Monthly Archives: August 2009

What's next for health care reform? Reconciliation

Democrats vs Republicans

Source: Gearlog

Optimists predict that media coverage of Senator Kennedy’s death will shame Republicans into changing their opposition to health care reform. Nicholas Lemann, writing in the New Yorker, says, “Kennedy’s death … will cost Obama a vote in the Senate, but this may be outweighed–is it too much to hope?–by the good feeling that Kennedy’s decades of large-heartedness have generated, and by the unmistakable sense that universal health care was his enduring wish. His death could spur health-care legislation the way his brother’s death spurred civil-rights legislation.”
That type of reconciliation – a kindly, all-is-forgiven meeting of the minds – would indeed be historic. Unfortunately, “too much to hope for” is right, I’m afraid. The Republican Party, having lost most of its moderates, is now dominated by its right wing. A Democratic strategy is already emerging that calls for playing a different sort of reconciliation card.

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A reason not to marry: Medical bankruptcy

If you’re a middle-class family and you learn that your beloved spouse is going to require long-term care, do you know what hospital social workers recommend? Get divorced. Otherwise you’ll go bankrupt.
And do it as soon as you can. It takes five years after a divorce before your assets are no longer subject to seizure. That’s because the government knows couples get divorced in order to escape medical bills.
Nicholas Kristof has an excellent op-ed piece on this problem in today’s New York Times. He describes the case of a woman whose husband had dementia. She knew he would eventually need to be institutionalized.

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Why is it so hard to reform health care? National identity

Diversity children

Source: Teachers.net

Documentaries, such as Sicko and Sick Around the World, visit other countries and ooh and ahh over their rational, effective, and equitable health care systems. Why is it that France, Italy, Japan, the UK, Canada – all the major developed countries – have managed to solve the problem of guaranteeing affordable health care while the US just can’t seem to get it together?

Every country is unique, so it’s unproductive to imagine the US duplicating another country’s health care system. What the US has now is a very complicated arrangement for delivering health care and paying for it, a convoluted system that’s been evolving for decades – ever since Marcus Welby-like family doctors stopped making house calls.
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Should Obama have pitched health care differently? Will Kennedy's death make a difference?

Barack Obama

Source: The AV Club

“Obama surely has made mistakes, among them focusing so heavily on how reform would reduce the cost of medicine. Had he spent more time reminding voters that reform would provide them with the security they now lack–security from financial ruin and medical catastrophe, the type private insurance too rarely provides–he probably would have been better off.”
So writes Jonathan Cohn in a New Republic article called “Hindsight.”
In politics, it’s much easier to be a Monday morning quarterback than a prophet, of course. Cohn doesn’t blame Obama for focusing on costs. At the time, that approach made eminent sense. “[T[he evidence of unnecessary, even harmful medical care … has simply become overwhelming. And the argument that health care is a threat to our long-term fiscal health … has become impossible to ignore.” Theoretically we can spend as much as we want on health care, but that’s money that doesn’t get spent on roads, schools, public housing, and wages.

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Edward Kennedy: Healthcare is a fundamental right, not a privilege

Edward Kennedy and health care

Source: WTRF

Some tributes to Senator Edward Kennedy and some honest recollections and assessments.
Ezra Klein in The Washington Post:
“Year after year, decade after decade, he labored to pass health-care reform. He sought deals with Republican presidents, with Democratic presidents, and even pursued the office himself. He tried to cut out the health-care industry and bring them to the table, to move forward on a bipartisan fashion and on a Democratic platform, to pass single-payer and to promote incrementalist approaches. The process wasn’t the point. Nor were the people. Nor, even, was Ted Kennedy. Universal health care was the point. Helping the excluded, and the endangered, was the point.

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Are insurance co-ops a reasonable alternative to the public option?

