Category Archives: healthcare

Republican Healthcare – or Lack Thereof

About the only way I know to lower the cost of health insurance for those willing and able to buy it is to let people die on the curb in front of the hospital. Yep, give up your humanity and you too can save on health insurance.

If you opt for humanity and take that person into the hospital, it will cost you, and likely cost you a lot. That person without health insurance will incur costs which the hospital must absorb. The only way a hospital to stay in business if they accept indigent care is to charge paying customers, usually insurers, more to offset the unreimbursed care.

If we are to be humane and provide care for the free riders, is there a better way? If we wait for high blood pressure to cause a heart attack, treatment of that one condition can cost hundreds of thousands to millions of dollars. Alternately, drugs to manage the high blood pressure can cost pennies a day – Penny wise, pound foolish.

The reason the republicans struggle to produce a health plan to replace the ACA, even though they have had several years, is there is no plan that actually works if it doesn’t include everybody. There are two ways to do that – make sure everybody has access to affordable care through private insurers or go to a less costly single payer universal healthcare system like just about every other country in the world.

Government managed systems work well. We currently spend much more per capita for healthcare and with poorer outcomes. There are over 40 countries with lower infant mortality rates, greater life expectancies and lower costs.

The new president said while campaigning that his replacement healthcare plan would cover everybody and cost less. As to the costs we won’t know until after the Congressional Budget Office (CBO) scores the new bill. I can predict immediately however that it won’t cover everybody because the first line of conservative talking points is repealing the mandate to purchase insurance, guaranteeing free riders. Another promise is to lower ACA spending, which means that subsidies for the poor will be lowered or eliminated, further reducing the pool of insured.

For those middle income folks there may be cheaper insurance policies available, but only because substandard policies will again become available. Lower costs mean lower coverage. The ACA policies required a minimum standard of coverage which included preventive care. Cheap policies will be available which only cover catastrophic costs. Ironically, avoiding the costs of preventive care leads to greater catastrophic costs.

The real winners with the proposed healthcare law are the rich, no surprise there. Taxes will go down while at the same time subsides not previously available to the rich will go up.

Conservatives continue to try to view healthcare as subject to the same market forces as buying unessential commodities, but it just doesn’t work that way. We are alone in the world with our failure to make that recognition.

Zika in Arkansas

Currently there are several confirmed cases of the Zika virus in Arkansas. The cases all involve individuals who contracted the disease while traveling in areas where the disease is prevalent, usually Latin American or Caribbean locales.

The virus can be carried by two related mosquitoes, Aedes aegypti and A. albopictus. Transmission of the disease occurs when a mosquito bites an infected individual and picks up the virus in the process. Then when that mosquito bites another uninfected person and inoculates them with the virus. Of the two mosquitoes, A. ablopictus is the lesser threat as it feeds on animals in addition to humans. On the other hand A. aegypti prefers humans and is therefore more likely to transmit the virus among humans.

Once contracted, an infected individual is capable of spreading the disease for several months, both via mosquito bites and also sexual contact. The virus has been isolated in the semen of infected men up to two months after acquiring the disease.

The range of A aegypti includes almost all of Arkansas, only the northeast corner near the boot heel of Missouri being outside the range. A aegypti is particularly problematic because it breeds rapidly and in amazingly small amounts of water. Eggs laid in a bottle cap’s worth of water mature to adults in as short as a weeks time. Also troublesome is that A aegypti is a daytime feeder when humans are more likely to be out and about.

The Zika virus causes a range of symptoms. A minor set of symptoms include rash, mild fever, joint pain and headache which may persist from a couple of days to a week or so. What has gotten the most attention of course is the teratogenic effect. If a pregnant woman gets infected, the virus can pass to the fetus and cause a condition know as microcephaly, an abnormally small head. The condition is severe and can result in seriously impaired brain function and premature death and.

Avoiding travel to the Caribbean or Latin America is no longer enough to be safe here in Arkansas. Because we have infected people and the transmitting mosquitoes, we are all at risk. So what is to be done? Obviously don’t get bitten by an infected mosquito, but that is easier said than done. The first line of defense would be to use an effective repellent. The gold standard, the agent which all others are compared to is DEET. Nothing is as effective nor lasts as long per application. The science is clear that all others have a weaker effect and don’t last as long.

