Map of life expectancy at birth from Global Education Project.

Tuesday, November 30, 2004

You don't have to take my word for it . . .

"Profit driven drug companies are not developing enough drugs and vaccines to address two major threats to public health -- influenza and resistance to antibacterial drugs -- that could kill millions of people across the globe, the World Health Organization says in a new report."

You can read about it in the British Medical Journal, here.

BMJ is free on-line only until the end of December, when you'll need a subscription. That's too bad, because in my opinion, it's the world's best medical journal, and the one of most interest to the non-M.D. public. It doesn't just focus on biomedical science, it's about the practice of medicine -- in its biological, social, political, and ethical dimensions -- and about public health. Oh well.

Monday, November 29, 2004

Politics and Public Health: First Installment

Public health is in large part a public good. It is grossly undersupplied by the market between individual sellers and buyers. The public health paradigm, in contrast to the medical paradigm, encourages us to look at health, illness and human welfare from a social and political perspective, rather than the perspective of an individual consumer or supplier of medical services.

There are innumerable ways in which the public health paradigm reveals the profoundly false assumptions at the heart of free market fundamentalism. One area which is getting a lot of attention lately is infectious disease. The shortage of flu vaccine this winter has made a lot of people take notice of the threat posed by emerging infections, such as new strains of the flu virus that may jump the species barrier from birds or swine to humans and cause a new pandemic of dangerous influenza. Individual consumers will never create sufficient demand for flu vaccine to prevent an epidemic, and manufacturers would never make enough if they were only responding to consumer demand. This is because individual consumers' judgments about this may be misinformed, they may not be able to pay for it, and their own calculations are unlikely to take into account the public benefit derived from so-called herd immunity. (The term is used with people. In a nutshell, if I'm vaccinated, I won't infect you, which presumably makes you happy.) The Bush Administration screwed up (as it usually does) by failing to assure an adequate supply of flu vaccine.

But there are other serious threats to humanity posed by market driven behavior. One of the most important is the practice of feeding thousands of tons of antibiotics to livestock, so that "farmers" can keep them in crowded, unsanitary conditions. This creates drug resistant strains of bacteria. The mechanism of course, is evolution by mutation and natural selection, which the majority of Americans say they don't believe in. The consequence, the end of the antibiotic era, will be an almost unimaginable catastrophe for humanity. But the immense political power of the corporate meat industry and the pharmaceutical industry have so far prevented governments from ending this depraved practice.

How can we organize effectively around such threats to our health and welfare, that don't come from obviously scary terrorists, but from our own collective foolishness, the greed of wealthy and powerful corporate executives and shareholders, and the dangerous delusions of our political leaders?

Event of interest

For those of you in the New England area, it's still not too late to register for Everybody Counts: A State Policy Agenda to Eliminate Health Disparities, an all-day symposium at Tufts Medical School on Dec. 6. The symposium is presented by the New England Coalition for Health Equity (NECHE), with support from the U.S. Office of Minority Health. Registration is $30, which includes lunch and continental breakfast.

Since we can't expect much from federal policy in the coming years, the states are the arena where action in this area will have to happen. The symposium builds on a report done for the Commonwealth Fund by McDonough, et al. You can download the report for free at McDonough Report . While you're there, browse the other Commonwealth Fund publications, they have a lot of great material.

To obtain a registration form, send an e-mail to But hurry! (That's Latin American Health Institute, which is NECHE's research arm.)

Wednesday, November 24, 2004

Strange doings in the cradle of liberty

The governor of Massachusetts -- the only prominent elected official named after a piece of baseball equipment -- has proposed a health care "reform" plan, which he claims will extend coverage to more people. Mitt Romney's reform consists of allowing insurers to sell plans with very limited benefits, such as no mental health or alcoholism treatment, which would be cheaper than standard plans; and some yet to be decided incentives or prods to get employers to offer coverage to more of their employees. Two ideas he has floated are raising the minimum wage for employers who don't provide health insurance, and making them put decals in their windows. A scarlet "U" I suppose, for Uninsured.

It turns out he had considered a proposal earlier which would have had the state providing about $800 million in subsidies for low-wage workers, and requiring people to get coverage. But, his aide tells us, "This is America, life, liberty, and happiness. The governor decided to see what could be done with softer mandates. Impinging on someone's liberty is not the first thing you should go to."

