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Sunday, March 17, 2019

A Margalit must-read. She is always worth the wait.

How will we pay for health care?
"One glaring commonality between all Medicare for All proposals is that they are neither Medicare nor for all. Nobody is proposing to make Medicare available to all Americans, which is rather strange if you think about it. The battle cries of Medicare for All, the ubiquitous #Medicare4All hashtags, are pure propaganda."
Margalit Gur-Arie
Disquisition on Medicare for all

Medicare for all Americans is on the table now. Think about it. The not-in-our-lifetime utopian vision of every progressive liberal, complete with dancing rainbows and unicorns, is now within reach. Alternatively, the socialized medicine Trojan Horse that will turn these United States into a toilet-paper free Venezuela is now before Congress. There are over half a dozen bills in Congress, introduced by serious people with serious intentions, proposing some version of government administered universal health insurance in America.

Whichever ideological camp you’re in, it is a profound disgrace that in America today many people cannot afford basic medical care, as profound a disgrace as having veterans sleeping on sidewalks, as profound a disgrace as having one in five children living in poverty, as profound a disgrace as having Americans going to bed hungry. This was not supposed to happen in our “shining city upon a hill whose beacon light guides freedom-loving people everywhere”. It just wasn’t supposed to be this way in a country founded on the inalienable right to pursue happiness. Regardless of why it happened, whose fault it is, or how to “fix” it, America was not supposed to be this way. It just wasn’t.
"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."
Our union is as far removed from perfection as it was in the years leading to the events of April 12, 1861. Whether you obsess over political affairs or social issues, our justice system seems to be established on very shaky and uneven ground. Domestic tranquility must have been some sort of eighteenth century inside joke. Our welfare is anything but general, the much-admired blessings of liberty seem to accrue to the few who do very little to secure them, and things don’t look any better for our children and grandchildren. We can debate the fine legal points, the Articles and the Amendments, but there is no question in my mind that we are failing miserably in at least five out of the six stated goals of our Constitution.

What do all these polemics have to do with “fixing” health care, you may ask. Health care is not a standalone issue. It cannot be debated, let alone “fixed”, in a political, historical and moral vacuum. Our health care woes are one manifestation of a much larger systemic failure of American society. The “concentration of power” in fewer and fewer hands is a calamity that was foreseen by a bitter, desperate man as he lay dying, and promptly ignored by many generations since, including our own. John C. Calhoun stared into his self-inflicted perdition and we stared back at him from the flames.

“At this stage, principles and policy would lose all influence in the elections; and cunning, falsehood, deception, slander, fraud, and gross appeals to the appetites of the lowest and most worthless portions of the community, would take the place of sound reason and wise debate. After these have thoroughly debased and corrupted the community, and all the arts and devices of party have been exhausted, the government would vibrate between the two factions (for such will parties have become) at each successive election … These vibrations would continue until confusion, corruption, disorder, and anarchy, would lead to an appeal to force”.
The tragedy at this point is that we, as an “E Pluribus Unum”, cannot rationally analyze, let alone agree on, either the nature or the cause for our failure to thrive, and as long as that remains the case, we will not be able to “fix” health care, or anything else for that matter. But perhaps there is still some room for discussion at the edges of Armageddon…


One glaring commonality between all Medicare for All proposals is that they are neither Medicare nor for all. Nobody is proposing to make Medicare available to all Americans, which is rather strange if you think about it. The battle cries of Medicare for All, the ubiquitous #Medicare4All hashtags, are pure propaganda. The proposed plans range from letting a few more poor people buy into Medicaid (not Medicare) to the Cadillac plans of Bernie Sanders, John Conyers and the brand new bill introduced by Pramila Jayapal, including prescription drugs, dental, vision and long-term care, with no premiums, no deductibles and no copays, given free to all citizens, regardless of financial status. In addition to the official bills introduced in Congress, there are lengthy proposals from policy groups touting their superiority and/or soundness compared to all other Medicare for All arrangements. The opposing faction is peculiarly devoid of grand ideas.

The problem with grand ideas though is that, by definition, they must rest on a multitude of assumptions and some assumptions are better than others. You can assume for example, that breaking an egg on a hot surface will get you breakfast. It’s been done trillions of times and therefore one can say that this is a pretty safe assumption, maybe even a fact. You can then be tempted to assume that putting a hot rod through an egg will yield the same results, since the egg is broken and in contact with a hot surface. Now obviously, the hot rod is just a first step, and after extensive tinkering you have a brand-new type of frying pan with an electronic egg breaker embedded in the middle. It costs ten times as much as the frying pan you trashed and it’s only good for eggs, but it does break the eggs, something you never knew was a problem. Oh, and it only makes scrambled eggs, so you save time on complex cognitive tasks.

