Repeal and Replace and Reminisce and Regret

President Trump laid out some major points he would like Republican plans to replace the ACA to address. The proposed issues straddle the fence between genuine expansion of health insurance penetrance and caving to Republican desires, and the outlook for the prized reform--Medicaid block grants--for Republicans is not especially rosy. While it does, in a sense, provide more flexibility and control to state Governors in addressing Medicaid funding allocation, the overall funding of Medicaid would potentially have to be slashed by 20% or more in the next ten years.

“The looming specter of automation rendering many more Americans jobless does little to assuage fears that enrollment in Medicaid will skyrocket as reimbursement declines.”

That’s not something to be taken lightly. States would likely have to adjust eligibility criteria to accommodate budget shortfalls, or cut reimbursements, which are already meager compared to normal insurance. Furthermore, the looming specter of automation rendering many more Americans jobless (nevermind the title of the article, even Forbes admits automation is already evaporating low-skill jobs) does little to assuage fears that enrollment in Medicaid will skyrocket as reimbursement declines.

There is no doubt that the ACA is fraught with problems, from the rollout of the website to the exit of key insurers, including Humana, from the exchanges. It was not a perfect piece of legislation; it did not fix all of the problems that face US healthcare--namely controlling costs of healthcare provision; collective bargaining for pharmaceuticals; lack of choice for insurance plans and providers; and the overall health of Americans writ large. There is debate as to whether or not Americans have gotten significantly healthier or longer-lived in the six years since the ACA was put into law, according to Margot Sanger-Katz, and some sources even claim American life expectancy has decreased slightly (note: primary data could not be found for this article). It is well known that American life expectancy has always lagged significantly behind other OECD countries and does not appear to be catching up.

“Repeal and replace without an actionable, transparent plan seems to be throwing the baby out with the bathwater.”

Despite this mixed review of the ACA’s performance, the refrain of repeal and replace without an actionable, transparent plan seems to be throwing the baby out with the bathwater. It is certainly no secret that Republicans would love to deny Barack Obama a critical piece of his legacy, but at what cost to American citizens? There is a widely-held sentiment that the ACA is “failing”, “a disaster”, and of course “socialism”--I actually couldn’t find a source I consider credible for that last one, but the word is bandied about frequently in conservative circles. Yet, gross medical debt or inability to see any provider has decreased, an encouraging sign. And furthermore, the pitfalls of the consortium of Republican replacement plans have a plethora of pitfalls all their own, as outlined by Healthcare Triage, not the least of which is the insanity of poor people to set up health savings accounts, or HSAs, and use tax credits at the state level not based on income to purchase private plans.

That rather undermines the entire point of expanding provision of care to the poor. I rarely appeal to religion, but it seems downright un-Christian to deny poor people comfort and care in their moments of greatest need, especially from someone who claimed to be the world’s foremost bible reader. Just like his bibliophile proclamation, the President’s health policy goals seem to be somewhat flimsy under even cursory examination.

But, then again, healthcare is super complicated, so who am I to judge?

Nestle moving into nutrition and wellness

Nestle recently announced that they have been quietly acquiring pharmaceutical companies in the hopes of folding health and wellness into their portfolio of food offerings, combining highly engineered and refined foods with targeted nutritional applications. The move effectively opens the door to a future of tailored foodstuffs, hyper-nutrient rich dietary choices and a medicinal aspect to consumer food choices. It also marks a stark departure from the idea that humans already have the most nutrient dense foods readily available to them, and that the solution to chronic disease is to eat whole, natural foods in moderate portions.

“On the one hand, a world where you can have your diet customized for your genetic predisposition to a host of diseases. On the other hand, divulging your genetic makeup to a titanic, multibillion dollar multinational food corporation seems, well, dystopian, to put it bluntly.”

Both ideas have their shortcomings. On the one hand, a world where you can have your diet customized for your genetic predisposition to a host of diseases, thus avoiding riskier food choices, seems utopian, and does indeed have the potential to reduce disease burden in at least the Western world. On the other hand, divulging your genetic makeup to a titanic, multibillion dollar multinational food corporation seems, well, dystopian, to put it bluntly. And while eating strictly whole, unprocessed food can indeed lengthen your lifespan and significantly lower your risk of a host of chronic diseases--from ischemic heart and brain disease to diabetes--eating healthy in and of itself is not a panacea. It is not going to stop the ravages of hereditary ulcerative colitis, or fix any inborn metabolic errors, though it can slow them.

