Half Changed World

Health care reform

I work on other programs affecting low-income families, not health care.  But if Congress passes a true health care reform year, and no improvements in the programs that I work on, I'll consider it a success.  And if we get everything on my organization's policy agenda for 2009 but health care reform crashes and burns, I'll be disappointed.

Ezra Klein is blogging for the Washington Post now, and he's got two really good pieces today, one from this morning on why the CBO cost estimates are putting health care reform in danger and one from tonight on the Finance committee's revised plan. Basically, the budget office has told Congress, no, you're not going to save enough money with comparative effectiveness research and improved health care IT to pay for the expansions in coverage you want to see.  If you want real health care reform, the choices are to come up with the money from some other source (e.g taxes of one sort or another) or to get serious about cost-controls (e.g. take a chunk out of insurers' hides, and possibly out of doctors' as well.)  The no-hard-choices fairy isn't going to save you.

It's looking like Congress isn't really going to tackle these hard choices until after the Fourth of July recess.  Which means that the next few weeks are a great time to weigh in with your Representative and Senators about the need for real health care reform -- including a public plan -- and the need to pay for it with comprehensive tax reform.  If you really want single payer, go ahead and tell them that, but then tell them about what you think is second best, because single payer isn't happening, not this time around, and it won't be more likely in 10 years if this round collapses.

Are you paying attention to the health care debate, or have all the different bills made your eyes cross?  Are you waiting until things sort out a bit to pay attention?  What burning questions would you like answered?  As I said, this isn't my area of expertise, but if I don't know the answer, I probably know where to find it.  If you want to get into the wonky details yourself, my favorite health policy sites are Families USA, the Kaiser Family Foundation, and the Center on Budget and Policy Priorities.

I don't know about the flu, but the hysteria is catching

There are only about 100 cases of swine flu confirmed in the US so far, but nearly 300 schools have shut down to prevent its spread.  Fort Worth, Texas has ONE student with the swine flu, but has shut down the entire system for 10 days.  This, in a country where nearly half of workers don't have any paid sick days, and many of those who do have paid sick time aren't allowed to use it to care for a family member.

But, not to worry, Vice President Biden "said he hoped U.S. employers 'will be generous' in allowing parents to take time off to keep their children home if there has been a confirmed case of flu at their school.”

“Fort Worth officials urged parents not to send their children to day care or 'any venue where groups of children may gather' and pleaded with the employers and the general population to make it possible for parents to accommodate this request.

"This is indeed an example of how the community can rally to support the health and well-being of students, their families and the District," schools superintendent Melody Johnson told reporters.”

I can write a report or take a conference call from home, but you can't cook and serve a restaurant meal, clean a hotel room, or care for a sick patient from home.  So what's going to happen?  Some parents will bring their kids to work.  Older kids may be left at home alone unsupervised.  Some parents will stay home, lose wages, and maybe not be able to afford to get their prescription filled this month, or will fall a little further behind on the electric bill.  But no one will point fingers at Ms. Johnson when a 12 year old left home alone sets a piece of toast on fire.

N has had a nasty cough the last few days, but no fever.  I'm 99.9 percent sure that it's allergies, but we've kept him home anyway, because there's not much downside to him missing a couple of days of preschool.  But there are real costs to closing schools, and I think it's hysterical overreaction to do so without any evidence that this is worse than an ordinary flu.

a victory for kids

Obama signed the SCHIP reauthorization today.  About 4 million more kids will have health insurance as a result.  Yes, it matters who is in the White House.

lose your job, lose your health care

One of the joys of our system of employer-provided health insurance is that the odds are pretty good that if you lose your job, you'll also lose your health insurance. 

Well, you can continue your coverage with COBRA, but relatively few workers who have just lost their job can afford to pay 102 percent of their premiums for an extended period of time. The average COBRA payment eats up something like half of the average unemployment insurance benefit.

If you're young and healthy, you might be able to buy an individual plan for less than your COBRA payments, especially if you're willing to accept a high deductible and hope you don't get sick.  If you have children, they might qualify for public insurance, through SCHIP or Medicaid, but unless you were seriously living paycheck to paycheck and have no assets, you probably won't qualify.

The Economic Recovery bills moving through Congress attempt to deal with this problem in a couple of different ways:

• it would provide a federal subsidy for part of the cost of COBRA payments
• it would extend how long you could continue to participate in your former employer's plan if you were within 10 years of qualifying for Medicare, or had worked for your old employer for at least 10 years.
• At least on the House side (it may be in the Senate bill too, but I haven't found it), it would let states cover workers receiving unemployment benefits under Medicaid, without regard to income or assets.

I'm not an expert on health care policy, but this strikes me as a bit of a kludged together package.  For one thing, it leaves out the 60 percent of unemployed workers who don't qualify for unemployment insurance, most of whom probably didn't get employer-provided benefits in the first place, and so can't get COBRA either.  For another, COBRA is a pretty expensive way to cover people -- Medicaid is  lot cheaper. 