Broad scale spraying of insecticides has been shown to reduce transmission rates, but in so doing kills off not only the target mosquitoes, but also any and all other insects. Many of these are not only desirable but a necessary part of human life. The FDA has recently approved an interesting strategy involving the use of gene modification to create a mosquito whose offspring can’t reproduce.

Most promising is an effective vaccine to prevent infection. This will have the least impact on the biosphere. No deaths on non-target insect species, nor any disruption of other organisms that rely to some degree on mosquitoes as part of their diet.


As if we didn’t have enough insect and tick born diseases to worry about, an emerging risk is the relatively new (to the western hemisphere) Mosquito born Zika virus. Add it to other scourges around Arkansas such as Rocky Mountain Spotted Fever, Erhlichiosis, and Tularemia from ticks (also deer flies for Tularemia), and mosquito born West Nile Virus and St. Louis encephalitis (SLE). Any and all of these diseases can have serious consequences especially if left untreated.

Zika is a new viral disease which is projected to be an issue in the future in much of the United States including Arkansas because of the ability of the host to breed and spread in a number of climatic niches. The mosquito vector, genus Aedes, is a day-time feeder and is said to be able to reproduce is a bottle cap’s worth of water. So far no known disease transmission from mosquito bites has occurred in the United States, but transmission from bites has occurred in two territories in western hemisphere, Puerto Rico and and the US Virgin Islands. There are reported cases in most states from travelers who were exposed overseas.

Zika was discovered in 1947 in Uganda. From the 1960s to 1980s, human infections were found across Africa and Asia, typically accompanied by mild illness. The symptoms are common to a number of other mosquito born viral infections. From there the virus moved to south-east Asia and across the Pacific. During a 2013-14 outbreak in French Polynesia, the neurological disorder Guillain-Barré syndrome was linked to Zika infection. In South America, the first reports of locally transmitted infection came from Brazil in May 2015. In July 2015 Brazil reported an association between Zika virus infection and GBS.

It is only a matter of time until the local mosquito population becomes infected with the Zika virus, and begins to spread the disease among humans. The most frightening aspect of the disease which has recently been confirmed by the US Centers for Disease Control (CDC) is a unique birth defect that occurs in the offspring of infected women. Microcephaly is a condition where the infant is born with an abnormally small head and underdeveloped brain. Brazil has reported a rate of about 2,500 cases of microcephaly.

The disease has also been shown to be transmitted by blood and semen. Men with the virus have been know to transmit the disease to sex partners. It is currently not know if women can infect partners.

The condition results in a poor prognosis for normal brain function and individuals have a greatly reduced life expectancy. Although there can be other causes of microcephaly, the CDC has affirmed the connection between the Zika virus and the Brazilian outbreak.

Two months ago President Obama asked congress to appropriate 1.8 billion dollars to fight the spread of the disease. The republican controlled Congress has so far refused to act on the request. Without congressional support to fight the disease the president has no choice but to switch funding within the CDC, taking it away from monies committed to surveillance and treatment of Ebola.

Congress, name your poison.

Interstate Health Insurance?

If the Republicans win the general election in the fall and Obamacare is repealed, what happens? Several common threads run through the various strategies from Republican front runners.

The most odious feature of the the Patient Protection and Affordable Care Act (PPACA) among conservatives seems to be the mandate, so it will go. If you don’t want to buy insurance, you don’t have to. If for example you get pneumonia from an untreated infection, you can go to the hospital and get free care. For the hospital to remain in business however, they have to cover the cost of the “free” care with higher costs to the paying customers – the insurance companies. And remember that emergency care is the most expensive way to deliver care, bar none. The cost to those who buy insurance will go up to subsidize the uninsured. This doesn’t do anything to lower costs, it’s what we had before and it is a silly way to keep everybody healthy.

So everyone, republicans included, realizes that steps need to be taken to bring down the cost of healthcare and one thing you hear constantly is that allowing the purchase of insurance across states lines will increase competition and thereby lower costs. Will it work? It works with widgets. If someone in another state sells widgets at a lower price than that can be bought here, then go there to buy where the price is lower.

