooping cough, childhood respiratory diseases, leukemia and others.

The authors, both from the London School of Hygiene and Tropical Medicine, found that America’s success in staving off these health problems has decreased over time. Between 1997/1998 and 2002/2003, preventable deaths fell by an average of 16 percent in all 19 industrialized countries considered; but the decline in the U.S. was only 4 percent. In 97/98, “the U.S. ranked 15th out of the 19 countries on this measure—ahead of only Finland, Portugal, the United Kingdom, and Ireland—with a rate of 114.7 deaths per 100,000 people.

“By 2002–03, the U.S. fell to last place, with 109.7 per 100,000. In the leading countries, mortality rates per 100,000 people [for 2002-2003] were 64.8 in France, 71.2 in Japan, and 71.3 in Australia.” [see graph below, courtesy of Commonwealth]

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Keep Criminals Healthy—Or Else

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One of the most infamous records the U.S. holds is that of the world’s incarcerator. As of 2006, 2.2 million Americans were incarcerated, more than even China—which has over four times the population of the U.S.

California is the most cell-happy state in the union, with its prison population in midyear 2006 at over 175,000, or 11.3 percent of the total prisoners in the country.  The Golden State’s 175,000 inmates are held in 33 prisons—meaning there’s roughly 5,307 inmates per prison.

Put differently, every prison health care system has 5,307 potential patients, day in and day out. That’s quite a caseload, and it’s made much worse by the fact that prisoners are in much poorer health than the general population. Indeed, the California prison system is in the throes of a health care crisis—one that highlights why we should all care about the quality of medical services for inmates.

As you might guess, prison is an unhealthy place. Prisoners are more than eight times as likely to be infected by HIV, four times as likely to have active tuberculosis, and more than nine times as likely to have hepatitis C. According to the National Commission on Correctional Health Care, about 3 percent of the U.S. population spends time in prison or jail—but between 12 and 35 percent of the total number of people in the nation with some communicable diseases (like AIDS and Hepatitis B) pass through a correctional facility.

Commission data shows similar trends occur for mental illnesses (see the table below). Prison inmates have rates of schizophrenia and other psychotic disorders that are three to five times greater than the general population. Their incidence of bipolar disorder is up to three times greater than people outside prisons. And prisoner rates of drug and alcohol abuse are also higher.

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Open Question: Should Physicians Be Involved in Lethal Injection?

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In the newest issue of JAMA, two authors affiliated with the AMA offer their opinions on physicians’ role in implementing the death penalty via lethal injection. Hint: they don’t approve of it.

The article says that unlike other methods of execution, lethal injection “has elements of medical practice: insertion of intravenous lines, intravenous injection of medicinal drugs, and monitoring vital signs.” Small wonder then, that 35 of the 38 states that allow the death penalty either require or permit physician participation in executions.

Typically the identity of physicians who participate in executions is held confidential by state authorities. Even if they are made known, licensing boards in death penalty states have trouble taking any action against physicians who participate in executions. Since the boards deal with illegal activities, they can’t crack down on physicians who participate in executions that are legal.

But medical societies have more wiggle room. AMA prohibits involvement of physicians in executions, saying that it goes against the physician’s role as a healer. As the authors put it, “any form of participation in causing death by lethal injection is unethical because it violates the physician’s role, thereby undermining trust….the penal system, not the medical profession, is responsible for finding a way to perform executions.”

Obviously this issue has a certain degree of timeliness, given the Supreme Court’s recent agreement to hear challenges to lethal injection on the grounds that the process often gets so mucked up that it constitutes cruel and unusual punishment. But I think the JAMA piece is right in addressing it as a big-picture best practices question. This is primarily a moral question.

And it’s a tough one, even for physicians who might support capital punishment in the criminal justice system. Just because they believe that murderers should die, it doesn’t follow that they feel criminals do or do not deserve a demise that is as painless as possible. Supporting capital punishment and consenting to having a hand in it are two very different things.

So imagine you’re a doctor and the state has asked you to preside over
an execution that will go on with or without a physician present.
What’s your medical duty—to try to ensure that things go smoothly and
spare the inmate unnecessary pain, or abstain from attending because
your presence would mean you were participating in taking a life? Which
choice is truer to the physician’s duty to be a healer?

