The Home of Steven Barnes
Author, Teacher, Screenwriter


Friday, June 26, 2009

Thanks, Erich

Tobias Bucknell sent me the following email this morning about the health care debate:

##

By the way, the comment you got about scores of Canadians coming to the US is another anecdotal fantasy:

http://content.healthaffairs.org/cgi/content/full/21/3/19

Turns out it's a small handful. Usually rich Canadians who don't want to wait.

Meanwhile, millions of Americans actually go to Mexico:

http://www.eurekalert.org/pub_releases/2009-05/uoc--n1m052609.php

##

About half of the million Californians who flee to Mexico to seek medical care are Mexican immigrants, so it might be reasonable to halve the numbers. What remains still appears to be multiples of the number of Canadians who come to America. Here's the trick: I've been hearing the "Canadians fleeing to America because their health care system is so bad" argument for years. I've never heard anyone offer numbers, and the whole thing started to stink. No one. All anecdotal, and you can prove anything you want like that. The tobacco lobby used anecdotal and twisted stats for decades to try to convince people that smoking wasn't harmful.

It feels very much like arguing backwards from a premise: X is what I believe, and I'm going to find some way to twist the data to meet my needs. I have no ideological preference here at all--except for the belief that I want to live, and my children to live as long as possible. So far, arguments against using Life Expectancy and Infant Mortality rate revolve around lifestyle factors (which access to medical advice can influence) and differing definitions of "Infant Mortality" without accompanying stats to demonstrate how exactly we are different, and to what degree. To my knowledge, when the WHO began collecting these stats, they had nothing to do with a Universal Healthcare debate, and America ranked very high indeed. And we trumpeted the results as evidence we were superior, and American society rocked.

Now that those exact same stats no longer favor us, we're supposed to ignore them? That's suicide. And it's fascinating that the only people who seem to believe those stats have to be wrong are those ideologically inclined toward the Right. Just as I'd expect, were the stats evidence that America's LE and IM rates were superior, that those who wanted government to pay their bills would reject said stats--not on scientific, but ideological grounds.

The question of what kind of system best drives innovation is still of great interest. I suspect that there is no way to resolve it absolutely, but it seems clear that those on the Right believe that profit is the greatest driving motivation for human beings in this arena. I personally believe that fear, compassion, and scientific curiosity are sufficient--people will stop seeking ways to prolong their and their family's lives when they stop being afraid of dying. No time soon.

But I don't know how this could be answered. And I think that there are some who simply think "I won't pay for someone else's health care" the same way there are some who simply think "I want it for free." And neither of these groups will tell the truth. While I automatically assume that no one posting on THIS blog is in either group, trust me: they're out there. And since we so very rarely see anyone saying that, they must be hiding behind the legitimate Left and Right arguments, as bigots hide behind rational arguments against Affirmative Action, and recreational pot smokers hide behind Medical Marijuana arguments.

The liars make it very difficult to discuss these things rationally. They troll and distort and misquote...and at the base of it, I suspect more all the time, are simply differences in the way people see the world. Does good flow from the top down? Or the bottom up? Do we enter the world fully formed? Does the world shape us as we go? Are different racial or religious groups (always their own) notably superior to others? To me, this is why they say don't argue religion and politics--in essence, they are the same thing, played out in different arenas.

My guess is that the Right is going to lose this one. It isn't like the drug legalization debate, where there are a limited number of places where it has been tried, and stats are hard to come by. No--in this case, most of the rest of the industrialized world has gone this way, stats are pleniful, and countries that are out-competing us, where people report higher life satisfaction indices as well as IM and LE are plentiful, and trying to ignore those statistics creates torturous epicycles.

When the percentage people "satisfied with their health care" is larger than the percentage of people who have it, you know something is wrong. When the wealthiest nation in the world is worried UHC would break the bank, when it is clearly working in countries doing better than us as well as those poorer than us...something is wrong. None of this means UHC is the best option...just that the argument that it IS seems clearer and simpler than the arguments that it is not. Statistical as opposed to anecdotal. Real-world as opposed to hypothetical (research MAY deteriorate). But the debate is an important one. Vital, even. And once again I appreciate it being conducted in a civil fashion. Mostly.

