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.

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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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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On Gooznews last week, Merrill Goozner made a provocative argument:

“…the latest polls show the economy has eclipsed health care as the most important domestic issue among voters. Even the health care-oriented Kaiser Family Foundation’s latest poll shows the number of Americans who name health care as their primary concern fell to 30 percent in early December from 38 percent just two months earlier. When offered a list of possible issues the candidates ought to address, the economy had pulled even with health care.

“The escalating fear that the nation may be heading into a recession because of the sub-prime mortgage meltdown and sky-high gas prices has certainly played a role in the turnabout. In that sense, 2008 is beginning to look a lot like 1992. The year before that election, health care dominated the national discussion after Harrison Wofford used the issue to win a surprise victory in a special Senate election in Pennsylvania. But by the time Arkansas Gov. Bill Clinton stormed to victory in the primaries, ‘it’s the economy, stupid’ had become the Democratic standard bearer’s watchword.”

Merrill may be right: certainly health care didn’t seem to be the driving issue in Iowa, and I doubt it will determine the results in New Hampshire. (See my last post on Iowa and New Hampshire.)

And I agree that, by November, the economy may well be the paramount issue. We are heading into a recession.

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When it comes to health care, the citizens of Iowa and New Hampshire are different from you and me: they enjoy higher quality yet much more affordable health care than citizens in virtually any other state. This may help explain why health care just hasn’t seemed to be a pivotal issue in these early primaries.

The chart below (click the image for a bigger version in a new window), published in Health Affairs in 2004, rates the quality of  health care state by state (see vertical axis) while also revealing how much Medicare spends, on average, per beneficiary in each of the states each year. (See horizontal axis.) Spending has been adjusted to take into account inflation, differences in prices in different states, and differences in the age, sex and race of the Medicare population in each state.  States that spend most appear on the far right of the chart. States that provide the highest quality health care are clustered at the top.

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Yesterday I appeared on a four-person health care panel that was televised in New Hampshire.  The panel included a conservative who surprised me by arguing that the difference between the progressive candidates’ proposals for health care reform and the conservatives’ position on health care just isn’t that great.

Looking at the candidates’ proposals, I disagreed.  Put simply, the conservatives would like to make government smaller. They want to “outsource” many of government’s jobs to the private sector. They tried to privatize Social Security, and they have partially succeeded in privatizing Medicare by paying private insurers a steep premium to take care of seniors under Medicare Advantage. (See my post about the high cost of the program here).

Finally, the vote on SCHIP split along conservative/ progressive lines, with conservatives voting against expanding SCHIP. As President Bush explained, more funding for SCHIP would expand the government’s role in our health care system.

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I promised to return with more information about who halted the use of life-saving checklists in Intensive Care Units in Michigan and at Johns Hopkins. (For my earlier posts on this shocking story, click here and here).

The Office of Human Research Protections (OHRP) is the agency that has nixed the use of checklists. Who runs the OHRP?  Until his recent resignation (as of Sept. 30), Bernard Schwetz was the director of OHRP. Who is Schwetz? He is a veterinarian (DVM). That’s right, he’s vet, not a M.D.

What’s even more surprising is that from January 20, 2001 to February 2002, Schwetz, who is also a toxicologist (Ph.D.), was Acting Deputy Commissioner of the FDA. This was not a bright period in the FDA’s history. During Schwetz’s tenure, the FDA’s counsel, Dan Troy, was running the agency from behind the scenes. Troy, a Bush appointee, was well-known as a long-time foe of FDA regulation. In the 1990s, he represented Brown & Williamson Tobacco Corp. in its effort to fend off the FDA, and just months before joining the agency, he had defended Pfizer in another battle with regulation. As a U.S. News & World Report headline summed up his career change: “Mr. Outside Moves Inside: Daniel Troy Fought the FDA for Years; Now He’s Helping to Run it.” (I have documented Troy’s power in my book, Money-Driven Medicine).

As for Schwetz, what can one say about a vet/toxicologist who becomes temporary deputy commissioner of the FDA? “Political appointee” is the phrase that comes to mind.