So it turns out that all those people in Canada, the UK, Ireland, France, Germany, Sweden, Norway, Italy, Switzerland, Belgium, Spain, the Netherlands, Norway, Finland, Denmark, Greece, Monaco, Luxembourg and the rest of the members of the Organization for Econonmic Cooperation and Development don't enjoy life, liberty or happiness. They once were free, but now they are enslaved by having health insurance.

Not to worry though. In Massachusetts, the threat of having to put a decal in the window will get everybody covered without having to become communist slaves.

Guess what? Mitt insists that the state can't afford to spend one more penny on subsidizing health care for all those shiftless landscapers and burger flippers. It would destroy our liberty to make people pay taxes to do something so socialistic. Gee, I wonder what happens nowadays when those good-for-nothing house painters get sick and show up in the ER. It's a miracle! They get health care, but nobody has to pay for it.

Tuesday, November 23, 2004

The Strange Ways of Insurance

Okay, so we've figured out that there are important reasons why we don't pay as we go for medical services, but rather buy something called Health Insurance. Most insurance is called casualty insurance -- we pay a premium, and we hope to get nothing for it. But if our house burns down or our car crashes or our spouse dies, the insurance company pays off. The insurance company does not, generally, in the meantime pay for a sprinkler system, driving lessons, or cancer surgery for our spouses. Health insurance as most of us know it today is different: it does pay for some routine expenses including regular physician visits when we don't even have a complaint, and medications such as statins and antihypertensives that are intended to prevent illness in people who aren't yet evidnetly sick.

So most health insurance is not casualty insurance. There is an increasingly rare version that is, major medical insurance that only pays if we have very large bills. And GW Bush wants to encourage more of us to buy that kind of insurance, and pay our regular, smaller bills on our own with the benefit of tax advantaged savings. What's wrong with that?

In order to understand what's wrong with it, we need to think about how insurance companies make money and what strategies they can use to make the most money on health insurance plans. One way you can try to make more money is to charge more for your product, or provide fewer services, but employers -- who do most of the buying -- will obviously try to get the most for their money, so it's tough to compete that way. What you can do, however, is try to sell your product selectively to cover people who are less likely to have expensive medical problems. You could do this in various ways.

You could charge more to employers (or other groups such as unions or voluntary associations, or individuals if they're buying) whose plan members are more likely to cost you money. For example, employers with many older workers, or just employers who cost you more last year. This is called "risk rating."

You could try to market your plan selectively to buyers who will cost you less. You could just refuse to sell to some buyers, or not return their phone calls, or keep the lowest possible profile in certain neighborhoods.

However you do it, if you succeed you can charge a bit less than the competition and attract more buyers who will enroll relatively healthy plan members. That leaves your competitors with customers who are going to be even more expensive for them, so they'll have to raise their prices. They're going to compete for the least costly segment of those remaining, more expensive potential customers, and as they cream them off, the remaining buyers will be the most expensive to cover. Nobody will want their business, and they won't be able to buy insurance for their employees, or it will cost exorbitantly. This phenomenon has a cute name: The Death Spiral.

So, since the purpose of insurance, after all, is to spread risk, this must be prevented by regulation. The cleanest way to prevent the death spiral is by requiring what's called community rating: premiums must be based on the average cost of a resident of the community, and all comers must be able to buy into the plan.

This post is too long as it is. But soon, very soon, I promise, we'll get to current events and actual, pressing political issues.

Comments, questions, and thought experiments based on all this are welcomed.

Monday, November 22, 2004


Apparently a few people have tried to post comments and found it difficult. I'm just using the Comment function provided by Blogger, and it is a bit more cumbersome than what some of you who are used to Haloscan or Scoop may be familiar with.

Yes, anybody can comment. If you click on the "X comments" line at the bottom of the post, you can see the comments. There is a "post a comment" link there.

If you don't have a blogspot account, you can still post, but it won't show a user name. If you want to have an identity, you do need to register an account, which you can do right from there -- but that doesn't mean you have to set up your own blog.

This is beneficial because it means identities can't be stolen. Please try it folks, your comments are essential to this site!