The story with health insurance is quite a bit more complex. The PPACA includes provisions that already allow the purchase of health insurance across state lines. The difference between the PPACA compact provisions and earlier interstate sales provisions are that the PPACA requires all states to comply with a minimum level of insurance coverage. But interstate sales is not happening, so why?

Insurance companies make money by negotiating prices for “healthcare commodities” – doctors fees, hospital costs, laboratory costs, drug costs etc. All these costs are negotiated to control costs to the policy holders. The nature of the policies sold in a state are regulated in the state.

Georgia, Maine, and Wyoming are states that have taken the step to promote interstate sales. The problem is not that regulations prevent it, but rather no insurers are interested. In none of the aforementioned states, has an out of state insurer expressed interest in selling in those states. This is partly due to the fact that out of state insurers will still have to abide by the rules in the states where they sell.

Eventually it may happen. There is a case to be made that costs are lower the bigger the pool of insured, and crossing state lines could expand the pool for a given insurer. In some markets such as large metropolitan areas that cross state lines, this could happen sooner rather than later, but the development will take time. How how much will this lower the cost to a consumer?

Experts cite the fact that insurance costs depends on how healthy a given group of policy holders are. Arkansans currently have the highest obesity rate in the country, Colorado the lowest. If an insurer from Colorado wanted to sell in Arkansas, the policy costs would be base on the obese Arkansas pool, not the fit Colorado pool. Consequently what cost savings may occur would be small.

In a final irony, a catch-22 of sorts, interstate sales of insurance means federal regulation, anathema to generally states rights conservatives.

Homeopaths Without Borders

Homeopaths without borders

There are a number of international organizations with the title “ … without borders,” most notably Doctors without Borders (Médecins Sans Frontières.) It is a humanitarian organization, founded in Paris France in 1971. This Nobel laureate organization has been sending doctors and their staffs around the world to provide health care where none is available. They go to treat extremely dangerous diseases such a Ebola and in extremely dangerous places such as active war zones.

Contrast that with Homeopaths Without Borders, who describe themselves as a humanitarian organization who travel to treat a relatively innocuous disease with sham treatments. Understanding just how preposterous Homeopathy is requires a little background. Before the time of modern medicine, treatments and drugs frequently were more dangerous than the illness itself. As just one example of many, George Washington died from bleeding to death – on purpose. He wasn’t supposed to die but he was being bled as a cure for what ailed him. You take out the bad blood and you get better, right?

Homeopathy was created by Samuel Hahnemann in 1796 (Washington died in 1799.) This medical modality was based on his idea of the law of similars. Substances that cause symptoms in “normal doses” can cure those same symptoms when given in infinitesimally small doses. One “drug” in the homeopathic pharmacopoeia is Nux vomica. A normal dose will make your stomach hurt (and then kill you) as this stuff is strychnine. A tiny dose however is supposed to be a cure for stomach aches.

A classic example of a homeopathic treatment is Oscillococcinum. This flu remedy is made from the liver of a duck. It is ground, dissolved in water, and then that water is diluted with ten times as much water. Take this water and dilute it ten fold. Do this 400 times.

For all practical purposes there is nothing left of the original preparation, only water. The water can be used directly or is added to chalk and evaporated. There is absolutely no chemical or biological reason that these treatments would have any effect at all.

Because there is nothing in these remedies, they can do no direct harm. Before modern medicine this alone could be beneficial to replace the use of dangerous things like blood letting. In this day and age however the substitution of magical thinking for real, efficacious treatments is not only unethical, but also dangerous.

Homeopaths Without Borders is currently working in Haiti to “treat” a disease known as Chikungunya, a viral infection spread by mosquitoes. The symptoms of infection are mild and flu-like with a moderate fever. Many of those infected have no symptoms at all. The condition usually resolves itself in a matter of days. Homeopaths treat this disease with another extremely diluted nostrum. The homeopathic treatment does nothing good, bad, or otherwise and the disease resolves itself.