Obamacare sounded pretty good before it morphed into a pugilistic contest between bureaucracies. Berniecare, sounds pretty good too. I mean what’s there not to like? All health care is free, and we don’t have to pay more than we are paying now for health care. We may even need to pay less, in aggregate. And the payments will be more justly distributed across the population. And every single person, no matter how privileged, will have the same exact glorious health care. Heck I’ve been arguing for a system like that myself. For those interested, I am also arguing for peace on Earth, prosperity, health and happiness to you and your loved ones.


Despite what hot-headed reformers are trying to tell you, American health care is not worse or scarcer than it is in other developed nations. It is better and more plentiful. The sole problem with health care in this country is that it is not affordable for most Americans. What does “not affordable” mean though? Does it mean that health care prices are too high? Does it mean that we don’t choose our care wisely? Or does it mean that people are too poor? The answer is of course yes and no on all counts. Furthermore, “fixing” any one of the above problems will likely exacerbate the others. Nobody knew health care could be so complicated, obviously, but it is.

Real GDP per household (2.2 persons) stands around $120,000. Median income per household is half as much. We currently spend on average $24,000 per household per year on health care. If every household got a fairer share of GDP, perhaps health care would be less “not affordable”, but even in the most egalitarian scenario, health care would still be a huge financial burden. Medicare for All seeks to shift the health care burden from individual households to the nation. When the nation is faced with burdens of this type, it either goes into debt or cuts budgets. Debt of this magnitude spells bankruptcy down the road, and budget cutting translates into Rationing. Pick your poison.

But maybe we can ration wisely. Maybe we can replace volume with value. Maybe. Either way, when volumes for one service line go down, another service line seems to miraculously become more popular. If we force all service lines to cut down on volume, prices per unit will inexplicably start soaring to keep the topline steady. Then how about combining nationalized health care financing with price controls, as all Medicare for All bills are suggesting? After all, this is working well for Medicare, no? Yes, it is working for Medicare, because hospitals and doctors can charge the difference to private insurers. If there are no private insurers, hospitals and doctors will need to cut their costs. How do most firms cut costs? By letting employees go and/or reducing their salaries.


Over 16 million Americans are currently working in the health care industry. If you want to cut that mythical 30% that is presumably waste, I can guarantee in writing that before one wasted piece of paper is eliminated, 6 million people will be out of work. In all fairness, a couple of the more radical Medicare for All proposals include income replacement and “retraining” for a few hundred thousand health insurance industry workers envisioned to be displaced, which amounts to a few drops in the disaster bucket. Such massive unemployment will wipe out entire communities, not to mention the stock market, pensions, retirement savings, tax revenues, and safety net budgets. It may also deal the long overdue coup de grâce to the struggling American middle class.

In a service economy, which is what all progressive minds are glorifying now, if you cut spending on services, you shrink the economy, with all attendant consequences. And no, having more money in your pocket to buy more crap from China does not improve the situation one bit. The supreme irony is that when we add the resultant financial aid for those who will lose their health care jobs, and the many more affected by the ripples of our trimmer health care expenses, we will end up precisely where we started, if we’re lucky, which is not very likely. The point here is not to bash Medicare for All plans. The point is to highlight the magnitude of what is discussed. By comparison to Medicare for All bills, Obamacare was just minor tinkering, and look where it got us.

There are only four countries in the world, including our own, that have a GDP greater than our annual health care expenditure. Restructuring health care in America is like restructuring the entire economy of, say, France or the United Kingdom, and then some. The United States is the third most populous country after China and India and has the greatest influx of new immigrants each year. Pointing to how great the Singapore model is working, or how quickly Taiwan transformed its health care system is, forgive me, laughable. If we learn one thing from the Obamacare escapade, it should be that in health care, nothing, absolutely nothing, scales as predicted on paper.

Finally, as hard as it may be for you these days, please remember that smart people, with yards of skin in this game, may disagree with your preferred solution, not because they are greedy, not because they hate poor people, not because they can’t do the math, not because they are evil, and not because they are deplorable or crazed Marxists. So, please, get off your soapbox (I certainly did), look reality in the face without fear or prejudice, start listening to ideas that make you uncomfortable, and understand that pontificating about Medicare for All is as useful as bloviating about free-markets.
"The not-in-our-lifetime utopian vision of every progressive liberal, complete with dancing rainbows and unicorns, is now within reach. Alternatively, the socialized medicine Trojan Horse that will turn these United States into a toilet-paper free Venezuela is now before Congress. There are over half a dozen bills in Congress, introduced by serious people with serious intentions, proposing some version of government administered universal health insurance in America."
She didn't post for about a year. After a while I quit checking her blog. My Bad. See "The Bonfires of Health Care." Bookmark her blog.
"By comparison to Medicare for All bills, Obamacare was just minor tinkering, and look where it got us."