##

And I wanted to thank Erich for pointing out that I wasn't requesting equal civility from both sides. My bad. I try very hard to remain conscious, but obviously, an insult that supports my side of the argument just doesn't sting me as much as one from the other side. But this is true about all arguments: whether about gender, race, class, whatever: we just don't react if the slight is in our favor, any more than we protest as loudly if a referee makes a bad call against the other team.

We just don't. This is why an all-white Senate was so horrible to me, and it was so irritating when whites pretended all was well. Why men who claimed an all-male executive staff could treat women as fairly as one where women were included at the table. Why a roomful of Christians debating whether Islam is inferior is such a joke. Might as well expect fair treatment for Republicans from a roomful of Democrats, or expect the truth of a Liberal argument from a Right-Wing talk show.

We can't help it. It's the way our minds and hearts are wired. And the only answer is to strive to remain conscious, and invite those we trust to slap us upside the head when we doze off.

31 comments:

Marty S said...

Steve: I rooted around and found a bunch of stats for 2004 on U.S. life expectancy and homicide rates in various links. The numbers I found for 2004 show White males with a life expectancy 5.9 years higher than Black males. The homicide rates for White males between ages 15-24 was 5 per 100,000 for Black males 84. Assuming a ballpark number of an additional 55 years if these young men were not murdered and adjusting for he overall death rates among Whites and Blacks the murder rate of young males between age 15-24 accounts for a ballpark 73% of the difference. So if life expectancy is our criteria the government should put its efforts into reducing the homicide rate rather than reforming health care.

Scott said...

Here's where I'm coming from on the drug legalization argument: I'm a lifelong teetotaler, never had a drink or smoked a cigarette or did any recreational drugs stronger than sugared coffee. I'll drink coffee - Starbucks java chip frappucinos, Thai iced coffee, like that - but I don't own a coffeemaker, or instant coffee. I'll take ibuprofen if I need it - maybe once or twice a year - but I don't own any.

That said, Prohibition has been tried, and it turns out to be a horrible idea. If it worked I might support it - to the extent I'm a good person I'm libertarian, but no-smoking-in-public laws, even ones that define private property like restaurants as public, make me happy.

But they don't; they just hurt people.

Anonymous said...

"My guess is that the Right is going to lose this one."

With a Democratic majority in both houses of Congress, the Dems can certainly pass any legislation that they have the collective will to pass. They don't need Republican votes for it. And the political impetus du jour is certainly on their side. After all, what could possibly go wrong? Surely Bush was so hideously awful that any random Change must be a Good Change?

But what I suspect will be the practical outcome of Obamacare (namely, to subsidize the public "option" with taxes on employers, while keeping the current state bans on low-cost high-deductible comprehensive medical insurance, thus driving private medical insurance completely out of business) is not what Obama has repeatedly promised ("if you like your current insurance, you can keep it"). If Obama actually thought universal single-payer health care (UHC) was a vote-winner, he'd be campaigning for it openly rather than promising people that their current health insurance would survive his reforms. Since he's not, I have to assume he knows UHC is actually not all that popular with 89% (or some majority) of voters.

Which tells me that the Dems can indeed pass whatever they feel like passing, but that the long-term political consequences may be quite negative if nationalizing medicine works as well as nationalizing any other industry has tended to work for the past 100 years.


--Erich Schwarz

BC Monkey said...

(Crap. I put this in the other post first. Sorry about the double post)

The question of what kind of system best drives innovation is still of great interest. I suspect that there is no way to resolve it absolutely, but it seems clear that those on the Right believe that profit is the greatest driving motivation for human beings in this arena. I personally believe that fear, compassion, and scientific curiosity are sufficient--people will stop seeking ways to prolong their and their family's lives when they stop being afraid of dying. No time soon.



But I don't know how this could be answered.


