Punk'd is Punk

         My TV cable subscription has a schedule crawl that usually runs one of several shows above it, so waiting to find out what Giada is cooking for dinner or whose design is divine, I see shows I might not otherwise. I am stunned by Punk’d, which plays often on the crawl. It is, of course, a variation on Candid Camera. What struck me was two things:
         First, it is cynical and mean: staging a car accident in which a woman might have been killed or badly injured; having a woman pretend to find glass in her salad after her mouth is cut and she begins bleeding; in-your-face illegal immigrant-squatters living in someone’s back yard. Isn’t if funny to put someone is a serious moral or legal situation, or scare him into thinking his girlfriend might be seriously injured, and watch?
         Yes, it is a relief that the woman wasn’t dead, the blood and injury were fake, and the squatters who were threatening to take the innocent homeowner to court were actors, perhaps that explains the second observation: “[Laughter] Wow! I’ve been punk’d!” Thank god I’m not a murderer! The victim accepts the joke.
         It’s easy to be cynical, it’s a biological imperative for all teenagers. As John Gardner said (On Moral Fiction), anyone can be cynical; but the essence of good writing is telling the same story but without being cynical.
         Isn’t it curious, that vast swaths of society can extol the virtues of diversity, political correctness, and sensitivity, and Punk’d can run several years without a peep.
         I’m read somewhere that when Punk’d has run its course, MTV will make Mr. Kutcher VP of Schadenfreude.

Dr. Atul Gawande, Health Care, and Costs: A Dim Prognosis

        Diane Rehm interviewed Dr. Atul Gawande, author of The Checklist Manifest, and he was interviewed on CSpan (links below). His advice and observations are sound and cogent, often simple but profound. His goal is to improve medical care and reduce health care costs.
        Three decades ago, Dr. Jonathan Miller, when asked what the most significant medical advancement were, he said covered, underground sewers. What about the polio vaccine? What about penicillin? Clean water and food preservation. What about x-rays? Understanding what newborns should and should not eat. And so with Dr. Gawande. His suggestions were much less high-tech and futuristic, than they were down to earth and practical.
        For me, the cynical optimist, when he talked about cost reductions, I knew he was right, but that his suggestions were only from the medical side, and could never match let alone cut out the cancer that is fraud. Diane Rehm said that he was the must-read author for the Obama administration’s efforts at healthcare reform. And so, the cancer remain inoperable. The prognosis is dim.

Diane Rehm, 01.06.10 interview with Dr. Atul Gawande: “The Checklist Manifesto.”
http://wamu.org/programs/dr/10/01/06.php#29280
CSpan (Video on Demand) “Interview with Dr. Atul Gawande”
http://www.c-span.org/Topics/Health-Care-Insurance-Reform-Legislation-Town-Hall.aspx