Cross-posted with permission.

Citing Margalit in 2015: "Are structured data the enemy of health care quality?"

More to come...

Friday, March 15, 2019

Science in my iPhone inbox

"That's Debatable"? Recall my post on "Selling Science"? See also "Selling pseudoscience to the gullible." Additionally, there are my "Anthropocene Denial" posts.


My latest hardcopy arrived.


The war on ‘prediabetes’ could be a boon for pharma—but is it good medicine?
A questionable condition

Sweeping diagnosis In 2004 and 2010, the American Diabetes Association (ADA) expanded the blood sugar range it considers a sign of prediabetes, creating tens of millions of potential patients in the United States. The U.S. Centers for Disease Control and Prevention joined ADA in raising the alarm, portraying the condition as a first step toward frank diabetes.

Little risk Prediabetes does little or no harm on its own, and fewer than 2% of prediabetics in the ADA range progress to diabetes each year. Many studies suggest that for most people the usual treatments for prediabetes, diet and exercise, do little to further reduce the risk of diabetes.

Strong medicine Industry is developing at least 10 classes of drugs targeted to prediabetes. ADA also lists existing diabetes and weight loss drugs as options for people with prediabetes, and doctors are prescribing them “off label.” Many of those drugs can have serious side effects.

Money trails ADA and some of its physician advisers who have discussed drug treatments for prediabetes receive extensive financial support from pharmaceutical companies. The organization and its advisers say the payments have not affected their recommendations.

Again, you have to read Seamus O'Mahony's "Can Medicine Be Cured?" (specifically chapter 6, "How to invent a disease.") Pay particular attention to his trenchant observations on the depressingly widespread misapprehension of clinical "risk" (some of it willful). How much money are we wasting inventing and "treating" specious "diseases?" It's not a trivial question.
Q: "What's the definition of a 'well person'?"
A: "a patient who has not been adequately worked up."
Iconoclastic psychiatrist Thomas Szasz once jibed irascibly about the ultimate medical px, the "humanectomy."

More to come...

Tuesday, March 12, 2019

Happy 30th Birthday, World Wide Web

[Per TechCrunch] The inventor of the World Wide Web, Sir Tim Berners-Lee, has published an open letter to mark the 30th anniversary of the day — March 12, 1989 — when he submitted his original proposal for an information management system that went on to underpin the birth of online services…
"Today, 30 years on from my original proposal for an information management system, half the world is online. It’s a moment to celebrate how far we’ve come, but also an opportunity to reflect on how far we have yet to go.

The web has become a public square, a library, a doctor’s office, a shop, a school, a design studio, an office, a cinema, a bank, and so much more. Of course with every new feature, every new website, the divide between those who are online and those who are not increases, making it all the more imperative to make the web available for everyone…"
Worth your time, all of it. BTW, the "internet" predates the "world wide web" by about another 30 years.

More to come...

Friday, March 8, 2019

Health care for the homeless

More on that logo art in a moment. Love it.

First, as part of my customary early morning online news review workflow, I ran across this at The Atlantic:
Medieval Diseases Are Infecting California’s Homeless
Typhus, tuberculosis, and other illnesses are spreading quickly through camps and shelters.

…“Our homeless crisis is increasingly becoming a public-health crisis,” California Governor Gavin Newsom said in his State of the State speech in February, citing outbreaks of hepatitis A in San Diego County, syphilis in Sonoma County, and typhus in Los Angeles County.
“Typhus,” he said. “A medieval disease. In California. In 2019.”

The diseases have flared as the nation’s homeless population has grown in the past two years: About 553,000 people were homeless at the end of 2018, and nearly one-quarter of homeless people live in California.

The diseases spread quickly and widely among people living outside or in shelters, helped along by sidewalks contaminated with human feces, crowded living conditions, weakened immune systems, and limited access to health care.

“The hygiene situation is just horrendous” for people living on the streets, says Glenn Lopez, a physician with St. John’s Well Child & Family Center, who treats homeless patients in Los Angeles County. “It becomes just like a Third World environment, where their human feces contaminate the areas where they are eating and sleeping.”