I'm not really objecting to the proposal -- it's better than doing nothing, and I recognize that health care reform isn't likely to happen in the next month.  But this really isn't a substitute for doing health care reform for real.

Beggars in Spain

What does it say about me (or modern life) that when I read Judith Warner's column last week about the use of brain-enhancing drugs my first reaction was to wonder how one goes about getting some Provigil?  (It's an anti-narcolepsy drug, which apparently allows one to maintain brain functionality in spite of sleep deprivation.  And for the record, the only drug I'm actually taking is claritin.)

I'm not a scientist, and I don't know what the side effects of these drugs are.  But a few months ago, after being up most of the night with one of the boys, I went to work, and was pretty fuzzy around the edges.  And then I realized that I had spent a good two years or more in that kind of a fog every single day.  And if someone had offered me a drug to make it go away (other than caffeine), I'm pretty sure I'd have jumped for it.

If asprin were invented today, it would probably require a prescription -- between its blood thinning action and the potential for Reye's syndrome, it's easy to make the case that it's too dangerous to be available without control.  Caffeine is ubiquitous, but I could argue that it's as much of a mind-altering substance as Provigil or Ritalin.  I think the editorial in Nature arguing for legalizing these drugs for people who aren't "ill" is pretty convincing.

*If you're wondering about the title, it's a reference to Nancy Kress' excellent sci-fi novel Beggars in Spain, where she explores what happens if some people are genetically engineered not to need sleep, and thus have an advantage over the rest of us.  Pills are certainly more egalitarian than genetic modification.

20 years of World AIDS Day

I knew that December 1 is World AIDS Day, but I hadn't realized that it was first observed 20 years ago.  

I'm young enough, and my friends are young enough, that I didn't lose anyone close to me to AIDS. But in 1990, I had a summer job working for a doctor whose practice was mostly AIDS patients  She was an internist in the West Village in the '80s, and was one of the first to notice that a bunch of people were coming in with diseases that were supposed to be incredibly rare.  She was always running really late, and gradually most of the healthy people stopped coming to her practice, but if you were sick, she was a great doctor to have on your side.  She spent hours dealing with the paperwork needed to get people enrolled in clinical trials, because that was the only way to get the drugs that might possibly help them.  And she'd visit her patients in the hospital and sit with them and read the riot act to the staff who were afraid to touch them.  (Me?  I answered phones and filed charts and entered data.)

I don't know what I'd have thought if a time traveler from 2008 had come with a news report.  So wonderful that HIV is a manageable infection, something you can live with, not an automatic death sentence.  But I don't think I ever imagined that 20 years later, there still wouldn't be a cure.  And if you had told me that gay rights groups would be focused on marriage equality, with hardly a mention of HIV/AIDS, I simply wouldn't have believed it.

Why not make organ donation opt-out?

An organ transplant -- especially when it's a repeat job -- is never a simple operation, but all things considered, Annika seems to be doing pretty well.  I'm still keeping her and her family in my thoughts and prayers.

On one of the posts about her (not here, on another blog), someone posted a comment urging people to join something called LifeSharers.  Their stated goal is to increase the number of organs donated and reward the people who choose to donate, by giving people who commit to donate organs higher priority to receive organs themselves.  They're doing this by creating a free membership organization, where the condition to belong is that you commit to a) donating your organs and b) specifying that other members should get priority for those organs.

There's an interesting logic here.  It gets around the primary objection to paying people for their organs (e.g. that the amounts involved could be coercive, and might motivate your next of kin to make decisions that were in their best interest rather than yours).  They explicitly don't require that you be in good enough health for anyone to use your organs to join, so there's no discrimination in membership.  (Although, as T points out, since they seem to be mostly recruiting through the internet, there's a procedural bias towards the populations that are more likely to use it.)  And this doesn't appear to be one of the predictably irrational cases where you make people less altruistic by offering an external reward.

But, in looking at their site, it seems like many of the people who are endorsing it are at least as motivated by a desire to show that incentives and free markets can produce a better outcome than government solutions as they are by they desire to have more organs transplanted.

Because there's another very simple way to increase the number of organs that are available for transplant, that they don't mention at all.  Make organ donation opt-out, rather than opt-in.  In other words, rather than having to specify that you want to donate your organs (and then have your next of kin confirm that intention), it would be assumed that you gave consent for donation unless you specified otherwise.  This sounds like a radical concept, but  a bunch of European countries do it, and they have donation consent rates between 85 and 99.9 percent*, compared to less than 30 percent in countries that have opt-in policies.

Fundamentally, these alternative approaches to increasing donation are based on very different hypotheses about why more people don't donate.  LifeSharers is based on the hypothesis that there's not enough of an incentive to donate.  Opt-out is based on the hypothesis that thinking about dying freaks people out and so they avoid doing it as much as possible.  I'd put my money on the latter.

The UK is considering moving to a system of presumed consent.  Does anyone think it has a chance in the US?