One may ask what’s the harm? The harm is that unsuspecting individuals see that a disease exists, a treatment is employed and the disease goes away. The conclusion is homeopathy works. It doesn’t. One may in the future be led to the idea that substitution of cheap homeopathic treatments can replace more expensive drugs that actually do have an effect. They can’t.

Homeopathy falls in the realm of what some call alternative medicine. Why alternative medicine? Because it it worked it would be called medicine.

Guinea Worm

Jimmy Carter and the Guinea Worm

The Guinea Worm, Dracunculus medinensis, is a nematode which has infected humanity for millennia. It is a subject of interest because of the large size, up to three feet long, and the fact that infection with the worm is extremely painful as the worm makes its way within the body. Secondary infections can be lethal.

Knowledge of the infection dates back to antiquity. Some authors suggest that the closing verses of three stanzas of a poem in the Sanskrit book Rig-Veda, allude to the Guinea worm. The worm was well known to ancient Egyptians and has been found in mummies dating back to 2000 BCE.

The life history of the Guinea worm begins when contaminated water is consumed. The Guinea worm spends part of its life cycle as a larva in an intermediate host, a tiny copepod. When consumed by humans, the copepod dies and releases larvae. They bore through the stomach wall into the peritoneum where they mature. The smaller males mate with the females. Adult females then migrate to the skin, ultimately boring through the skin. When an the infected person then bathes the inflamed tissue in a body of water the female releases larvae, only to be consumed by copepods, renewing the cycle.

Traditional treatment is to extract the worm by slowly winding it onto a stick after it has broken through the skin, a process that can take hours to months long. This may be the source of the biblical allegory of Moses and the serpent. So the story goes, at one point while wandering in the wilderness, the Israelites were again being sinful so God sent serpents to the camp and the people started dying. God told Moses “ Make a snake and put it up on a pole; anyone who is bitten can look at it and live.”

This is also likely to be the origin of an ancient symbol – the Rod of Asclepius, the Greek god of healing. It is the major symbol for professional healthcare associations in the United States, the staff and snake being a proxy for a worm on a stick. It’s a single image instructional manual so to speak.

The disease due to infection is called Dracunculiasis. It has affected millions into the twentieth century, mainly in parts of Asia and sub-Saharan Africa. In 1986 the Carter Center, founded by President Jimmy Carter, estimated that there were 3.5 million people infected. With a small amount of funding and a big educational outreach, that number has dropped to 186, and is likely to be completely eliminated within a year or two. This will be the second disease eliminated from mankind, after Smallpox.

And the solution is so simple. The intermediate host, the copepod, is not a microscopic organism, but rather a little crustacean about the size of a small grain of salt. All that is necessary is to filter drinking water through a gauze-like membrane, even a bandana will do! Because there is no alternate host, once the organism is eliminated from the human population, the worm will be extinct.guinea
The Carter Center set in motion a program to train locals to teach this simple hygiene measure which will soon eliminate a grotesque disease which has afflicted humans for thousands of years. Thank you Jimmy Carter.

Affordable Care Act

Disincentivizing Work

The Republicans have a bright and shiny new word they’re using to bash the Democratic Party in general and Obamacare in particular — Disincentivize. As in Obamacare disincentivizes Americans to work.

This characteristically disingenuous attack on The Affordable Care Act (ACA) comes from a purposeful misinterpretation of a recent Congressional Budget Office report titled “The budget and Economic Outlook: 2014 and 2024.” About 30 pages out of 175 addressed the ACA.

The point the Republicans tried to exploit was a couple of lines that said “The ACA will reduce the total number of hours worked, on net, by about 1.5 percent to 2.0 percent during the period from 2017 to 2024, almost entirely because workers will choose to supply less labor — given the new taxes and other incentives they will face and the financial benefits some will receive.”

See, ensuring access to healthcare takes away jobs! No, not really. What the report said is some people who previously had to keep a full-time job just to be insured may not need to. The ACA ensures that affordable insurance is available to individuals regardless of pre-existing conditions or income.

People who can now get insurance on the open market can decide to work less, or retire a little earlier than they would have. If a person retires early, this opens up a job for another worker — a far cry from taking away jobs.

Once it was clear that jobs weren’t being taken away, the Republicans switched to the disincentivise mantra. This is their argument: If a person doesn’t have to work to maintain access to expensive health insurance, then they won’t work. Access to affordable healthcare makes us lazy. Really, that’s what they think.