And if anybody knows of a better commenting system, and how I can attach it to this blog, please let me know -- Blogger doesn't give out that information.

Basic Assumptions Examined, Part I: Medicine and the Mythology of the Market

In a post coming soon, we'll examine the medical paradigm of health vs. the public health paradigm. But let's start with economics.

Some people say (as they put it on Fox News) that the problem with health care in the U.S. is that we don't allow the Free Market(tm) to work its magic. If government would just get itself off the back of the medical industry, the Free Market(tm) would control costs and allocate resources efficiently.

The idea that the so-called Free Market(tm) can do this depends on several assumptions which are seldom true in any context, but are particularly far from true in the case of medical services. These include (and this is just a telegraphic discussion):

No externalities: All of the costs and benefits to society of the transactions are captured in the exchange between buyers and sellers. Obviously not true in the case of medicine: medical care stops infectious diseases from spreading, society loses the productivity of sick people and their dependents lose support, it's unpleasant to watch people dying on the sidewalk, etc.

Perfect information: Sellers and particularly buyers have all the info they need to purchase in their best interest. But in medicine, what you are buying is expertise. You don't know what's wrong with you or what to do about it, that's why you go to the doctor. As consumers, we have little or no ability to compare the quality of various providers, even if we could shop based on price. We have to depend on licensing requirements to give us at least some assurance that our providers are competent.

Consumers create demand: Not in medicine: the doctor tells us what we need. In medicine, once we make the initial decision to go through the door, demand is largely induced by providers. Okay, not in special cases like some cosmetic surgery or sales of Viagra, but generally. Think about the consequences of that, absent some sort of non-market intervention.

Willing sellers, willing buyers: This concept is philosophically tricky -- in some sense, everything we do is a result of free will. Even if somebody's holding a gun to your head, you could choose the alternative of being shot. But common sense tells us that medical services are often necessities -- we'll die or suffer horribly if we don't get them. And we might have to watch our friends, neighbors and loved ones suffer or die unnecessarily. Anyway, we could go into the ER unconscious or demented, unable to make decisions for ourselves at all!

Justice: Actually, the theory of the Free Market (tm) doesn't say anything about justice -- the economists' definition of "efficiency" has nothing to do with what is good or right, although they usually forget that. But regardless of what we do or do not do to keep ourselves healthy, a lot of illness is not our own fault. People consume medical services not out of choice, but because they've been hit by a bus or poisoned by pollution or infected with HIV by their philandering husband, or for whatever reason, and we can't predict when, where or how much medical services we will need.

And that's why we universally think it proper, just and reasonable that medical services be paid for by insurance -- that the financial burden be shared so we can all get what we need, when we need, for the sake of ourselves, each other, and the public health. If people don't agree, let's hear why!

There are additional basic assumptions of market theory that are violated in the case of medical services, but that's enough for now. People may wish to add more in comments, or discuss these further.

Next up: How insurance works, and some of the oddities of insurance markets.

What this blog is about

As has been said by a million people, a million times each, the United States is the only wealthy country on earth that does not provide universal health care to all its people. We spend about twice as much per person on medical services as the typical industrialized country, but we obviously get less for it -- among the wealth countries, the U.S. has some of the worst indicators of population health. We also have substantial disparities in health among ethnic groups. And, as everywhere, but to a greater degree than most countries, we have large inequalities in health and life expectancy among rich and poor. (We also have large and growing inequalities in income in the first place.)

Here, we're going to cover the latest news in public health and health care policy. But we're also going to talk about the fundamental issues that are often misunderstood by the average person and misrepresented by the politicians and lobbyists. Health care policy in this country is controlled by pharmaceutical manufacturers, hospital chains, and insurance companies. The American Medical Association used to be extremely powerful but it's lost a lot of influence in Washington over the years and it's also lost the support of many physicians, although it still does have some influence.

My perspective is that of a medical and public health sociologist. I know a little about medical economics, ethics, epidemiology, and politics. But I sure don't know everything. So substantive comment, and suggestions for topics, guests, references and links are encouraged.

My next post will be about those fundamental issues. For now, I invite comment about what subjects others would like to discuss here, and also I invite people who may be interested in this project to introduce themselves.