Dan Roam’s visual presentation of the issues involved in health care reform lists three possible options for health insurance: Private insurance, non-profit insurance exchanges or co-ops, and a government insured plan (the “public option”). There’s been much media speculation lately that the public option is now out of the picture. There are also rational voices who believe this conclusion may be premature.
There are many commentators who argue that insurance co-ops are an inadequate alternative to a public option. For example, Nobel Prize winning economist Paul Krugman:

[T]he supposed alternative, nonprofit co-ops, is a sham. That’s not just my opinion; it’s what the market says: stocks of health insurance companies soared on news that the Gang of Six senators trying to negotiate a bipartisan approach to health reform were dropping the public plan. Clearly, investors believe that co-ops would offer little real competition to private insurers.

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Why is it so hard to reform health care? The issues are complex

One reason it’s so hard to make progress on health care reform is that it’s an extremely complex problem. Although President Obama does an excellent job of articulating the issues simply and clearly, it appears his message is not getting through clearly enough.

Dan Roam, a business consultant and the author of The Back of the Napkin, believes in visual thinking as a way to understand and communicate complex ideas. His basic argument is that if you can identify the specifics of a problem and communicate them clearly, then you can get the response you need to fund the solution to that problem.

For example, if you say “Global warming is a momentous, important problem,” that may be true, but it may not inspire action. On the other hand, If you draw simple illustrations and say “Making all roofs and streets white would give us a onetime energy savings equivalent to removing all cars for 18 years,” you may find investors who can relate to that image.

Here’s what Dan Roam comes up with when he applies his visualization technique to the problem of health care reform.


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A doctor assesses Michael Jackson’s cause of death

Since shortly after Michael Jackson’s death, the powerful anesthetic propofol has been suspected as the cause of death. Details of Jackson’s final hours were released today by the Los Angeles coroner’s office. Although the final injection of propofol may have been the immediate cause of death, it’s only one small part of the larger and tragic picture.

There are good accounts of Jackson’s final hours in the Los Angeles Times and at CNN.

The sequence was as follows:
10 mg of Valium at about 1:30 AM
2 mg Ativan (an anti-anxiety drug) at about 2 AM
2 mg Versed (a sedative) at about 3 AM
An additional 2 mg of Ativan at about 5 AM
An additional 2 mg of Versed at about 7:30 AM
Jackson still could not sleep and pleaded for the anesthetic propofol.
25 mg of propofol at about 10:40 AM.

Dr. Kevin Pho provides an analysis from a medical perspective.
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Health Culture Daily Dose #17

Additional stories related to health. Categories include: More articles on Health Care Reform, History of Medicine, Medical Journalism, Medical Technology, Medical News, Pharmaceuticals, Pop Culture, Social Media and the Internet, and The So-Called Obesity “Epidemic.”

HEALTH CARE REFORM

A ‘Common Sense’ American Health Reform Plan (The New York Times – Uwe Reinhardt)
After studying this nation’s perpetual “national conversation” on health reform for over three decades now, I am firmly convinced that any health reform that is the product of logical cerebral processes automatically misjudges what Americans appear to see as “simple common sense” in health care.
The Experts vs. The Public on Health Reform (Kaiser Family Foundation)
In repeated Kaiser polls, we see a divide between what experts believe and what the public believes about some of the key issues in health reform. There is a wide gulf on basic beliefs about what is behind the problems in the health care system and key elements of reform.

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The So-Called Obesity "Epidemic"

I was planning to include a category called “The So-Called Obesity ‘Epidemic'” in the next Daily Dose, so I thought I should first explain what I mean by that.

Back in June, there was an article in The Washington Post called “Judging Fat People.” Here are some excerpts:
“Be honest: What’s your first reaction when you encounter an obese person? I’m guessing it’s not sympathy.”

Don’t think the fat person doesn’t notice. … [T]he stigma associated with being overweight or obese is enormous and has broad implications. … [S]ociety’s disdain for overweight people often contributes to their feeling defeated, to a sense of “nihilism” that makes them just want to give up any efforts to lose weight. …
As one whose weight has fluctuated over the years, I know that being overweight can stem from all kinds of circumstances, from emotional stress to the simple fact of being relegated to sitting at a desk all day. I know I feel crummy when I’m heavier than I should be, and I can tell when other people notice my weight, too. It would be nice if we could all cut each other a break.