Obesity: The Next Frontier

         As the cynical optimist, I see obesity as the next frontier.
         For months, congressmen have explained that through “health behaviors,” we can make healthcare reform cost neutral.
         The Lewin Group report suggests that between $264 and $552 billion can be saved through behavioral modification of us, the users of healthcare. The report identifies 3 unhealthy behaviors: tobacco (35%), alcohol (26%), obesity (39%). Reducing the related health problems would unquestioningly be a blessing to millions of people and would reduce health costs, by as much as $1800 per man, woman, and child in the US per year.
         The first catch is obvious, we cannot get rid of tobacco, alcohol, and obesity. The savings of some 17% of health expenditures, could only be realized if tomorrow it all stopped. How? And if tobacco and alcohol use ended tomorrow, and all obese people shed 25-200 pounds over night, the 17% reduction in national health costs would not be realized in the short term.
         I have read articles mainstream that for the greater good, we could use our police and military. If Bush had troubles with phone calls . . . .
         The second problem has to do with an unfair burden. I know several people who have adult onset diabetes. They went on the Atkins diet and within days no longer needed insulin. Anecdotal, yes, but this could be the story of the year in terms of health care cost reduction. But the Atkins diet is expensive. It requires access to good grocery stores, and time to plan and cook.
         A frequent complaint about most inner cities, and about social, economic, and educational disparities between the poor and everyone else, is lack of money, lack of access to grocery stores . . . the lack of everything that would encourage or permit such a change of diet. A recent study reported on NPR, found that given $5 for food, the average poor person would buy a MacDonald’s hamburger and fries, than broccoli and lettuce. No surprise. Which is more filling?
         And yet congressmen have unashamedly spoken on camera about how we should not pay for the health problems of people who knowingly abuse themselves by smoking, drinking, and over eating. Many of the people most at risk of preventable health problems are the least able to prevent them. Such comments are insensitive, insulting, and display the arrogance and ignorance within the Washington beltway.
         The problem with “The first area, ‘unhealthy behavior’ is the largest in magnitude and is the subject of a large body of peer-reviewed research” (“Can We Reduce Health Care Spending?”)is that while it is true, as an argument for health care reform, it is irrelevant today and will be irrelevant tomorrow. (Lots of things are true but irrelevant in this way—the sun will someday burnout; the earth will be struck by a massive asteroid; since the dawn of life, climate has changed with or without man’s help.) It is an admirable goal; it is why we post warnings; it explains the often unexplainable nutritional information of packages of food; it is part of what should be taught in schools.
         Without understanding just how specious such arguments are: how seductive but false, we’ll reform health care to the benefit of few, including organized crime, and the detriment of the many.


See “Prohibition: A Cautionary Tale,” WSJ, 01.04.10, http://tinyurl.com/ybwzcd3
Lewin Group: “Can We Reduce Health Care Spending?” (10.26.09)
http://www.lewin.com/content/publications/LewinReport-CostDrivers.pdf

Fairness

        Abdulmutallab is being represented by attorney Miriam L.Siefer (Federal Defender Office: with 22 attorneys, four investigators and 11 support staff under the direction of Chief Defender Miriam L. Seifer, the Federal Defender office represents indigent clients in all federal courts for the Easter District of Michigan, including Detroit, Ann Arbor, Flint and Bay City.). I firmly believe that any defendant should have the best representation possible—and it should be aggressive and competent. Whether Abudulmutallab should have been held as an enemy combatant or indicted on criminal charges is not the thought here. (However, read WSJ: “The Ramzi Yousef Standard,” http://tinyurl.com/y8dhxul, has an interesting take on that question.) I wonder about fairness.
        After Hurricane Katrina, the problems with the public defender’s office in New Orleans made national news: vastly over worked attorneys, too many clients per attorney, minimal resources, etc. Despite the headlines, what happened? Not much; who cares? Even without a hurricane to exacerbate the problem, most cities don’t provide good public defenders . . . certainly not like the representation many of the Guantanamo Bay detainees and terrorists have gotten.
        I don’t begrudge Abdulmutallab’s defense, or anyone else’s, but I wonder if we shouldn’t express concern for the thousands of defendants who get lost in the system for want of good counsel.

Vanishing Fraud, Abuse, and Waste

         Did you hear this story?
         Yesterday NPR ran a story that opened, “Politicians in Washington may disagree about a lot in the health care overhaul, but pretty much everyone agrees that costs have to come down. . . . One proposal is for physicians to form what are called Accountable Care Organizations or ACOs” host Michele Norris.
         (A timely reminder: In the mid1970s, we embraced Health Management Organizations, or HMOs, as the way toward better patient care and reduced medical expenses. The explanation was that through proper management and associations, doctors could provide more and better care that would, because it aimed at being preventive, reduce the large expenses associated with disease and illness.)
         Without qualification, because his statement is a blanket assessment of all methods of health care cost containment, “nonpartisan” expert Randy Brown, of Mathematica, says, “If you’re going to cut costs, the spending pie has to shrink. And that means somebody is goin to make a lot less money. And there’s no discussion about who that’s going to be. . . . Who’s going to take that hit?”
         Mr. Brown is correct. Cutting costs means cutting costs (either services or reimbursement, or both). But nowhere in this 1400 word story are the words “fraud,” “abuse,” or “waste” used. If one looks at the “spending pie,” and sees some combination of fraud, abuse, and waste equals somewhere between 20% and 60% (see my posts on fraud and costs), why wouldn’t that be the piece of the pie that should take the hit?
         Where was NPR reporter Sarah Varney? Where were her editors? Where was host Michele Norris?
         The consummate professional, Sarah Varney ends on an upbeat note: "Congressional leaders and health system reformers, though, are optimistic there are enough incentives in the bills for physicians to at least give it a try."