In the modern age of science we have already had this experiment. The communist world removed the "profit" consideration from its researchers for a period of close to 80 years. How many medical reseach breakthroughs came out of that?

I do think that your breakdown of innovation in counrties with socialized medicare vs. The US is missing a very critical factor. Right now any medical innovation which is made in a country with medicare is still made with the profit motive full in mind. Why? Because anything they produce can be sold in the US medical market for profit.

It's not correct to say that research in those countries is driven by altrustic concerns instead of profit. Once the US goes to a full on socialized medicare system, that chance for profit will be drastically curtailed. When you reduce the incentive for something, you're going to get less of it.

***

Talking about the levels of satisfaction in nations with different systems. I'm under Canadian medicare. No bill for insurance comes out of my bank account at the end of the month. (well, it does in my taxes, but it's not labelled as such) I don't have to pick health insurance coverage. I don't get documents detailing policy changes or anything like that. neither do any of my friends or family. Until I urgently need medical care, what's the likelyhood that I'm going to be dissatisfied?

Now if you're buying your own coverage and paying for it every month, you have to select your coverage, apply for it, get details of policy changes, etc, and so do my friends and family, what are the odds that I'm going to have some complaints and dissastisfaction before I need care urgently?

Oh, my premium went up. Dammed insurance!

(Compared to my "Oh, my taxes went up. Dammed taxes! Not, "Dammed medicare costs!" even although much of those taxes go to the medicare)

Pagan Topologist said...

I think that the profit motive skews medical advancement. If it turns out that an old out-of-patent drug works better than a new very expensive one for some condition or other, drug companies will try to suppress this fact and maybe even ban the old one, since there is far more profit in the new one. Advancement in the effectiveness of care and maximizing drug company profits are sometimes aligned together, sometimes not.

I think an example is that very low dose dilantin (I am not sure about the spelling) is better than SSRI's for many people with depression, but the SSRI's make more money for the drug companies, so even though the research exists, the marketing does not, and most physicians will never know about it.

Anonymous said...

As a society we still are denying the inevitability of it all and our health care system is a symptom of this.Two jokes summarize it for me
- Doctors says I have good news, we can add years to your life. The bads news is that they are all at the end.
- To paraphase Red Fox. " I feel bad for all the people who took care of themselves. Someday they'll be lying in a hospital bed dying of nuthin.
For sure it's not that simple but....
Rod

Anonymous said...

"Why a roomful of Christians debating whether Islam is inferior is such a joke."

Currently, the most credible and scathing condemnation of Islam is issuing from Atheists, particularly those who were once ardent Muslims, but who apostated upon witnessing its full horror. The criticisms of Hirsi Ali, Wafa Sultan and Tasmina Nasrin are far harder to dismiss than are those of the NeoCons.

http://www.youtube.com/watch?v=0txwUT8Csh4

Ethiopian_Infidel

Dan Moran said...

Erich,

Pardon me? Is it my fault that the documentation I'm citing is in a BOOK rather than a blog?

Nope. It's your fault that you didn't cite any passages in it, though. If typing to make your argument is more work than you want to do, fair enough, but if your theory is that I'm going to go buy a copy of this book, read it, and come back in some weeks to continue this argument, you're probably expecting a bit much from me -- certainly a lot more effort on my end than you're willing to invest on yours.

I'm actually researching this online today, so that we can continue this argument in something like real time. There's not a lot out there -- as important political arguments go, this one seems to have been neglected for some reason. I can't think why.

You still haven't pointed to a drug or treatment that Democrats have banned.

And since when is your ignorance of my profession my fault?

There's a lot of things I'm ignorant about in the world. There's a lot of things most people are ignorant about in the world. When I make an assertion about modeling hierarchies in the real world, as I did recently, I explain my background and my thinking: I don't say, I've been designing databases for 27 years and you're ignorant: shut up and listen. Instead I try to explain myself, my background, and my reasoning, in ways that are relevant to the people bothering to read me. You should try it.

Dan Moran said...