Those infectious diseases are not limited to homeless populations, Lopez warns: “Even someone who believes they are protected from these infections [is] not.”…
Shit. Literally and metaphorically.

I have never been homeless (came close once, in 1967, in the wake of an extended period of illness). I can't imagine.

More recently, before my younger (now late) daughter was dx'd with Stage IV pancreatic cancer, I was a weekly volunteer with the San Francisco "" senior dog rescue center. The nation's most highly overeducated dog rescue shelter laundromat attendant. My parents never let us have pets. I've been a stray magnet ever since. "Senior dog rescue?" I'm there.

The seven or so blocks between the 16th and Mission BART station and Muttville burst at the sidewalk / curbside seams with the shopping carts, blue tarps, tents, and raggedy deitrus of the homeless.

Nasty. Sad. Pungent odors in the air. Watch where you step.

I try to imagine. And I am so grateful for our relative good fortune. As I write, Cheryl and I are doing the final paperwork to close on our 3rd (and likely final) home purchase, in Baltimore, to be close to our son, who happily lives there with his (Baltimore native and state environmental engineer) Eileen in Pigtown.

He has now lost both of his elder sisters to cancer and is the last kid standing. We have to be nearby.

In light of our lovely over-the-ingoing-budget-cap price tag on this place we settled upon, I feel a coming-out-of-retirement stint looming in my future (Cheryl has certainly earned her slack). With my new aortic valve firmly pounding away, I'm loaded for Bear. (There's always Busking, LOL.)

So, just out of curiosity I started putzing around on Talk about a target-rich environment in Baltimore-DC area: "writer," "analyst," "policy analyst," "ethicist," "ASQ," "quality engineer,"... tons.

"Lean health care?" Yes!

Which led me to "Health Care for the Homeless" of Baltimore (and Maryland more broadly). They're soliciting for a (Lean) "Performance Improvement Specialist."

We need to talk. These folks are doing important work.

to wit, apropos of the above Atlantic article, see their page "Homelessness makes you sick."


Their national affiliation:

Wow. Just wow.

Below, is this cool, or what?

Again, The Atlantic:
"People living on the streets or in homeless shelters are vulnerable to such ['medieval' disease] outbreaks because their weakened immune systems are worsened by stress, malnutrition, and sleep deprivation. Many also have mental illness and substance-abuse disorders, which can make it harder for them to stay healthy or get health care."

In 2012 while covering one of my many conferences I met and immediately befriended techie internal med physician Jan "Doc" Gurley, a well-known authority on the medical plights of the homeless. She'd long been with the San Francisco Department of Public Health.

A couple of years ago, she just seemed to fall off the planet. No one among my Health 2.0 crowd knows what has become of her. The last time we spoke she told me of her new effort to address the medical plights of parolees (who overwhelmingly become homeless--if not reincarcerated--in short order). I told her I'd love to help with that. She told me she was taking CCTV classes at Berkeley to learn how to do video documentary episodes.

Then, "poof." Vanished.

Disconcerting. Anybody?


Amazon's "AI" has certainly "got my number."

I expect this book will cohere nicely with my prior post "Can medicine be cured?"

"Polypharmacy?" "Overdo$ed America?"

More to come...

Tuesday, March 5, 2019

Can medicine be cured? Some views from across the Pond

If you're concerned about where things are headed, this is a compelling read.

At once witty and sobering. Has me re-thinking a few of my own opinions, even as it reinforces a number of others.

Welcome Page
About Can Medicine Be Cured?
Chapter 1. ‘People Live So Long Now’
Chapter 2. The Greatest Breakthrough since Lunchtime
Chapter 3. Fifty Golden Years
Chapter 4. Big Bad Science
Chapter 5. The Medical Misinformation Mess
Chapter 6. How to Invent a Disease
Chapter 7. ‘Stop the Awareness Now’
Chapter 8. The Never-Ending War on Cancer
Chapter 9. Consumerism, the NHS and the ‘Mature Civilization’
Chapter 10. Quantified, Digitized and for Sale
Chapter 11. The Anti-Harlots
Chapter 12. The McNamara Fallacy
Chapter 13. The Mendacity of Empathy
Chapter 14. The Mirage of Progress
From the Amazon blub:
A fierce, honest, elegant and often hilarious debunking of the great fallacies that drive modern medicine.

'A deeply fascinating and rousing book' Mail on Sunday.

'What makes this book a delightful, if unsettling read, is not just O'Mahony's scholarly and witty prose, but also his brutal honesty' The Times.