*Sweden is the outlier here, at 85.9 percent, with no other opt-out country at under 88 percent.  I wonder if there's some cultural issue here against organ donation, or if they're more aggressive than the other countries in making sure people know of their right to opt-out.  Either way 85.9 percent is a heck of a lot higher than 30 percent.

Paid sick days

"Achoo!"
"Bless you."
"Achoo!"
"Gezundheit!"
"Achoo!"
"Damn it, you better not be getting sick."

Tomorrow evening, I'm attending a fundraiser in support of the Ohio Healthy Families Act, which would guarantee full-time workers 7 paid sick days a year (with part-timers eligible on a pro-rata basis).   The ability to take a paid sick day is something that professionals take for granted, but only about half of American workers have any paid sick days, and many of those that do, can only use them if they're personally sick, not to care for a sick family member.

Paid sick days are good for workers, good for families, and good for public health.  Trust me, you don't want restaurant workers coming to work sick, and you don't want other families sending their kids to school sick because they can't afford to keep them home.

I support federal legislation for paid sick days, but I also think it's great that folks in Ohio are using the ballot initiative process to try to move the idea.  For one thing, it might well get passed before anything happens at the federal level.  For another, it helps mobilize low-income workers to vote in November.

Online rally for paid sick days

Head over to www.everyonegetssick.org and join the online rally for paid sick days.

Because you shouldn't have to choose between taking care of your sick kid and having the money to pay your rent.  And from a public health perspective, you really don't want the people who are preparing and serving your food, or loading your groceries at the supermarket, to be dragging themselves into work even though they're sick because they can't afford to stay home.

If you live in DC, check out www.dcsneezes.org and give your city councilmember a call.  They're voting on the DC Accrued Sick and Safe Leave Act on Tuesday.

And if you're in Illinois, read this post to learn how you can help.

Here's the NY Times editorial, Catching Up on Family Values, from earlier this week.

Hyde: 30 years is enough

In honor of the Roe v. Wade anniversary, I'm highlighting the Hyde- 30 Years is Enough campaign to lift the restrictions on Federal funding of abortion services to poor women who receive health insurance through Medicaid.  Here are some of the reasons I oppose the Hyde amendment restrictions:

• I believe that the ability to control one's reproduction should not be limited on the basis of income.  NNAF says it better than I can:

"We call for full public funding of abortion as a part of comprehensive health care for all, and support for low-income women to care for their children with dignity.  We stand for reproductive justice, a world in which all women have the power and resources necessary to make healthy decisions about their bodies and their families."

• One of the main effects of the Hyde restrictions is to push abortions from the first trimester into the second.  This increases the health risks to the woman, raises the cost of the procedure, and pushes closer to the viability line.

• The logic of the Hyde amendment -- and the related laws that prohibit coverage of abortion for federal employers, military personnel, and their dependents -- is fundamentally flawed.  Supporters argue that even though abortion is legal, people should be able to avoid having their tax dollars support something that they consider immoral.  Well, I can think of a number of things that my tax dollars support that I consider immoral, and I don't get to opt out. 

If you're not poor, a federal employee, or a member of the armed services, these bans don't affect you.  Now.  But if you hope to someday be covered by a public health insurance system, you should be paying attention.

Choose your candidate

The Washington Post website has an interactive "choose your candidate" tool that purports to show you which candidate you should be supporting, based on their public statements on a variety of issues, and how important you say these issues are.  I spent some time playing with it, and it mostly demonstrated to me how close the Democratic candidates are on most of the issues that I care about.  If you can parse the differences between what they're all saying on Social Security or immigration, you're doing better than I am.  And while the tool lets you say how much you care about the issue in general, it doesn't have any way for you to indicate how much you care about the differences in the candidates' positions.  I think I gave up on it about halfway through, when it was saying I should be supporting Chris Dodd.

Precisely because the candidates are so close together on policy, the areas where they disagree, even a little, are getting a lot of attention, perhaps excessive.  One of the areas where some differences have shown up is on health care.  Kucinich is the only one standing up for a true single payor system, while Obama has criticized Edwards and Clinton for requiring everyone to get health insurance.  He's dead wrong on this -- both because you really do need to get everyone into the insurance pool in order to avoid people freeloading until they actually get sick, and because the attack on "mandates" is likely to come back and haunt him if he actually gets elected.  (I don't have the energy to go hunting for a full set of links right now, but this has been exhaustively discussed in the wonkosphere. )

So, on one of the few areas of substantive difference, I think Obama's wrong.  But I still think he's my pick.  I'm embarrassed by that.  I'm a self-proclaimed policy wonk.  But he makes me want to believe. 

***

On a related topic, this week you'll see an ad in my sidebar from the fine folks at One.org, who have asked all the candidates about what they'd do to fight international poverty and disease. Spotlight on Poverty and Opportunity is a similar exercise focused on domestic poverty.  Check them both out.

FlavorIT

A month or so ago, I got an email from FlavorX, asking if I'd be interested in a sample of FlavorIT, their new home kit for adding flavorings to medicine.  I responded with an enthusiastic yes.