I do think Republican policies have been very bad for the people who've supported them most enthusiastically. I'll tone down the language I'm using, though; "X screwed Y" is flame war talk that isn't going to convince anyone. My apologies. I do appreciate the civil tone on Barnes blog, and would hate to damage that.

Dan Moran said...

I love Redd and I've told that joke myself, but the purpose of staying healthy is only marginally to live longer. Mostly it's so that you have the energy to live well. I know guys my own age, mid-40s, who can't walk a mile without getting out of breath.

Anonymous said...

"It's your fault that you didn't cite any passages in it, though."

In other words, we've reached Schwarz's Law.

Godwin's Law is that every political argument on the Internet eventually results in somebody invoking Hitler.

Schwarz's Law is that every political argument on the Internet eventually results in somebody saying (in effect): "Please write a review article for me on your own time." (Except that they usually don't say "please".)

Dan, I really am a working biologist who has a day job and even a semblance of a life. I'm writing this from the lobby of a lecture hall at UCLA, in between seminars at the biennial C. elegans meeting, at which I both gave a lecture and ran a workshop on comparative genomics yesterday. Tonight I have another presentation to give on transcriptomics, and Saturday I'm running yet another workshop on the C. elegans genome database.

I'm not going to walk out of this conference, drive across town to the Caltech library, check out its copy of The DNA Story, and write a review of it with well-excerpted passages ... just so that you can then languidly inform me that you still aren't convinced that continuing the Asilomar procedures from 1974 to 2009 would have made development of HIV protease inhibitors practically impossible.

Instead, I'm just going to have to let you "win" this argument, through the power of being the one with less work than me and more time to keep being loudly opinionated about my field.


--Erich Schwarz

Dan Moran said...

Well done. You have a good job, can't be bothered to make an argument rather than pronouncements, and you still can't name any drugs or treaetments Democrats have banned. I assumed as much in all areas.

Marty S said...

My opposition to changing the health care system is simple and selfish. My has Barret's Syndrome. This is a disease of the esophagus which has a half percent chance per year of turning cancerous. If not caught quickly it is 100% fatal. She therefore has an endoscopy every two years. I am a good candidate for colon cancer. My mother and aunt both had colon cancer and I have needed polyps removed during my colonoscopy, so I need one every three years. My current insurance pays for these tests. I have no faith that once the government takes over health care and sees the cost that it won't decide that the risk doesn't justify the expenditure and reduce this testing.

Steve Perry said...
This comment has been removed by the author.
Steve Perry said...

Marty --

Nobody wants to take your health insurance away. They want to give it to people who don't have it. Show me where Obama says he's going to rip out the insurance companies' throats and toss their bodies into the abattoir of history.

Where is this coming from? It smells like a Limbaugh scare tactic -- and it's simply not true.

The sky is not falling. Somebody wants to take care of the poor and the sick. People running around thinking that we are all going to be card-carrying communists if we stop letting the least of us die or suffer aren't paying attention. It ain't gonna happen.

Marty S said...

Steve Perry: That sounds nice in theory and I would be all for it if I thought that it could work and work at a manageable cost, but I don't believe it. How will who gets government insurance be determined. If the government gives free health care to anyone who doesn't have paid health care, how many companies are going to keep providing health care as a benefit. This is especially true if such benefits are treated as taxable income. Had the company paid portion of my benefits been taxable last year it would have doubled my taxable income.

Anonymous said...

"...you still can't name any drugs or treaetments [sic] Democrats have banned."

The Dems banned most molecular biology, 1974-1980, under the Asilomar guidelines. Had that ban continued, development of HIV protease inhibitors to prevent AIDS HIV-positive patients would have been impossible.

I've pointed it out to you and cited a book-length description of the Asilomar bans. That's as much work for you as I can or will do.

On another thread on this blog, where the subject matter was more recent and getting three different URLs for primary literature references was fast and easy, I did indeed provide such references -- to no effect whatsoever.


" I assumed as much in all areas."

Assumptions are easy, knowledge is hard. Assumptions always conveniently fit one's own ideology, 100% of the time, with no incovenient exceptions; facts don't.