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Taxes: Weight Watchers for the Health Care System

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A few days ago San Francisco Mayor Gavin Newsom proposed adding a surcharge on soft drinks with high-fructose corn syrup as part of a campaign to combat obesity.

Newsom’s “soda tax” is just the latest development in a series of metropolitan initiatives aimed at promoting healthier living. New York, which pioneered smoking and trans fat bans, has been the most gung-ho city and similar bans now have been passed, or are being considered, by cities across the nation—and the world. 

Efforts like the soda tax are often derided as unnecessary big government intrusions, especially for something like corn syrup (or trans fat) that doesn’t hurt bystanders the way second-hand smoke does. Those who eat or drink poorly only hurt themselves; and the right to self-destruct is a right the government should respect (or at least this is what some say).

But here’s the problem: the cumulative effect of saying that obesity isn’t my problem is to make it everyone’s problem. Newsom’s spokesman, Nathan Ballard told the New York Times that “there’s a well-established nexus between obesity, which is caused by high-fructose corn syrup, and the increased health care costs for the city.” According to a 2004 study in the Annual Review of Public Health, obesity is responsible for between 5 percent and 7 percent of total annual medical expenditures in the United States. Every year excess weight costs our health care system more than $90 billion. Even employers shoulder the burden of obesity: overweight workers require as much a $2,500 extra in health care costs, adding up to almost $300,000 in medical expenses for a 1,000 person firm.

The reason why obesity costs so much is obvious. Individuals who are carrying too much weight are at an increased risk of hypertension, osteoarthritis, high cholesterol, type 2 diabetes, heart disease, stroke, gallbladder disease, respiratory problems, and cancer. And it’s only getting worse. A RAND study from earlier this year found that from 2000 to 2005 the obesity rate in the U.S. (, i.e. the number of people with a body mass index of 30 or above,) increased by 24 percent. Meanwhile the number of people with a BMI over 40 grew by 50 percent, and the number of people with a BMI over 50 grew 75 percent.

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Are Americans Working Health Care into the Ground?

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We Americans are proud of our work ethic. We work longer hours, and more productively, than any other nation. Our industriousness has long been cited as a source of strength of our economy—but it just might be a source of some of our health care woes as well. 

According to a just-released study from Wake Forest University, professional flexibility is an important contributor to better health. Employees at all levels who have, or feel they have, more job flexibility (e.g. the ability to work from home, choose their hours, etc.) engage in healthier behavior than those that don’t. The study found that employees with flexible schedules exercised more, attended more employer-sponsored health classes, were more likely to describe themselves as living a healthy lifestyle, and reported getting more sleep. When the researchers checked in a year later, they found that as job flexibility improved, so did healthy habits: more flexibility meant more sleep, more health classes, and a healthier lifestyle.

This study deserves attention. Changing behavior is the single most powerful way to prevent health problems. As experts from the Robert Wood Johnson Foundation noted in a Health Affairs article earlier this year, “behavioral issues represent the greatest single domain of influence on the health of the U.S. population,” with 40 percent of early deaths in the U.S. due to behavioral patterns. Anything that promotes health behavior needs to be seriously considered as a strategy for making America healthier—and by extension, health care costs lower. 

Obviously, somehow ensuring that everyone in America had more flexible hours wouldn’t cut early deaths by 40 percent. And there’s no guarantee that more flexible hours will translate into better sleep, more exercise, or more education on a national scale. Any movement for universal job flexibility would have to be coupled with a concerted effort to translate free time into healthy time.

But this study gets us thinking about behavior as more than just the usual spate of no-nos like smoking or eating poorly. Work is behavior. Work is relevant to health—more so even, than the Wake Forest University study suggests. There’s an argument to be made that more job flexibility can translate into a shift away from medication in two big arenas: childhood disorders and depression.

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The Drug War versus Health Care

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Yesterday President Bush gave a speech on the success of his drug policies in celebration of a new report showing that teen drug use has continued a decline that began in 1997. But it is not entirely clear that there is much cause for celebration: use of some of the most hardcore stuff—such as cocaine, crack, LSD, and heroin—has held steady over the past five years or so. True, recently the use of marijuana, amphetamines, and methamphetamines has dropped, but that’s hardly reason to declare victory in the war on drugs.

Like any good president, Bush wants to take credit for good news. But as the lack of progress in the battle against heroin and crack suggests, the U.S. is on the wrong track when it comes to drugs. Our institutional bias is still to see drug use and drug control as criminal justice issues when we should really be thinking about them as public health concerns.

