Thursday, October 25, 2012

Piercing the (medical) gloom

kw: book reviews, nonfiction, medicine, policy

I have read at least a dozen books about the medical profession in the last several years, all warning about various risks or decrying doctors' greed or incompetence. At last, a physician has taken up the cudgels from the other side to argue that medicine in the United States is not nearly so bad as all that. The book is In Excellent Health: Setting the Record Straight on America's Health Care by Scott W. Atlas, MD.

Dr. Atlas is a member of the Hoover Institution's Working Group on Health Care Policy. He aims to overcome certain myths about the quality of medical care in America, and to propose appropriate policy, particularly with a better and less intrusive focus as compared to the Patient Protection and Affordable Care Act (PPACA), popularly known as Obamacare. (My own view: The PPACA should be called Less Patient Protection with Barely Affordable Care, and I am being generous. In contrast to most legislators, I have read major portions of it).

An opening caveat: This is a fact-filled book, meaning it is dense reading, with 44 pages of endnotes. In spite of that, I found it well worth paying attention. Of the book's seven chapters, the first six deal with six myths or misconceptions that the author wishes to correct. The seventh chapter presents his policy suggestions.

The first chapter tackles the World Health Report 2000, by WHO, that ranked nearly 200 nations' medical systems. America's showing was reported to be rather dismal. The report has been discredited time and again ever since, yet it is still treated by many as gospel truth, and is the basis for most of the arguments put forward as the "need" for passing the PPACA. Of a great many weaknesses in the WHO report, the most singular is that the yardsticks used to measure each nation's performance varied from nation to nation. In many cases, there was so little data that a particular "metric" was simply someone's estimate.

In the following five chapters, Dr. Atlas has picked apart the ways that medical metrics are determined, particularly life expectancy, infant mortality, overall quality, ease of access, and specialty care. Consider "overall quality". This is so complex, we need a way to brush aside the clutter. Just ask, when rich and powerful people leave their country to get medical care, which country are they most likely to go to? It's funny, I have never heard of foreign officials traveling to Canada or Norway for a heart transplant or cancer treatment.

In certain ways, America is different from other countries, in ways that underlie the seemingly poor statistics gathered for the WHO report. First and foremost, this country has unequaled diversity. Look beyond the WASP image; The U.S. has large contingents of African Americans and Latinos, of all kinds of Asians (where I work I am outnumbered by Chinese and Indians), and of Native Americans. Secondly, as a very prosperous nation, in spite of a temporarily faltering economy, there are lifestyle issues here that play a great role in our overall health. Just as being too poor can take years off your life, so can being too rich. Although the rich can afford the best of the best medical care, too many are like Diamond Jim Brady, who ate himself to death at the age of 61. What other country needs a TV show like Extreme Makeover: Weight Loss Edition?

Our very prosperity has thus pushed us "over the top" of the health curve as measured from both ends of life. So-called Life Expectancy is impacted by more than just the quality of medical care. It strongly depends on overweight or obesity, on diabetes, and on other risky behavior such as the use of recreational drugs. And the attitude of doing something just because we can has led to American doctors turning millions of miscarriages into "live births", of infants that weigh a pound or less (.45 kilo), even though 70% or more die within a few days. In most nations, they don't even try to "save" infants under two kilos (4.4 lbs). So if you measure infant mortality for each cohort by weight, the American rate of infant death is better than everybody else's for each weight class, and in the lower weights, so few even try that it is little use making the comparison. Then as to life expectancy, if the ranking is done, not starting on day one (even for a 9-oz, or .34 kilo, baby), but from age one month, the U.S. is nearly at the top. A very few nations, such as Japan, would still rank higher, because Japan is so homogeneous; they don't have any enthnicities that tend to have shorter lives, but we have plenty. And on the matter of "access"? Whatever you need, you can get quicker here, hands down, compared to every country with a "centralized" system.

Dr. Atlas contends that the PPACA is misdirected, and in its place, has three recommendations: new tax policies that are really helpful where they are needed most (the opposite is now true); keeping the government out of the health insurance business (in contrast to PPACA which will gradually make the government the only game in town); and something similar to the labeling requirements for food, forcing transparency of price and quality.

I will close by summarizing the book's 5-point critique of the PPACA:
  • It imposes centralized controls that resemble those in nations that are, even now, trying to privatize controls so as to increase competition, shorten access times, and reduce costs;
  • It would increase the number on Medicaid by about 25%, breaking the back of a system that is already failing;
  • It sets up "exchanges" that restrict plans and require coverages that most don't need, adding unneeded expense;
  • It increases taxes on technological innovation, just as we are on the verge of breakthroughs in molecular biology converging with medicine;
  • It greatly reduces funding for specialist care, expecting your family doctor to be your cardiologist, urologist, etc., unless you want to wait months or years to see the specialist.
I would add, it makes the IRS the collector of insurance premiums; how crazy is that? We can do better. Will we?

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