--Erich Schwarz

Dan Moran said...

"...you still can't name any drugs or treaetments [sic] Democrats have banned."

Down to typos now?

http://www.waronscience.com/home.php

As much work as I can or will do for you.

Anonymous said...

"Down to typos now?"

No, there's plenty of things wrong with your writing on the logical level. It's just that your typo was pretty florid and seemed to merit a '[sic]'.


"As much work as I can or will do for you."

When have I asked you to do anything? Go on and be Dan Moran.


--Erich Schwarz

Marty S said...

Since we are having such a spirited debate on the health care plan, I thought I would post the AMA position on the plan as outlined in an e-mail I received.

The American Medical Association has weighed in on the new health care plan being developed by the Obama Team. The Allergists voted to scratch it, but the Dermatologists advised not to make any rash moves.
The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve. The Obstetricians felt they were all laboring under a misconception. Ophthalmologists considered the idea shortsighted. Pathologists yelled, "Over my dead body!" while the Pediatricians said, "Oh, Grow up!' The Psychiatrists thought the whole idea was madness, while the Radiologists could see right through it. Surgeons decided to wash their hands of the whole thing. The Internists thought it was a bitter pill to swallow, and the Plastic Surgeons said, "This puts a whole new face on the matter." The Podiatrists thought it was a step forward, but the Urologists were pissed off at the whole idea. The Anesthesiologists thought the idea was a gas, and the Cardiologists didn't have the heart to say no.

In the end, the Proctologists won out, leaving the entire decision up to the assholes in Washington.

Steven Barnes said...

Erich--

If I'm not mistaken, I asked if anyone had stats to counter the Life Expectancy and Infant mortality. The links you posted had commentary on stats, but not stats.
##
BC--
No one is talking about Communism. We ARE talking Universal health care, so you'd need to compare innovation from one capitalistic system to another, changing the minimum number of variables: in this case, socialized medicine compared with free-market. This you have not done.
##
And I did not say "driven by altruistic concerns." I'm disturbed by the tendency in passionate discussions to take a single aspect and then imply it's the only one. I said that in addition to fear of death, there is concern for family and community. That's not altruism, if the family and/or community supports you back. Is it altruism that makes a man support his children?
##
If you want to discuss levels of satisfaction, you've made it clear that you aren't satisfied with Canadian care. Great! That's balanced out by any one person dissatisfied by American health care. To be convincing, find those surveys that ask both groups--anecdotal evidence just isn't real useful in comparison to stats.

Marty S said...

Steve: You and Dan have both criticized Eric for providing a link that has commentary on stats rather than stats themselves. But, stats themselves are less useful than commentary to someone who

1)isn't professionally trained in statistics.

2)doesn't know how the statistics were collected

3)Doesn't know how they were analyzed.

Consider the following there are two groups of people, the red people and the green people. The red people live three years longer than green people on average. The reason for this is that green people are more prone to itchiness, which reduces lifespan by one year and stomach upset which reduces life span by two years. If we do a study and only collect data on itchiness and life span we will find a three year difference and ascribe it to itchiness, if collect data only on stomach ache and life span we will conclude stomach ache causes a three year difference. Only by collecting data on both itchiness and stomach ache and properly analyzing it using the correct multivariate statistical technique will we be able to correctly estimate the effect of either one.

Anonymous said...

"The links you posted had commentary on stats, but not stats."

Specifically, the three links I've posted so far were commentary on stats by three different economists and a practicing endocrinologist.

The Harvard economist Greg Mankiw gave links to commentaries both by himself in the New York Times and by the Nobel laureate in economics Gary Becker on his blog. I think their arguments are correct, but even if they were mistaken, they'd at least be instances of dissent from Obamanomics based upon informed and rational thinking -- something which I've seen people here claiming is oxymoronic.

I also cited the economist Arnold Kling, who wrote an entire book about health care costs, Crisis of Abundance. If you want Kling's full documentation for the arguments he makes in his short Web article, his book's the place to go.