Seamus O'Mahony writes about the illusion of progress, the notion that more and more diseases can be 'conquered' ad infinitum. He punctures the idiocy of consumerism, the idea that healthcare can be endlessly adapted to the wishes of individuals.

He excoriates the claims of Big Science, the spending of vast sums on research follies like the Human Genome Project. And he highlights one of the most dangerous errors of industrialized medicine: an over-reliance on metrics, and a neglect of things that can't easily be measured, like compassion.
Indeed. to wit,
14: The Mirage of Progress

Progress – rather than compassion – is the core belief of the medical–industrial complex. The philosopher John Gray wrote that ‘questioning the idea of progress at the start of the twenty-first century is a bit like casting doubt on the existence of the Deity in Victorian times’. The belief in progress reflects the power of science to change our lives. Over the last one hundred years, longevity has increased dramatically, and immunization has reduced or eradicated diseases that used to kill millions of people. The benefits of science seem so self-evident that only a fool or a madman would question it, or the idea of progress. But science, which gave us all these unalloyed benefits, also gave us nuclear bombs and napalm; it is entirely possible that technology may render the world uninhabitable for humans. Then, progress will end. John Gray has never denied the reality of scientific progress, or its benefits, but has consistently argued that although scientific knowledge increases from generation to generation, gains in ethics and politics are more easily lost: ‘They have to be learned afresh with each new generation.’…
[Kindle edition location 2696]
One nice attribute of this book is that you need not read it in chapter order. My path thus far has been that of introductory material, Chapter 1, Epilogue, 14, 13, 12, 10, 5, 2, and 3 (some of it driven by my frequent cut-to-the-chase keyword/phrase searching).

Seamus is not a big fan of Eric Topol, nor Bertalan Mesko, btw.
Eric Topol views doctors like me as the chief professional obstacle to digital health: ‘Half of American physicians are over age fifty-five, far removed from digital native status (under age 30).’ Topol (sixty-four), with his 2.8 million Instagram followers, is the disco-dancing dad of digital health. The self-styled ‘medical futurist’, the Hungarian Bertalan Meskó, is Topol’s ideal digital native doctor: ‘Since the age of fourteen, I have been logging details of my life every single day. It means not one day is missing from my digital diary which now consists of over 6,600 days with data.’ Like Topol, he argues that ‘the ivory tower of medicine is no more’, and that ‘patients, now called e-patients or empowered patients, who are ready to hack and disrupt healthcare need guidance.’... [Kindle location 1962]
Yikes. Ahhh... "Futurists."

Update: Below, I am reminded of this book, from a 2012 post:

"Slow Medicine"
See also my recent post "Overcharged?"


On my way to OAK airport recently to pick Cheryl up, I heard a KQED Forum segment whose guest was Benjamin Dreyer, Copy Chief at Random House. They discussed his new book:

I bought it. I'm a pretty fair writer, but this book will help me improve significantly. Very witty and informative. It's giving me some recurrent SMH "Edwin Newman Moments."

They discussed the nexus between "critical thinking" (which I've taught) and clear oral and written prose. Yep. Would that I take my own advice more often.

"Most of the diseases that kill us now are caused by, and associated with, ageing. We just wear out. Dementia, heart disease, stroke and cancer kill us now, not smallpox and Spanish flu. Medicine can still pull off spectacular rescues of mortally sick young people, but these triumphs are notable for their relative rarity. The other flaw in the Big Science theory is that a great deal of what is laid at medicine’s door to fix has nothing to do with malfunction of the machine; much of the work of GPs is helping people cope not with disease but with living problems, or ‘shit life syndrome’, as some call it…

…Research, unfortunately, will never help most of what ails mankind: growing old and dying. These are eternal human verities, but we expect medicine to somehow solve this riddle. Epidemiologists and public health doctors would argue that medicine now contributes little to health in developed countries, and that poverty, lack of education and deprivation are now the main drivers of poor health. This is almost certainly true. Although vaccination and antibiotics contributed significantly to the increase in human longevity in the mid-twentieth century, medical care now has little direct influence on the health of a population, accounting for only about 10 per cent of variation. Furthermore, some have argued persuasively that if we were to simply apply evenly and logically what research has already proven, health care would be transformed..."
[Kindle locations 532 & 561]
I'd better leave it that, in terms of "Fair Use." You should buy this book. Seamus' book is a veritable abattoir of clinical Sacred Cow Herd demise.

BTW, Dr. O'Mahony wrote an earlier book that is not available electronically.


Jus' sayin'.

More to come...