I'd heard of FlavorX a couple of years ago, but at the time, they only had products for use by pharmacies.  Pharmacies add the flavorings either free or for a nominal charge, but generally only for prescriptions that they fill -- it's a way to stand out from other companies, in what is basically a saturated market.  But because we have a HMO, we have to get our prescriptions filled at the HMO's pharmacy -- and they don't do flavorings.  So after much calling around, we finally found a kindhearted pharmacist (at Alexandria Medical Arts, for anyone in the area) who was willing to do it.  (We had our cat's prescriptions filled there, so they did make some money off of us.)

So, I was thrilled to hear that these flavorings were now available for home use.  But, I didn't want to post about it until we had actually tried it, and D has been relatively healthy of late.  But the other day, he complained of a stomach ache until we broke out the Zantac, and gave it a try.  The kit comes with a bottle of sweetener and four different flavorings.  I think we did a drop of the sweetener and one of the bubblegum.  He still grimaced at the taste -- but he drank it. 

So, if you have a kid who resists taking medicine, I'd definitely give this a try.  The one thing that I wish they did differently is provide a medicine syringe for mixing the flavorings in, rather than a spoon.  The syringe wastes less medicine, and is good for shooting the medicine into the back of the mouth, so there's less opportunity to taste it.

Good news, bad news on SCHIP

The good news is that the House passed the SCHIP reauthorization bill.  The bad news is that the 265-159 vote margin is not going to be enough to override a veto.  Congress will presumably include SCHIP in the continuing resolution that it will need to pass by September 1, and it will continue at current levels until at least sometime next year, probably until 2009.  That's going to mean real cuts in some states.

Here's the roll call.  What immediately jumped out at me is that my representative, Tom Davis, is one of the Republicans who voted against the original House bill but for the compromise bill.  I had been wondering about that after getting his response to my email plea for SCHIP last week, which said, in part:

"H.R. 3162 was not SCHIP.  It was an excessive expansion of a good program, an expansion that could undermine the program's effectiveness and a backdoor effort to move toward government run health care....   

Given the wide range of problems with this legislation I voted against it when it came before me in the House. It passed, however, by a vote of 225-204.  The Senate passed a narrower expansion of the SCHIP program. I am hopeful that as we proceed to a conference we will return to the core principles established in the original SCHIP."

I assume that Davis is going to run for the Senate seat that John Warner is vacating.  I think this vote will hurt him in the Republican primary, but help him in the general election if he gets nominated.  Or maybe I'm being too cynical -- many Republican voters support health care for kids too.

Added: I heard this afternoon that there's been another recall of Thomas trains for lead-based paint.  Unlike the first go-around, we do have some of the affected pieces, and will send them in for an exchange.  But I still wish that the American public was half as outraged about SCHIP as it is about lead in toys.  Nick Anderson got it right a month ago.

Support health care for kids

I don't have a lot of energy to post tonight, but I wanted to be sure to share Families USA's website on how to contact your representatives to urge them to support the bipartisan SCHIP reauthorization against Bush's veto threat.

Or call tollfree: 1-866-544-7573 -- thanks to SEIU.

Some quick points:

• In a country as rich as this one, no one should have to choose between taking their kid to the doctor and having enough to eat, or having the heat turned off.
• Kids with insurance are more likely to get preventative care, more likely to be seen when sick before something minor becomes something big.
• Families with insurance are more likely to get to make doctor's appointments, rather than have to wait to be seen in a clinic or ER.  That means their parents don't lose as much pay.
• Covering children is actually remarkably cheap as good public policies go, on the order of $2,000 per child per year.
• In the states that are covering higher income families, they're requiring families to put up copays and premiums.  It's not a free ride.
• As far as I can tell, the Bush Adminstration's main complaint about SCHIP is that it works, and that other people might start asking why they can't buy into public health insurance pools.
• On the radio this evening, Dennis Smith was claiming that the problem with expanding SCHIP is that it would create adverse selection against private insurance programs, by making the insured pool older and sicker.   Funny, the Administration doesn't seem to worry about adverse selection when it comes to their proposed tax subsidy solution to uninsurance.
• When the Administration starts talking about crowd-out, they never talk about the quality of the private health insurance plans that people are abandoning.  In many cases, they're insurance in name only, with overly high deductibles -- or worse, ridiculously low annual limits.  In some cases that's because the employers are being stingy, but just as often, it's because they're desperately trying to find a way to keep offering health insurance in the face of constantly rising prices.
• In a country as rich as this one, no one should have to choose between taking their kid to the doctor and having enough to eat, or having the heat turned off.  Yeah, I know I said it before, but it's worth repeating.

Update: go read Cecily's post on health insurance

Our mental health "system"

Point of evidence #1: The Cho family speaks out.

Point of evidence #2: David writes about his brother.

Point of evidence #3: One in four children in Virginia's foster care system are there because it's the only way to for them to get mental health treatment.