While I am in principle opposed to Nestle trying to, as one observer put it, process your foods to counteract the negative effects of processed foods, this is where the future of food is heading. Soylent, the meal replacement company, is constantly tinkering with their formula in the hopes of providing an increasingly complete, broadly palatable nutritional supplement. Novartis Medical Nutrition, acquired by Nestle a decade ago, is steadily advancing in producing high quality nutritional supplements specifically geared towards infants, the elderly, and athletes, i.e. people who require highly specialized dietary supplementation. One of my favorite food frontiersmen, Herve This, has been harping on the idea of selective taste and nutritional modulation for decades--what he calls Note by Note cooking, or NbN.

“And for the entirety of that time, we have been relatively comfortable with the idea of food getting more and more modified in order to make it more accessible, longer lasting, more complete and, especially, tastier.”

But, for all of the potential, for all of the billions of lives that these kind of advances could save, they still seem somewhat unnatural, or at the very least, a radical shift from what we know food as today. Throughout the vast majority of human history, food has been enjoyed in much the same way. It is only in the last hundred or so years, a single heartbeat in the lifetime of humanity, that we have found a plethora of new preservation, fortification, and manipulation means to make food barely recognizable. And for the entirety of that time, we have been relatively comfortable with the idea of food getting more and more modified in order to make it more accessible, longer lasting, more complete and, especially, tastier.

Food purists have a point: the explosion in diabetes, MetS, obesity, heart disease, gut dysbiosis, and a coterie of other chronic health problems has risen in parallel with the vast increase in processed foodstuffs peddled largely by companies like Nestle, Kraft, and Unilever. The ambitions of Nestle may be quite noble, but the execution will likely have unforeseen consequences, and raises concerns about privacy and ownership of genetic data. The plan is already in motion, however, so get ready in the coming years for foodstuffs tailored specifically for you.

Changing attitudes to medical marijuana (and its role in public healthcare)

A few weeks ago, my whole family gathered for my uncle’s 60th birthday in Fort Lauderdale, Florida. Actually, my mother’s side of the family--northeastern liberals--gathered. My father’s side lives in Norway, and they are all pretty much like him: stubborn. They relish conflict, especially of the political variety, and my father is almost always spoiling for a spirited debate (read: an tirade about liberal media conspiracy).

Only this time, there were no hackles being raised. No voices gradually rising in volume and intensity. I found my dad out on the patio, sitting calmly and reflecting on the sunset.

"I heard your uncles talking about politics,” he said, "so I came out here instead."

Flabbergasted, I blinked my eyes and thought, "Who are you and where is Lars?”

But then he explained. A few minutes before, he had taken a steady pull off of my uncle’s vaporizer, and for the first time in months, the shooting nerve pains in his leg were leaving him alone, and his back felt less stiff. He was at peace, calm, and tranquil.

“But then he explained. A few minutes before, he had taken a steady pull off of my uncle’s vaporizer, and for the first time in months, the shooting nerve pains in his leg were leaving him alone, and his back felt less stiff. He was at peace, calm, and tranquil.”

Let me back up. My father does not smoke weed. He has always seen claims of medical marijuana as dubious excuses for people to abuse a recreational drug under the pretense of medicine. According to my mother, he had railed the day before about the dopers’ conspiracy. And yet here he was, living the actual benefits, seeing with fresh--if a bit bloodshot--eyes that there is real medicinal value in cannabis.

This year’s Florida ballot contains a proposal for Amendment 2, which would expand the use of medical marijuana in the state considerably. The proposed amendment does, however, make it very clear that marijuana is still a Schedule 1 narcotic, federally illegal, and that the potential Florida constitution change did not change those facts. Despite this, a further three states--North Dakota, Arkansas and Montana--will vote today on medical marijuana and five--California, Arizona, Maine, Massachusetts and Nevada--will vote on recreational legalization.

“The pros and cons of recreational cannabis are debatable, but there is consistent—if somewhat modest—evidence to suggest cannabis as an effective treatment for pain management, neuropathy, and certain types of cancers.”

The pros and cons of recreational cannabis are debatable, but there is consistent--if somewhat modest--evidence to suggest cannabis as an effective treatment for pain management, neuropathy, and certain types of cancers. But, it is nonetheless a federal schedule 1 drug, and there seems to be no motion on behalf of the DEA to loosen federal restrictions on cannabis. This would also likely mean that any potential public healthcare option floated by (please God) President Clinton would exclude a working treatment that has already attracted immense support. 

A few states are already considering exercising the 1332 waiver, allowing them to opt out of certain mandatory features in the ACA in order to provide state-level innovation in healthcare delivery. A lingering question, then, is if states that already have medical marijuana will be allowed to reap any federal benefits or count on federal support for expansion of medical marijuana programs. The answer, likely, is no. Although, who really knows? The notion, though, that the federal government would stand in the way of a safe, efficacious, proven treatment for a host of chronic conditions--especially HIV and cancer-related pain and weight management--is preposterous, and stinks of grandstanding. It will be incumbent on my generation to divest the old guard of the myths of the distant past, and to push for more transparent, better funded, better controlled scientific research on the subject to drive the point home.