Congress Proposes New Physician Payment System

NPR, All Things Considered, 01.04.10, "Congress Proposes New Physician Payment System" reporter Sarah Varney, host Michele Norris.
http://www.npr.org/templates/transcript/transcript.php?storyId=122217323

Prohibition: A Cautionary Tale

Prohibition: A Cautionary Tale, WSJ, 01.04.10, tells a story about prohibition that differs remarkably from the Carry A. Nation one we read about in school. It is a tale of consensus, between science and economics, and politicians and social activists. Does it apply to health care reform or climate change? I don't know, but it is worth thinking about when assessing major reforms in government policy.

Illegal Immigration and Healthcare Reform

        The cynical optimist, I have followed the health care “debate.” I believe that the goal of universal health care is something we should aspire too. Sprinkled throughout the sound-bites were questions and comments about whether or not the health care reforms would apply to illegal immigrants.
        President Obama said in his address to Congress, “the reforms I’m proposing would not apply to those who are here illegally.”
        You’ll remember the quote, because Representative Joe Wilson yelled, “Lie!” a moment later.
        Illegal immigration used to be a problem along the border with Mexico, but it has become a national issue, with most states feeling the pressures. But let’s take emotion out of the question.
        The House bill would cover illegal immigrants and would allows them to enroll in the public option. CNN reports that: “The Senate plan exempts illegal immigrants from the health coverage mandate, and prohibits illegal immigrants from participating in the insurance exchanges.” The NYT says that “The budget office estimates that the bill would provide coverage to 31 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.” According to most experts, to get a bicameral bill the House will basically adopt the Senate bill rather than subject it to the reconciliation process.
        Why should we care, illegals are here illegally. Humanitarian arguments from bleeding hearts will bleed the country dry. Illegals are simply not entitled to the same rights as US citizens. Period. Does this sound selfish? It isn’t, it’s stupid.
        Illegals should and must be covered. It is a public health matter. Many illegal immigrants are at higher risk than citizens for a range of diseases that could effect everyone. Schools routinely insist on vaccinations, and most places have laws that permit quarantining certain sick people, all to protect the community. For example, look at TB:
        Some 1 in 3 people worldwide are infected with TB; however, it isn’t until the TB bacteria become active (often due to reduced immunity—other illnesses not least HIV aids, poor diet, stress, age, etc.—that TB develops. Although most forms of TB can be treated, mismanagement of anti-tuberculosis drugs can result in MDR-TB (multidrug-resistant TB). Further mismanagement of drugs can result in XDR-TB, extensively drug-resistant TB). Not only is treatment of TB and public health issue of top priority, but if the treatment is mismanaged (illegal immigrants denied health care and at risk of being caught and deported either do not seek help or get it in the underground, where treatment mismanagement is a probability not a possibility), the likelihood of MDR-TB and XDR-TB developing increases. The resulting costs of treating an outbreak of drug resistant TB would dwarf the costs of providing safe—safe from deportation, safe from financial complications—and competent health care to illegals.
        HIV/AIDS, STDs, mumps, measles, chicken pox, meningitis, typhoid . . .
        If people at risk—at risk of disease and deportation—are denied health care either directly by being excluded or indirectly by being turned over to immigration, the community, you and me, are at risk.
        While immigration is a complex question, health care should not me.

References

CNNPolitics: “FAQs about health care reform” (December 21, 2009)
http://www.cnn.com/2009/POLITICS/12/21/health.care.faqs/index.html
The New York Times, “Senate Passes Health Care Overhaul on Party-Line Vote (December 24, 2009)
http://www.nytimes.com/2009/12/25/health/policy/25health.html