Hypnosis and the placebo effect

My mother in-law is getting a new car, and she very kindly offered to give us her old one.  It's 4 years newer than our second car, and was a much nicer car in the first place.  The catch is that it's a stick shift, and I haven't driven one in approximately 11 years.  Ok, everyone promises it will come back to me.  I spent some time practicing in an empty parking lot, and then last week I started using it to drive to the metro station.

Overall, it's gone pretty well.  Yes, I've stalled out at stop lights a few times, but overall the drivers around me have been remarkably gracious about waiting for me to get the car moving again.  After a week and a half, I'm doing a lot better, and am no longer terrified.

Or at least my conscious mind is no longer terrified.  My body seems to have a different opinion.  Every day last week, I needed to use the bathroom pretty much nonstop from when I woke up until I left for work, and by Friday, I felt sick pretty much all day.  I was fine over the weekend (when I drove our automatic transmission minivan) and then my gut acted up again Monday morning.  Not fun.

So, I spent some time on Monday googling, and wound up downloading two MP3s from this hypnosis site, one on stopping irritable bowel syndrome,* and one on overcoming fear of driving.  Since the problem was clearly originating in the mind-body link, it seemed logical that was a good place to start trying to fix it.  And telling myself that I was being ridiculous didn't seem to be helping.  I'm pretty sure that hypnosis can't hurt, and the downloads are cheap enough that it was worth a try.  I listened to them on both Monday and Tuesday, and yesterday my gut was better and today was better yet.

I told T, and he said he was glad it was helping, even if it was the placebo effect.  My response was "what exactly do you think is the difference between hypnosis and the placebo effect?"  As far as I can tell, hypnosis is essentially a way of harnessing the power of mind over body that makes the placebo effect work.  I suppose you could test whether hypnosis directed at a specific goal was more effective than just putting someone in a trance and not making specific suggestions, but that would only work if you were able to get people into enough of a trance that they didn't know what you had said.  (I  personally have no idea what's on either MP3 I listened to between the introductory section and the ending, but I've had that happen in meetings too.)

* The MP3 begins with a disclaimer that only a doctor can diagnose IBS and that you should seek medical treatment, etc. etc.

Prayers for Elizabeth Edwards

If you want to send a note to Elizabeth Edwards, the campaign has set up a page for people to write to her.  I know she'll be in my thoughts and prayers. 

My guess is that John would have suspended his campaign (as was inaccurately reported this morning), but that Elizabeth told him no way.  I hope she stays in good health for as long as possible.  That family has certainly had its share of heartbreak. 

black mothers' sons

Last year, Landismom wrote that the essence of organizing is to give people anger, hope, and a plan.  In that spirit, I offer these links:

• Anger:  I was filled with fury at this story in today's Post, about a 12 year boy who died for want of a dentist.  By the time he was seen, the infection in his abscessed tooth had spread to his brain.  My office is opposite the break room at work, and all day I heard my coworkers exclaiming in outrage as they picked up the newspaper.  We work on poverty issues, and so sometimes we get a little jaded, lose a little of our outrage.  But this story hit home.
• Hope:  Via Miriam at Everyday Mom, and Nanci at From the Mom Zone, I read about Wakanheza, a program of the Ramsey County public health office to get people to identify people in stressful situations and reach out with a helping hand.
• A Plan: Campaign for Children's Health Coverage.  Insuring all children is only a start of a solution -- adults need health insurance too.  But kids are relatively cheap to insure, and there's an existing program -- the State Children's Health Insurance Program -- that provides a lot of the framework for doing so.  And it's up for reauthorization this year.  So sign the petition, and write your Senator and Representative.

I've had Ella's Song stuck in my head for half the day.  I'd like to see as many people learning about the death of Deamonte Driver as about the death of Kyle Miller.  (And yes, I know the odds of dying from an abscessed tooth are probably about as low as the odds of dying from seat belt failure.  But a kid shouldn't have to walk around with his teeth rotting out of his mouth for months either.)

wear sunscreen

Today I'm reviewing two books that were sent to me by their publishers.  Both are about health and disease prevention, and have a forward or introduction (what's the difference?) by the authors of YOU: The Owner's Manual.  One focuses on kids, while the other is organized decade by decade, from pre-natal to "the eighth decade and beyond."  Both of them basically tell you to exercise regularly, eat your veggies, and wear sunscreen.

First up is the book about kids: Good Kids, Bad Habits: The RealAge Guide to Raising Healthy Children, by Jennifer Trachtenberg, MD.  The email I got offering me the book showed the cover, which has the title spelled out in refrigerator magnets, with a carrot and some broccoli magnets thrown in for good luck, so I knew it was likely to push some buttons for me.  As long-term readers of this blog know, I have some issues around nutritional advice for parents -- I know darned well what a healthy diet looks like, and that my older son's diet isn't quite making it to Planet Power but have more or less accepted that we can only control what we offer him, not what he eats.