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Health Culture Daily Dose #16

Here are some things I’ve come across recently. Categories include: Aging/End of Life/Death, Doctors, Influenza, Genetics, and Health Care Reform.

AGING, END OF LIFE, AND DEATH

End-of-Life Care: Where Ethics Meet Economics (The New York Times – Uwe Reinhardt)
Health spending in the United States has doubled every 10 years during the last four decades. Americans sooner or later will have to confront the hard questions about access to expensive treatments, perhaps after a rational national conversation, if such can still be had in America.
Health Care’s Generation Gap (The New York Times – Richard Dooling)
Money spent on exorbitant intensive-care medicine for dying, elderly people should be redirected to preventive care for children and mothers.

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Is there a doctor on board?

Medical emergency on airplane

Source: flickr

Imagine you’re a doctor flying back to the US from Singapore with a medical colleague. Shortly after your first class lunch, the Korean man across the aisle groans and regurgitates his meal. The flight attendant announces: “Could I have your attention, please. Is there a doctor on board?”
Moments later a female passenger also vomits. Both the man and the women have a nasty rash. You consult your colleague — who happens to be your boss – and she fears this is an outbreak of meningitis and soon the whole plane will be infected. Next thing you know, your boss is vomiting and is positive for a rash. Three more passengers follow suit.
You perform a tricky, in-flight spinal tap, with crude equipment, on the Korean man. Your conclusion: The sick passengers are suffering from mass hysteria. It’s not meningitis. But the Korean man is still extremely ill.

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Health care: Reminding people of death triggers irrational emotions

Sharon Begley, science writer for Newsweek, has written one of the best articles I’ve seen so far on the acrimony of the current health care debate. It’s not about the politics, which are unpredictable. It’s an analysis of the underlying psychology, which will not easily be changed.
I recommend reading the entire article. Here are some highlights.

The idea of death panels gains … credibility, … “because many people are vaguely aware that end-of-life care is bankrupting Medicare and that at some point we have to figure out how to deal with that.” …
The power of “death panels” as a phrase and a scare tactic also works because Americans are deeply uncomfortable with death. We don’t like to think about it or talk about it. … As a result of that discomfort, reminding people of death sends them off the deep end, into the part of the neuronal pool where reason cowers behind existential terror.

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Fear of flying: Will I catch swine flu on an airplane?

When you breathe recirculated airplane air, do you expose yourself to the coughs and sneezes of everyone onboard?
Well, not quite everyone. Most airlines do not circulate air along the length of the cabin, allowing it to interact with every passenger. Air is circulated from side to side in discrete sections of the plane. The passengers you’re most exposed to are those sitting near you, which would be true even if the air wasn’t recirculated.
A review of research, published in The Lancet, concluded that the chances of contracting an air-borne disease increase when you sit no more than two rows away from an already-infected passenger. This assumes an eight-hour flight. More recent evidence suggests the safety margin is more like seven rows on a three-hour flight. This risk is not unique to airplanes, of course. It applies to any confined public space, such as a classroom.

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Contempt and compassion: The noncompliant patient

homeless woman

Source: Salvation Army

“After I had berated the patient for his obvious failure to comply with my recommendations to correct his ‘misbehavior,’ he said, ‘You know, doctor, there is more to life than good health.’ These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.” (Lewis E. Foxhall, M.D.)

Patients who fail to follow a doctor’s orders are labeled noncompliant. In the current national conversation on health care reform, noncompliant patients are one of many targets blamed for rising costs. If only everyone took their meds as directed, lost weight, exercised more, and used less cocaine, we wouldn’t be in such a mess.
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‘Mad Men,’ the sixties and the culture war over health carepolitics

John Hamm as Don Draper in Mad Men

Source: The Insider

The current emotional polarization around health care reform is not so much about specific issues – rising medical costs, reprehensible insurance industry practices, the number of uninsured. It reflects a deep division in American culture that began in the sixties.