“A lingering question, then, is if states that already have medical marijuana will be allowed to reap any federal benefits or count on federal support for expansion of medical marijuana programs. The answer, likely, is no.”

My dad took another hefty drag from the little vaporizer on the table before we stood up to finish making the food for the party.

"I want to make something clear to you,” he said, "I’m not doing this because I like getting high. I’m not changing my mind because I like the euphoria.” He looked down at his legs: ashen, swollen, purple.

"I feel better than I’ve felt in a long, long time.” I smiled and hugged him, glad at the sea change in his attitude.

And if my doctor decides he wants to be a dick about it, there are other ways I can get it without his help.”

Just for the record, his doctor expressed his opinion thusly:

"Ask me two years ago I would have told you it’s all a scam. But today, I know patients from other states that say it’s changed their lives, and the evidence continues to mount.”

It’s a brave new world, dude.

American healthcare: more expensive, worse outcomes, and what to do about it.

The majority of Western democracies are equipped with robust public health systems. The infrastructure is designed to keep costs low and deliver maximum benefit to the citizens. In most cases, the results are quite tangible: lower infant mortality rate, higher life expectancy, reduced burden of preventable disease, and lower morbidity among seniors (i.e. fewer seniors living with 2 or more chronic conditions). These are all despite a general trend--in Europe at least--toward more smoking and alcohol consumption, with varying rates of illicit drug abuse.

In the United States, as anyone who has ever had a serious injury, chronic condition, or unexpected bout of illness can tell you, there is next to no public health infrastructure, unless you are very poor, very old, a veteran, or have certain chronic conditions like asbestosis. Costs are absurdly high and outcomes pale in comparison to our NATO allies. According to the Commonwealth Fund, US expenditure on healthcare as a percentage of GDP topped 17% in 2013, compared to just 12% in France, 11% in Germany, and less than 9% in the UK. And what do we get for all our dollars shelled out? Three fewer years of life than the OECD average, nearly twice the infant mortality and the highest obesity rate by a country mile (an antiquated phrase that basically means “a whole lot”).

“And what do we get for all our dollars shelled out? Three fewer years of life than the OECD average, nearly twice the infant mortality and the highest obesity rate by a country mile (an antiquated phrase that basically means “a whole lot”). ”

When T.R. Reid wrote his comparison of world health systems, The Healing of America, he traveled to France, England, Germany, Japan, and India among other countries to examine healthcare norms and practices. What he found was that, contrary to popular belief, Americans visit the doctor far less than other OECD countries, yet get far more CAT, PET and MRI scans than anywhere else on the planet. Indeed, the Japanese visit a doctor on average once a month, where as we in the USA visit perhaps twice a year, and then only for serious issues. This was a pivotal conclusion: other countries seem to value preventative care far more as a means of halting potentially costly and debilitating disease early. Furthermore, the reduction in mortality from these kind of regular visits was staggering: three times as many people per 1000 citizens die in the US of ischemic heart disease as die in France, and twice as many as in the Netherlands.

So, why then, is there no will to implement a single payer system in the USA?

A frequent claim is that single payer public health systems come with a rash of intolerable problems. These range from long waits for surgery, to subpar care quality, to rationing of resources, to bureaucrats having access to all your personal information, insinuating themselves between you and your doctor. Another oft-repeated refrain is that price controls, such as those in Japan and Norway, stifle innovation and punish medical device and pharmaceutical companies. Then there is a more insidious argument that America would be embracing the dreaded S-word, the one that has led European economies to ruin and spits in the face of American exceptionalism: Socialism. The utterance alone is enough to make the Heritage Foundation shudder and hiss.

“Contrary to popular belief, Americans visit the doctor far less than other OECD countries, yet get far more CAT, PET and MRI scans than anywhere else on the planet.”

These claims have degrees of legitimacy ranging from “meh” to “come on, man.” There are, on average, twice as many doctors per 1000 people in Norway than in the United States, and all the OECD countries from the Commonwealth Fund with the exception of Canada and Japan have more physicians per capita than here. While Canadians do sometimes have to wait for surgery openings, what many Americans perhaps obfuscate with this argument is that so do we. To be fair, urgent coronary procedure waiting times in the US are far lower than in Canada by an average of several days, according to a 1995 report in the Journal of the American College of Cardiology. More recent data is harder to come by. Despite this, mortality and morbidity rates in Canada are much, much lower following open heart surgery. This may also have to do with an economic system that pushes sick workers back into the labor force ASAP.