So, when I got the book, I was predictably irritated by the blithe assumptions that involving children in food prep and cutting food into fun shapes would be enough to win over a picky eater.  But I was somewhat surprised (and pleased) to see that the book covers far more than nutrition, covering topics from good hygiene (wash your hands, floss your teeth) to safety (buckle your seatbelt, wear a bike helmet) and emotional well-being (spend one on one time with kids, develop relationships with extended family).  Overall, the book offers pretty solid, standard advice. 

My fundamental concern about the book is who is the audience for it.  It seems to me like the sort of well-educated middle-class parents who are likely to buy this book will generally know almost everything that's in it already.  Certainly, that seems to be the conclusion of the parentbloggers who have reviewed it.  Anxious new parents might buy it, but relatively little of the book is about babies. Maybe it could be a text for a parenting class?  Or you could give it to grandparents who might listen to a doctor about seat belts more than to their children?  I don't know.  I find it pretty hard to imagine anyone reading the book cover to cover.

The second book is The Checklist: What you and your family need to know to prevent disease and live a long and healthy life, by "Dr. Manny" Alvarez.  I focused on the chapters for 0-9 (the age of my children) and 30-39 (that would be me). 

The chapter on young children suffers from the problem that they've only got 38 pages to cover a huge developmental range.  So Alvarez makes no attempt to discuss the full range of health issues, but rather goes through a checklist of topics that you might have heard about in the news -- cord blood, circumcision, vaccines, autism, ADD.

The chapter on 30-something adults has a different problem, that there are very few health problems that are unique to this age group.  So instead you get a bland discussion of nutrition, skin care, and urinary tract infections, and then a laundry list of ailments that (fortunately) relatively few people in this age group are actually likely to experience, from cervical cancer to MS.

Fundamentally, I think the decade by decade organization just doesn't work.  Good preventative habits don't really change that much from decade to decade, and the litany of diseases would have worked better in simple alphabetical order.   The only people I could imagine reading this book cover to cover are hypochondriacs looking for new diseases to obsess about.

Also, the writing/editing was sloppy.  For example, from the circumcision discussion: "The AAP also found that the risk of penile cancer in an uncircumcised man is three times more likely than in a circumcised man, though penile cancer is rare in the United States, just one in one hundred thousand males has it."  Someone get this man a semicolon.

Doctor, doctor

When people ask me what aspect of parenting has been the biggest surprise to me, my answer is always that I didn't realize how much time I would be sick.  I've been coughing or sneezing pretty much constantly since the new year.  That's why I don't buy the argument that exposure to lots of germs in preschool means that kids won't get sick later on -- if that were true, I should be immune to just about everything by now.

It hasn't been a terrible winter in terms of illness -- no one has ended up in the hospital or the ER, which is my primary measure of success -- but it hasn't been a great one.  D's been on oral steroids twice for his asthma, which doesn't make me happy, although he seems to be doing much better now that we've increased his maintenance dose of Qvar.  We also have an appointment for him to see the allergist next week.  And N's now on oral antibiotics for an ear infection, as well as a topical antibiotic for impetigo.  I feel kind of guilty about that one -- we had assumed that he had just rubbed the skin under his nose raw from the constant drippage, but as soon as the doctor saw it, she said it was an infection.

And N was complaining about an ear ache for several days before we finally brought him in.  We got the memo that many ear infections will go away without antibiotic treatment, so were giving him advil and waiting and seeing.  But when his fever started to come back, I concluded that this wasn't going away on its own.

I hate having to make these decisions.  This is why the Republican argument that the problem with our health care system is overuse drives me crazy.  I'm smart and well educated, but I didn't go to medical school.  I probably err on the side of avoiding going to the doctor, because I know that there's not much they can do for routine colds.  But this means that sometimes with hindsight I wish I had gone sooner.  It's nuts to make it more expensive to bring a kid in for a doctor or nurse to take a look, just in case.  Because the one night that D spent in the hospital with asthma two years ago cost our insurance company more than all the medical treatment everyone in the family has received put together since.

Update:  N puked in the middle of the night.  Is it the Amoxicillan?  Or another bug?

Bush-care

I'm watching the state of the union address and trying not to grind my teeth. 

I'm expecting that the most interesting part of the speech will be the health care proposal.   Based on the advance info, it's a terrible proposal, but I think it's massively significant that Bush feels a need to have a health care proposal.  12 years after the crash and burn of the Clinton health care proposal, the demand for change seems to have outweighed the ghosts of Harry and Louise.

The one part of the Bush proposal that I agree with is that it doesn't make sense for employer-provided health insurance to be fully tax exempt, with no limit.  It costs the government a huge amount of money, and mostly benefits the wealthy and middle-class.  I'd be happy to limit it if the funds went to something that was actually going to expand coverage.