Forty years after Woodstock, it’s clear that a major shift happened in that decade, politically, socially and psychologically. Despite the communal love fest, Americans had begun “bowling alone.” Crime rates started to rise, as did divorce rates. Quite suddenly, in 1965, a vast majority of people stopped identifying themselves as Democrats or Republicans and became Independents.
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Music: Aaron Neville and the Neville Brothers

Aaron Neville

Source: Rolling Stone

Here are three songs – the first two from the group the Neville Brothers and the third from an Aaron Neville solo album.
You may know Aaron Neville from the song Tell it like it is, which was a hit in 1967 (here’s a YouTube version). The Neville Brothers are a New Orleans band that’s been around since the 1950s. They’ve never received as much acclaim as their fans feel they deserve.
See the first music post for details on the playbar, Amazon, and iTunes.

The Neville Brothers – Little Piece of Heaven

From the album: Valence Street
Warm Up Two (5:08)

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Real men don’t use doctors

Too much machismo can be bad for a man’s health. A recent study finds that the John Wayne/Sylvester Stallone types are half as likely as their less “macho” counterparts to visit a doctor for preventive health care.

The study was presented at the annual meeting of the American Sociological Association on August 10, 2009 by its author, Kristen Springer. The men who participated in the study were all 65 years old, and preventive care was defined as annual physicals, testing for prostate cancer, and getting a flu shot.

The men’s “macho quotient” was determined from a questionnaire that asked things like “When a man is feeling pain, he should not let it show. Do you agree or disagree?” Other questions designed to identify traditional masculinity asked whether men should be the main bread winner, act confident even when they’re not, or have the final say in the decision to buy a house.
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The tactics of health care opponents may discredit their message

Healthcare protest New Hampshire

Source: Telegraph

After all the recent media coverage of angry crowds at town hall meetings who oppose health care reform, it’s a relief to come across a reassuring piece of journalism from a neutral source. Reuters reports that the entire ruckus will probably not make any difference in the broader debate on health issues.

The shouting captured media attention and overshadowed debate on the complex details of Obama’s top domestic priority, but the furor could limit the influence of the town hall meetings when lawmakers take up the issue again in September.
“A lot of this is the base of the two parties screaming at each other and I don’t know if it’s changing a lot of minds one way or the other,” Republican consultant Dan Schnur said.
“It just turns people off,” said Jim Kessler, vice president for policy at the moderate think tank Third Way. He said extreme elements on each side are battling and “for everyone else this is a revolting spectacle.”

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Collateral circulation and the cat concerto

collateral-circulationLike the appendix , collateral circulation is another part of our anatomy that was more useful to our ancestors. Collateral circulation refers to systems of veins and arteries that allow blood to continue flowing when the main pathway is blocked or damaged.

These extra vessels sometimes develop in response to a circulation blockage. But certain parts of the body – the elbows, knees, shoulders – are equipped with these redundant vessels right from the start.

We’re not born with collateral circulation in those really important places like the brain and the heart. Why would we have these surplus vessels in the elbows, but not in the places that keep us alive?
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Still useful after all these years: The gall bladder

gallbaldderThe gall bladder is another useful but expendable organ (see recent posts on the appendix and the spleen). Unlike losing your spleen, living without a gall bladder is not detrimental to your health, though it may be inconvenient at times.

The gall bladder is located under the liver, on the right side of the body. It’s a small sac, about three inches long and 1 ½ inches wide when it’s full. It can hold a little under two ounces of bile (less than a quarter of a cup).

Bile is produced in the liver and stored in the gall bladder until it’s needed to digest fats. Fats need to be broken down (emulsified) before they can used by the body. When they’re not broken down, they pass right through the digestive track. That’s what can be inconvenient about not having a gall bladder. If you eat foods rich in fats, you may need to stay close to a restroom.
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The Spleen in Chinese Medicine

The philosophy that informs Chinese Medicine is very different from the science that determines Western medicine. These two cultures do not start from the same assumptions about what it means to be healthy.

Those who dismiss Asian medicine as being of no value fail to take this into account. You can’t compare an apple to an orange and conclude that the apple is superior because the orange is not an apple.