Republicans have traditionally resisted just about everything which contributes to the quality of life. People are lazy because they would like to be able to spend more time with their family? People are lazy because after working long and hard, and saving their money, would then like to retire a little earlier? People are lazy because they would rather not work two jobs if they didn’t have to? Really?

Americans already work the longest hours among workers in the industrialized world. That means we have less time to be with our families, less time to enjoy time with friends, less time to volunteer for our church or club. What is wrong with this picture?

You know what else disincentivizes people to work? Those things that contribute to the enjoyment of the American dream — the 40-hour work week, overtime pay, Social Security, Medicare, Medicaid, and now the Patient Protection and Affordable Care Act.

Should we get rid of the mortgage deduction for home ownership and the dependent allowances on our income tax? Saving money disincentivizes work? Meanwhile, the Republican controlled House of Representatives will be taking the next two weeks off, on our dime. What’s that about disincentives to work?

The Real Costs of Fossil Fuels

Arguments against sustainable energy sources always include the fact that they are taxpayer subsidized and so more costly than they appear. These kinds of claims have been expressed before, but it is always worth reviewing the subject. How about the subsidies for fossil fuels? The direct cost of a gallon of gas, the cost at the pump, is currently about three bucks a gallon. The indirect costs can add as much as another $10 or more to the real price of a gallon of gas, bringing the total to something like $15 a gallon.
The direct costs are easy to calculate and include the cost to find produce, transport, refine and distribute the gasoline. These costs will continue to rise as crude oil becomes more scarce. It is increasingly harder to find the oil. And what oil is found is in smaller fields, deeper in the ground, farther out to sea, or all of the above.
As an example of the extremes taken to find and produce crude oil, the BP oil spill in the Gulf occurred at a well in 5,000 feet of water,

BP oil spill

BP oil spill

which was to be drilled another 18,000 feet below ground for a total depth of about 23,000 thousand feet. That is more than 4 miles below the surface of the ocean. Existing leases in the Gulf will necessitate drilling in water twice that deep.
The real run-up on the price of a gallon of gasoline comes from the indirect costs which include, but are not limited to military, environmental and healthcare costs.
Military costs to secure access and transportation of foreign oil are difficult to calculate, but the Congressional Research Service estimated well over $100 billion per year. These cost estimates do not include the direct cost of two wars in the Persian Gulf region. Estimated addition to the cost of that gallon of gas: $4.
war for oil

war for oil

Indirect costs for healthcare come about from burning that gasoline. Much asthma, chronic obstructive pulmonary disease (COPD), lung cancer and heart disease can be attributed to air pollution from automobile exhaust. Additional healthcare costs in Los Angles due to air pollution are put at about $1,200 per person, per year. Nationwide, the estimate is $75 billion dollars per year. Estimated addition to the cost of that gallon of gas: $3.
What is hardest to calculate, but in the long term the most damaging is the cost to the environment.
Obvious costs include everything from lost profits and wages for tourism and fisheries in the gulf due to oil spills to various global phenomena. Some are quantifiable — others not. Insurance companies are at the forefront in trying to put a value on property losses due to climate instability.

global warming is triggering more severe storms

global warming is triggering more severe storms

Here is one example. The estimate to mitigate a one-meter sea level rise from global warming is about $250 billion. Increased droughts, floods, hurricanes and tornadoes are all costly and the predicted result of global warming. This is admittedly a guess — but, estimated cost to that gallon of gas: several more dollars per gallon.
Finally there is the incalculable cost of environmental degradation – loss of habitat and biodiversity. What is the value in dollars to maintain a stable environment for our children’s future?


Republican Irresponsibility

The real irony of Republican pique over Obamacare is the fact that it is a Republican idea. The final form of the Patient Protection and Affordable Care Act (PPACA) relies on Americans to take personal responsibility for their healthcare. It is not a complex formula; buy insurance that covers for the eventualities we all face, be it accident or illness. For those who can’t afford it, costs are subsidized by tax payers according to a sliding income scale.