But it's nuts to think that everyone is going to buy health insurance on the individual market.  It's way too expensive for low-income families (and a tax deduction doesn't help those who don't owe income taxes) and out of reach for anyone with a pre-existing condition.  One of my friends who lives in Massachusetts says that the plans there are costing 2 -3 times more than estimated when the individual mandate law was passed.  Health insurance has to involve risk pooling or it's just a way of smoothing out spending over time.

Some links:

• Urban Institute analysis of the plan.
• Ezra Klein at TAPPED on the plan.
• Paul Krugman's column and further explanation.  (You can find these copied out from the select wall at Economist's View which also has a roundup of other comments on the plan.)

Ok.  I was wrong.  The proposal to reduce gasoline usage by 20 percent in the next 10 years is more interesting than the health insurance.  I have no idea how he thinks we're going to achieve this.

Poverty, Income and Insurance, 2005

This morning, the Census Bureau released the 2005 poverty figures, as well as data on income and health insurance coverage.

• The official poverty rate was 12.6 percent, statistically unchanged from the 2004 level (12.7 percent).  The Administration may try to spin this as good news, but it's really a sign of how little the benefits of this "recovery" are spreading.  As my friends over at the Center on Budget and Policy Priorities point out, it's unheard of for poverty to still be higher four years into a recovery that it was at the low point of the recession.
• Median household income increased slightly, even though median earnings of year-round full-time workers, both male and female, fell slightly.  I think that has to mean more people per household were working, or were working more hours.
• I think the biggest story in this release is the decline in health insurance coverage.  46.6 million people in the US didn't have health insurance, for an uninsurance rate of of 15.9 percent.  And that figure would look much worse if there hadn't been a big expansion of public insurance for children in the 1990s.  I just don't see anything turning around the movement away from employer-provided coverage.  I read something recently (in the New Yorker, maybe?) that argued that the campaign to require WalMart to provide health insurance benefits is really a back door way to try to get universal coverage, by getting employers to push for it.  Makes sense to me.

For those of you looking for a Tuesday Book Review, I'll be posting about The Price of Privilege tomorrow.

Back on the meds?

D's been off his asthma medications for a couple of months.  He hasn't had a real attack since the first one, in February 2005.  Last winter, we treated every cough as if it might be asthma-related.  He's been totally symptom free since the spring, and his pediatrician agreed that we might as well see how he did without the steroids.  There's pretty good evidence that long-term use of inhaled steroids retards growth slightly, and lord knows that he could use the extra inches.

He's got a cold, and a little bit of a cough.  School's about to start, and I've read the study showing the dramatic peak in attacks among school-age kids in September and October.  The doctors quoted in that article argue forcefully that asthma should be treated as a chronic, not episodic disease.  But a lot of kids also grow out of asthma.  No one's been able to give me an answer as to how to find out of he's outgrown it other than keeping him off the meds and seeing what happens.

Vaccines

Last week, the federal Advisory Committee on Immunization Practices recommended adding a new vaccine, Gardasil, to the standard immunization schedule for 11 and 12 year old girls.  Gardasil immunizes against several strands of the Human Papilloma Virus (HPV), which causes genital warts and cervical cancer.

As Rivka at Respectful of Otters explained, the conservative groups that had initially responded to the prospect of such a vaccine in a hysterical snit ("How are we going to stop people from having sex if we can't threaten them with deadly disease?"  -- no that's not a literal quote, but the real ones aren't far off), have moderated their message, and are now saying that they're glad the vaccine is available, but it shouldn't be mandatory.  This change is rhetoric seems to have been effective: the NYTimes says that "a few religious groups have expressed mild reservations about the vaccine."  But Rivka argues that there will always be exceptions available for religious objectors, and if the vaccine isn't made mandatory, states may not pay for it.

If I understand the issue correctly, assuming that HHS accepts the ACIP recommendations, the new vaccine will be covered under Medicaid and the federal Vaccines for Children program.  So really poor kids should get it (as long as they have access to the documents to prove their citizenship, but that's a topic for another day).  And most private insurance will cover it as well.  The problem is the state programs that provide vaccines for kids who aren't poor enough to qualify for Medicaid, but don't have insurance.  Gardasil is expensive -- $120 per shot, with a series of three shots required -- and covering it would nearly double the cost of some states' immunization programs.

However, on the parenting lists that I'm on, most of the discussion has been from parents who aren't sure that they want to give their daughters a new vaccine, especially if they're not sexually active.  I'm not going to quote anyone without permission, but what I've been hearing is pretty similar to the parents quoted in this article about the vaccine.  My kids are way too young, and the wrong gender (although eventually Gardasil or another similar vaccine is likely to be available for boys and men as well), so it's not a decision I'm personally facing.  But I tend to be pretty pro-vaccine in general.

***

I saw a poster on the metro over the weekend, seeking healthy volunteers to participate in clinical trials for a malaria vaccine.  I don't remember the URL and google has failed me in digging it up, but I'm going to look for the poster again.  Obviously, I want to learn more about both the vaccine and the study protocol, but I'm seriously considering doing it. 