Regarding subpar healthcare quality, the data speaks for itself. Americans have some of the poorest outcomes in the developed world for a plethora of diseases. One of the areas in which we do triumph is cancer treatment. However, we also suffer higher rates of most cancers than most of the OECD countries, so our priorities are obviously stacked in favor of dealing with such an eminent problem. As far as rationing of care goes, the UK’s National Health Service is frequently held up as the example based on the hypothetical needs of two kidney transplant patients: one in his early 20s, one in his late 90s. In all cases, the early-20s recipient will be given priority for a kidney transplant. It sounds harsh, but then again, the kidney may prolong the 90 year old’s life by a paltry five years, whereas it may bring several decades to the younger patient. Additionally, this is essentially the same protocol used here in the USA for prioritization. Given the prospect of growing organs de novo on washed connective tissue scaffolding, this may be a problem relegated to the past, as well.

“Bureaucrats already have access to your health information, and if you have a health insurance provider with a strict in-network coverage policy, your choices are already being interfered with. ”

Bureaucrats already have access to your health information, and if you have a health insurance provider with a strict in-network coverage policy, your choices are already being interfered with. Because of the labyrinth of coverage providers and networks, we spend up to five times as much as our allies on the bureaucracy part of healthcare each year, money that could easily be put towards, I don’t know, actually providing healthcare. And price controls? Well, it would certainly be good for the consumers, but how about the providers? Doctors in this country are usually in the upper tier of income, and around the world that is not exactly the case. They are well off, but by no means, as Reid put it, part of the country club set. But in most other countries in this comparison, those doctors paid no money to go to medical school, other than books and housing. Reid also found that in Japan, when the government instituted rigorous price controls, it stimulated demand from providers for better, cheaper, more effective and efficient medical devices that could conform to the new models. Honda, Mitsubishi, Yamaha and various other daihatsu were happy to oblige.

As far as socialism in the medical field goes, allow me to push the bold question: so what? At the heart of socialism is the idea that the society functions well when its members are cared for. Isn’t that sort of at the heart of medicine as well? But, I digress.

“While Japan, Norway, Germany and France are, by and large, ethnically homogenous populations which cluster for the same diseases, and have populations ranging from 1%-25% of the United States, the USA is an immense, multicultural, young nation.”

There is one perfectly legitimate argument against a comprehensive single-payer system. While Japan, Norway, Germany and France are, by and large, ethnically homogenous populations which cluster for the same diseases, and have populations ranging from 1%-25% of the United States, the USA is an immense, multicultural, young nation. It is difficult to provide a framework for the treatment of ALL the diseases that significantly affect Americans, because the population genetics, environments, and cultural norms are incredibly disparate in many cases. To boot, insurance companies in the USA are for-profit corporations, and thus have a vested interest in trying to minimize the amount of money paid out in care each year. If that seems confusing, infuriating, or downright dastardly, then you’re feeling a completely normal emotional response and you should sit down and write your Senator today that you think it’s bogus.

I propose a compromise on the front of single payer insurance. We cannot simply copy and paste any nation’s public health infrastructure, but we can learn a lot from our allies. We could create a suite of services that are covered through general taxation, folding parts of Medicaid, Medicare, the VA and SCHIP into a single comprehensive unit and then expanding it to cover all citizens for a variety of procedures, treatments, and provider visits. This could include immunizations, yearly checkups, X-rays, MRIs, CT scans, mammograms, prostate exams, mental health counseling, diabetes prevention, neonatal and maternal care, just to name a few. The approaches must be data driven and evidence based, and incentive payments for patient survivorship and comorbidity could be awarded to physicians to encourage best practices. Patients could contribute small copays to avoid abuse, with the bulk of cost both negotiated and covered by federal, state, and local government partnerships. Collective bargaining for drugs and medical devices could significantly drive down costs of treatment. For special diseases not covered by the plan, supplemental nonprofit private insurance companies could step in and fill the gaps, again driving competitive pricing models by offering suites of services for specialized care. Another idea is drastically reducing the cost of attending medical school, but I don’t have a well-thought out framework for how to accomplish that. Finally, grants for experimental treatments and novel approaches could be made available to physicians and researchers alike.

“We cannot simply copy and paste any nation’s public health infrastructure, but we can learn a lot from our allies. ”

Of course, if CRISPR and other gene editing tools take off as predicted, and if Watson and his ilk supplant traditional physicians, all of these points may be moot, as we’ll all be superhumans being cared for by AI doctors with the collected knowledge of thousands of human physicians.

That seems like a long way off, though, so let’s keep pushing for solutions to present problems.