I’m told that the OHRP is a “strange creature.” It was created in 2000 to replace the small, underfunded Office of Protection from Research Risks. That office reported to the NIH. OHRP, by contrast, reports directly to the Assistant Secretary of Health, putting it under the White House’s control.

OHRP began sending what only can be described as threatening letters to Michigan and Johns Hopkins last summer—on Schwetz’s watch. He announced his resignation at the beginning of August. I haven’t been able to find an explanation for the resignation or whether it is in any way connected to OHRP’s decision about the checklist.

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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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Perhaps you saw the headlines over the holidays:

• “CIGNA Defends Decision To Let Teen Die—On Christmas Eve”
• “As CIGNA Insurance Waffles on Liver Transplant, Girl Dies”
• “Lawyer: CIGNA’s refusal to pay for liver transplant ‘killed’ teen”
• “Teenage Girl Dies So CIGNA Execs Can Get Richer”
• Metroblog: "Merry ******* Christmas, From  CIGNA Healthcare "

Without question, this is a tragic story. Here are the bald facts: Nataline Sarkisyan, a 17-year-old who had been battling leukemia for three years, received a bone marrow transplant from her brother the day before Thanksgiving. She then suffered complications; her liver failed, and she went into a coma. At that point her doctors at the UCLA Medical Center recommended a liver transplant, saying that the transplant would give her a 65 percent chance of living another six months.  Within four days, a matching donor was found.

But on December 11th her insurer, CIGNA, refused to cover the transplant on the grounds that for a patient this sick, the transplant would be an “experimental procedure.” And her insurance policy "does not cover experimental, investigational and unproven services.” 

The doctors told the family that their only alternative would be to make a $75,000 down payment on the operation. Unfortunately, the family didn’t have $75,000. 

Observers both in the mainstream media and in the blogosphere were outraged when they heard that CIGNA had denied coverage.  Daily Kos led the protest with “Murder By Spreadsheet: CIGNA  Denies Claim and 17-Year-Old Will Die.” Responding to the firestorm, on December 20 CIGNA relented, saying that  "despite a lack of medical evidence regarding the effectiveness of such treatment,” it would cover the transplant.

The letter from CIGNA came too late. That same day, the hospital called to say that Nataline’s condition was deteriorating and her family was forced to make the decision to take her off life support.  She died within the hour.  The next day the Sarkisyan’s lawyer announced that the family planned to sue CIGNA for “malicious” murder.

This is both a tragic tale and a complicated story—far more complicated than the headlines suggest.  As Dr. John Ford, an assistant professor at UCLA’s medical school observed on his blog, California Medicine Man, “While I’m not surprised at the intensity of emotion that has arisen from this case, the utterly inflammatory and often mindless rhetoric being propagated is sobering. It seems that nuance has taken a hike, never to reveal itself.” 

Here are just a few of the questions that this vexed and vexing case raises:

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Today (Sunday, Dec. 30) the New York Times published a shocking op-ed by Dr. Atul Gawande revealing that a U.S. government agency has stopped an enormously successful "checklist" program that was being used to reduce infections in intensive care units at Johns Hopkins and throughout the state of Michigan. (To see my original piece  on checklists, scroll down to my Dec. 14 post below.)

Below, an excerpt from today’s op-ed:

" In Bethesda, Md., in a squat building off a suburban parkway, sits a small federal agency called the Office for Human Research Protections. Its aim is to protect people. But lately you have to wonder. Consider this recent case.

"A year ago, researchers at Johns Hopkins University published the results of a program that instituted in nearly every intensive care unit in Michigan a simple five-step checklist designed to prevent certain hospital infections. . .

"The results were stunning. . . . Over 18 months, the program saved more than 1,500 lives and nearly $200 million

"Yet this past month, the Office for Human Research Protections shut the program down. . .

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I hope everyone has a wonderful holiday.  Health Beat will be taking a vacation—but we’ll be back January 2. And sometime early in the New Year, we’ll have a new design—with the larger typeface that some of you have asked for.  Be well.