What conservatives now seem to be saying is that personal responsibility is an onerous burden and purchasing insurance which covers the full cost of accidental injury or illness shouldn’t be necessary. Conservatives think that cheap policies with limited coverage, high deductibles, large co-pays or caps on payments are just fine.

But what happens when these inferior policies fail to pay the cost of care? Then who pays? Currently very close to half of all bankruptcies involve medical costs. That’s no way to run a healthcare system. And conservatives know it, at least knew it. Even before President Clinton proposed a single payer “medicare for all” type of healthcare system, the Heritage Foundation proposed an individual mandate for the purchase of insurance, just like Obamacare. It included a minimum standard of coverage, just like Obamacare. It even included a mandate to insure those with pre-existing conditions, just like Obamacare.

Whether we’re talking about Romneycare, Obamacare, or the Heritage Foundation policy, they all keep the private for profit insurance market alive. They all reduce costs because greater coverage increases access to preventive care, the cheapest and most effective expenditure. And they all mandate that personal responsibility is the centerpiece for healthcare in the United States.

We collectively provide for our national defense, isn’t our national health just as important? We have a single payer military, where everybody, through income taxes, pays their share. We don’t get to choose just how much defense we want, we are mandated to buy the same military. And single payer courts, and single payer disaster relief, and on and on and on. It’s the personal responsibility to our general welfare. E Pluribus Unum – from many, one.

The focus of the Republican party has been to avoid any collective action on healthcare. Democrats since at least the Truman administration have tried to make healthcare more inclusive. To the point of adopting a Republican approach. They’re still not happy.

Get the Shot!

Being a geek, I’m a big fan of the TV sitcom, “The Big Bang Theory”. It is well written and does a good job of reflecting real science. Several of the characters are scientists. Amy Farah Fowler is Sheldon’s sort of girlfriend. The character is portrayed by actress Mayim Bailik, a neuroscientist who holds a PhD from UCLA .

Here’s the problem; Amy the character, appears to be more scientifically literate than Mayim the real life scientist. Mayim is the spokesperson for a group with views that go far beyond main stream medicine, such as recommending homeopathic treatments and not following scientifically accepted vaccination schedules for infants. The former would substitute ineffective sham medicine (homeopathy) with scientifically proven, efficacious drugs. In the case of the latter, rejecting vaccinations or even delaying an appropriate vaccination schedule puts not only the person or their children at risk of unnecessary illness, but also society at large.

The effectiveness of vaccinations depends on so-called herd immunity. To stop communicable disease does not require absolutely everybody be vaccinated, just a high enough percentage to disrupt transmission. Some individuals can’t be vaccinated for certain diseases for example neonates and pertussis- whooping cough.

Fall and rise of Whooping cough

Fall and rise of Whooping cough

They are protected from this once common disease by virtue of the fact that those around them have been vaccinated and therefore don’t carry the disease. If an older unvaccinated child gets pertussis s/he can transmit the bacterium to an infant with fatal results.

A real problem with getting a vaccination is a misperception of risk. A person may known of someone who got a flu shot, and had a bad reaction or had the shot and still got the flu. This knowledge introduces a bias. It doesn’t however change the fact the the overwhelming odds are in favor of getting the shot. Depending on the vaccine, the strain of influenza, and several host factors,

“ …How well a flu vaccine works is challenging, in general, recent studies have supported the conclusion that flu vaccination benefits public health, especially when the flu vaccine is well matched to circulating flu viruses” – Centers for Disease Control statement. The odds of a severe negative outcome, usually to an allergic reaction to the vaccine are in the one to millions range.

Back to the bias of knowing someone for which a flu shot didn’t work, or had a reaction. Does knowing someone who won the lottery make you more likely to win the lottery? Most folks would say of course not. But this is the same kind of bias. You think of just one outcome among many, many. But that doesn’t change your odds.

We all know someone who doesn’t wear a seat belt. S/he frequently justifies the self-endangerment by claiming that they know of a case where someone died due to the seat belt. The same bias. Evidence from literally billions of passenger miles shows seat belts save lives.

Vaccinations are generally safe and are generally efficacious. Vaccinations protect not only those vaccinated but also others through the herd immunity. Participate in society, get the shot.