Some Western medical practitioners are vehemently opposed to alternative therapies, including Chinese medicine. I can understand why. Chinese Medicine is about prevention: Keeping the body healthy, preventing disease before it begins. If you have cancer, you need to avail yourself of all the resources Western medicine can offer. You don’t put your faith in an alternative therapy when there is no scientific evidence that it can cure cancer.
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Still useful after all these years: The spleen

The spleen

Source: danielle2

While some anatomical organs are dismissed as totally unnecessary (see Still useful after all these years: The appendix), others are considered useful but dispensable. Consider the spleen.

Located on the left side of the body, under the ribs and behind the stomach, the spleen is about five to six inches long and one and a half inches thick. It weighs about six ounces (the weight of a can of tuna).

Until recently, we thought the spleen was limited to filtering out red blood cells and supporting the immune system.

What we already knew the spleen did for us

Red blood cell gets old, tired and damaged after 120 days or so, at which point we make new replacement cells. The spleen filters out the old blood cells. Not only does the spleen remove the aging cells. It recycles them. It breaks down the hemoglobin so the liver can use it for bile, and it makes the iron in hemoglobin available for the manufacture of new red blood cells.
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Still useful after all these years: The appendix

You can live without an appendix, true, but you should no longer think of this “vestigial” organ as a useless part of your anatomy. The appendix is finally getting the respect it deserves.
We have ten times as many bacteria in the body as we have cells (and we have 10,000,000,000,000 cells). The human digestive system runs on bacteria, where they’re called gut flora. The appendix turns out to be a storage container for the beneficial bacteria that digest our food. When an illness such as cholera empties the contents of the digestive track too rapidly, we lose bacteria. The appendix reboots the digestive track by repopulating the intestines with the bacteria stored in its little pouch.

The downside of an overly hygienic society

Why did it take so long to appreciate the appendix? “It’s hard to figure out what the appendix does when you’re studying superclean animals and people,” according to Bill Parker, a Duke professor of surgery. The appendix evolved when lifestyles were much dirtier and were plagued with parasites. People got sick with diarrheal diseases much more often.

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Waste, Fraud, Abuse and the Mafia

Tony Soprano

Source: Silive.com

One of the arguments against health care reform is the government’s inability to run an efficient and financially sound business. Government bureaucracies are considered breeding grounds for waste, fraud, and abuse.
Here’s a typical complaint I found online: “The Government Loses Over $200 Billion A year To Medicare/Medicaid Fraud!!!! Should they be taxing us more to grow their control of the system??? Isn’t it a bottomless pit???”
This individual continues:

The federal Health Care Financing Administration, which oversees Medicare & Medicaid …, estimates that the government loses 30 cents to every dollar from fraudulent practices in the medical community. This is a huge problem that must not be ignored.

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How much water do we need?

The idea that drinking eight glasses of water a day is the healthy thing to do has been around since the 1940s. It’s not true, but at this point it’s a widely held myth. On a site called Optimum Health, for example, I found this statement: “The average person needs 8-10 glasses of water daily… Read more

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Music: Shakira, Michelle Shocked, Sacha Nairobi

Source: Rolling Stone Three more songs I used in class this week: Shakira for the first Circle song, Michelle Shocked for larger leg movements in Circle, and Sacha Nairobi for Across the floor. The whole Michelle Shocked album (Short Sharp Shocked) is great. I use four songs from this album in classes, but When I… Read more

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Music: Peggy Lee, Steve Tyrell, Rosemary Clooney

Rosemary Clooney There’s so much good music that it’s hard to know where to begin. I’ll start with something I used today. It was the last class in the summer session for Mountain View students, and I used some old standards for warm-up. If you click the “Play” button below, you can hear 30 to… Read more

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Rosen Method Movement Music

Source: Smarthistory A Rosen Method Movement class takes students through a sequence of movements. The sequence prepares the body to move with ease across the dance floor. All movements are done to music, but not just any music. The songs used in a class need to have a tempo that’s not too fast and not… Read more

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Rosen Method Movement teachers

Rosen Method Movement: Gentle, yet powerful movement and dance designed to lubricate all the joints in the body. Classes help you stay active and healthy, improve balance and coordination, and cope more effectively with stress. Developed by an innovative physical therapist as a way to prevent difficulties before they arise, each class follows a sequence… Read more

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