The endocrinologist Mark Sklar pointed out the obvious: a lot of our health care statistics involve comparing Americans who overeat to Europeans who don't. As an endocrinologist, the man must be seeing the epidemic of type II diabetes that we've had rising in this country for the past 25 years; he notes that were we still practicing the eating habits of 1980, we'd see a lot of the morbidity in our health care go away. He also notes that nothing being proposed in Obamacare is going to do much to change that.

I myself have the same objection to Obamacare that I have to the cap-and-trade-and-rent-and-seek bill that just passed the House of Representatives: while the stated goals are unexceptionable, the practical means being proposed strike me as ineffectual, and very unlikely to improve the statistics being invoked as a justification for what in the end -- with either Obamacare or cap-and-trade -- looks much more like a power grab over the private sector by the Democrats in Washington than anything else. The articles I cited give detailed arguments why one might think that.


--Erich Schwarz

Dan Moran said...

No, there's plenty of things wrong with your writing on the logical level. It's just that your typo was pretty florid and seemed to merit a '[sic]'.

You are a first rate spell checker, Erich.

Scott said...

Sklar said: If we could prevent even a small percentage of people from becoming obese and developing these conditions, the costs of health care could go down far enough to cover everyone's insurance. To that end, we need incentive programs to encourage healthy eating and exercise. Vending machines and fast food should be banned from our schools. Children should be provided with meals that are low in saturated fat, refined carbohydrates, and sugar.


My libertarian knee jerk response is to suggest as an alternative simply not subsidizing the production of flour and sugar (and tobacco, and alcohol), at least as a first step.

Anonymous said...

"You are a first rate spell checker, Erich."

Hey, I can't do comparative metazoan genomics all the time.


--Erich Schwarz

Steven Barnes said...

I disagree with the contention that life style choices that affect life span (obesity, smoking, etc.) have nothing to do with medical care. The amount of simple ignorance around how to eat and move to live absolutely staggers me. When we are all invested in the outcome, social pressures change. Just like there used to be pressure on teenaged couples not to make babies...it had an effect. So these other countries where people live and eat and exercise more healthfully? I say that is most certainly a side-effect of a "we're all in this together" attitude that leads to less ignorance about "what to do" and more cultural pain attached to doing the wrong things, and social approval attached to doing the right things. Carrot, stick, and a clear view of the doorway out.

Scott said...

"If we extrapolate these findings (assuming that nonrespondents show a pattern similar to that of respondents), these facilities in the three large metropolitan areas combined saw approximately 640 Canadian patients for diagnostic radiology services such as computed tomography (CT) scans or MRI and 270 patients for eye procedures such as cataract surgery over a one-year period."

Hundreds would be more than scores, and much more than a small handful, right?

suzanne said...

The amount of simple ignorance around how to eat and move to live absolutely staggers me.

alas I hate to tell you
that many doctors are among the simply ignorant
because nutrition gets only the
barest 0f pass-throughs in most of the 127 medical schools on the North American continent

At the medical College where I worked
for 12 years in the office of Medical Education
trying to revise the curriculum
to make it more pertinent
and less torturous and
compassion draining
it took great effort to insert more than a few hours
into a curriculum overloaded with hours
as it was
many of them full of unnecessary
or fragmented knowledge irrelevant
to the practice of medicine

I said at the time
(I hope things have changed a little bit)
that the woman who read Women's Day
kn ew more about nutrition than most MD's

Scott said...

"The amount of simple ignorance around how to eat and move to live absolutely staggers me."

Almost no one squats heavy below parallel on a weekly basis. I don't know why, it's not like it's a secret; but as a consequence I am stronger than almost everyone at almost everything, and I lack talent. Certainly shocks the guys who can outbench and outcurl me when we tie up. Lifting *reverses* aging, see www.plosone.org/article/fetchArticle.action?articleURI=info:doi/10.1371/journal.pone.0000465

As for diet, high insulin levels promote fat deposition and high carb intakes promote high insulin levels; how hard is it to derive a fat loss strategy from that?

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