Just take a look at history. According to a Health Affairs article from earlier this year, since 1987 public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. From 1987 to 2003, the average annual total growth rate for SA treatment was 4.8 percent, while U.S. health care spending grew by 8.0 percent each year. Because of this mismatched growth rate, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Compare this drop in treatment spending to the increase in drug arrests: according to the Bureau of Justice Statistics, in 1987 drug arrests were 7.4 percent of all arrests reported to the FBI; by 2005, drug arrests had risen to 13.1 percent of all arrests. Our spending on SA treatment and the volume of drug arrests are moving in opposite directions. And for all the political pageantry surrounding yesterday’s report, President Bush’s FY 2008 budget calls for cutting $158.7 million from the Substance Abuse and Mental Health Services Administration (SAMHSA) budget and $278.9 million from the Safe and Drug-Free Schools and Communities (SDFS) program. 

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Immigrants Exploit Our Health Care System…Right?

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There’s no easier punching bag in politics today than undocumented immigrants. They can be blamed for any number of problems—including high health care costs. The Federation for American Immigration Reform (FAIR), for example, insists that “the costs of medical care for immigrants are staggering.”

But a handful of hot-off-the-press reports tell a different story. A just released Congressional Budget Office (CBO) study concludes that while immigrants are indeed “more likely [than American citizens] to rely on emergency rooms or public clinics for health care” the cost of caring for immigrants is much less than alarmists would have you believe.

This conclusion clashes with the widespread conception that emergency rooms around the nation are filled to the brim with Mexicans—all on the dime of the American taxpayer. In fact, a November UCLA study showed that “undocumented immigrants from Mexico and other Latin American countries are 50 percent less likely than U.S.-born Latinos to use hospital emergency rooms in California,” the state that incurs the most undocumented immigration-related costs. (The lower rate of hospital use is due to the fact that undocumented immigrants tend to be young and healthy. After all, border-crossing is a rough experience).

Of course, it’s not the rate of health care use that has people worried—it’s the cost of use. But a 2006 RAND study concluded that in 2000, health care for undocumented immigrants between 18 and 64 years old cost taxpayers about $11 per household—roughly the price of a cheeseburger in Manhattan.

Part of the reason the price tag is so low is that our health care
system does only the bare minimum for undocumented immigrants. The CBO
reports that 1986 Medicaid reforms stipulated that immigrants could
receive emergency Medicaid for must-have-care situations like
childbirth. But “emergency Medicaid covers only those services that are
necessary to stabilize a patient; any other services delivered after a
patient is stabilized are not covered.” Undocumented immigrants are
only assured enough health care to make sure they don’t die; so the
costs of emergency Medicaid are very low.

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The Academic Buzz around Health Care

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Being a young whippersnapper, it never occurred to me that health care policy was a relatively new field of study within our universities. But when Health Beat reader Bradley Flansbaum passed along the  Reuters story below to Maggie (original here)  and she passed it on to me, I gained a new perspective on the issue. It turns out that until very recently, health care used to just mean medicine. But today, thinking about health care demands thinking about  a lot of different things, like public policy, public administration, economics, politics, and even sociology.

This mixed bag is reflected in the diverse academic offerings at colleges and universities—as well as the swell of students interested in them. The Reuters story below suggests that there are three main motivations for the increased student interest: fascination, idealism, and profit. That sounds about right. You can either be genuinely interested in the complexities of health care or the politics surrounding it; want to fix the system for the greater good; or want to learn as much as you can about the system to better navigate it for GlaxoSmithKline.

There’s obviously a lot of good to be had from generations growing up understanding more about our insanely complex and counter-productive health care system. Teaching college students about the system now might instill a long-term openness to reform and improvement that wasn’t present in generations who never knew about health care until they got sick.

But I can’t help but wonder about the faddishness of it all. After all, health care isn’t the only broken system that could use some attention. Consider the criminal justice system. Back in the day, law and order meant being a lawyer or a cop. But today there are criminology and criminal justice programs around the world that focus on issues like incarceration, community policing, cost, risk management, and more. Yet the buzz surrounding these issues hasn’t been comparable to the much louder debate about health care—even though one out of 32 Americans is currently in the corrections system and a black male is more likely to have served time in jail than have a college degree. This too is a crisis.

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