Heath insurance

AP had a depressing story this week on the increase in "moderate to middle-income" Americans who were uninsured for at least a part of last year.  It's not particularly surprising, though, since fewer employers are providing insurance, and buying individual insurance is out of reach for most lower-income families.

A couple of people have asked me what I think of the new Massachusetts health insurance law, which requires everyone in the state to have health insurance (or face fiscal penalties) and provides subsidies for low-income individuals and families.  I'm a little dubious about whether it will work, but it's certainly worth trying.  No one else is even making a serious attempt at achieving universal coverage, and I have to admit that the Massachusetts model is a lot more politically feasible that my preferred choice of a single payer model.  And I've got a lot more confidence in this approach than in Health Savings Accounts as the solution to the uninsurance problem.

If you want to know the details of the argument for an individual mandate system, check out the New America Foundation, which has been pitching this approach for a while.  But in brief, the argument is that there are a significant number of young healthy people who could (theoretically) afford to pay for insurance, but gamble that they won't need it.  They know that if they really get sick, they can show up at a hospital, and won't be turned away for inability to pay.  An individual mandate therefore both makes them pay their fair share, and reduces the costs of uncompensated care, freeing up funds to pay for insurance for those who really can't afford to pay.

The reason I'm skeptical is that I haven't seen anything that explains how the Massachusetts approach deals with the problem of the small minority of people who have major health problems, people like Annika.  Unless you have some way of putting such people in a risk pool with a large number of mostly healthy people (as in the typical employer-provided plan), there's no way they can afford an insurance plan that charges their actuarial costs.  As soon as people are choosing their own plans, anyone who is healthy will keep their costs down by staying out of insurance plans that are attractive to very sick people.  And so the costs of those generous plans spiral up and up.  If anyone knows how Massachusetts is dealing with this problem, I'd love to hear about it.

Doctors and work hours

My dad sent me two articles that he thought I'd find interesting in light of the ongoing discussion here about work hours.

The first is an article on The Relationship between Specialty Choice and Gender of US Medical Students, 1990-2003.  It debunks the idea that the increase in the fraction of doctors who are women is responsible for the decreasing interest of medical students in specialties where hours are considered "uncontrollable," especially internal and family medicine, pediatrics, ob/gyn and general surgery.  In fact, in every time period examined, women were more likely than men to be planning on uncontrollable specialties.

The second is an article from the Johns Hopkins Medical School alumni magazine about the changes involved in implementing the 80-hour/week restrictions on interns' and residents' working hours.  On the one hand, it's a little surreal to read about a world in which 80-hour work weeks are considered virtually part-time.  But, it's also a story about a place where people swore that it was impossible to limit working hours without destroying the experience, until they didn't have a choice, and then they managed to do it.  And if law firms and game companies suddenly faced economic disincentives to working people huge hours (instead of strong incentives to do so), they'd change as well.

Sad and Angry

Tuesday book review is postponed, because I'm too sad and angry.

I'm sad because Mr. Badger died yesterday.  No, he's not someone I know in person.  He's the husband of an anonymous blogger, known to me only as Badger.   He was my age, with a young son.   And just under a year ago, he was diagnosed with liver cancer.  Her writings have been heartbreaking.

And I'm angry because of the mess that passes for a health care system in this country.  I'm angry because one of Badger's friends had to pass the virtual hat to raise money to pay for Mr. Badger's hospice care.  I'm angry because Cubbiegirl has a tooth infection and is puking from the pain and can't afford to have it extracted.

And the scary thing is that neither Mr. Badger nor Cubbiegirl is one of the 45.8 million Americans without health insurance, as reported today by the Census Bureau.  Mr. Badger had health insurance, but he ran through the $100,000 annual limit and it only covered a portion of the cost of hospice care anyway.  And Cubbiegirl is a veteran, but the VA health system doesn't cover dental care, unless it's service related. 

This week's New Yorker has a nice article by Malcolm Gladwell on the problems caused by lack of insurance and under insurance, and how the current Administration is full of people "who regard health insurance not as the solution but as the problem."  It's worth a read.  But it will make you angry too.

Sick kid

D. had a full blown asthma attack (his first) yesterday afternoon and spent the night in the hospital.  He's doing well now, and we hope he'll be home later today, but I'm obviously not going to have a chance for a while to respond to the very thoughtful posts on Warner's articles.  I will second the recommendation to check out the dicussion at Chez Miscarriage.

One thought before I shower and head back to the hospital.  I have a job where I can take leave on short notice, with pay and without risk of losing my job.  I have an extremely involved spouse.  And I have good health insurance.  And this is still really hard.  Lots of people are missing at least one of these, and there's a significant number of parents who don't have any of them.  And poor kids are disproportionately likely to have asthma, probably due to environmental factors.

Update: We're all home, and D is breathing easily (although with regular nebulizer treatments).  We need to meet with his regular pediatrician next week to figure out where we go from here with identifying the trigger and deciding whether he needs ongoing maintenance treatment.  But the immediate crisis is over.  Thanks for the good wishes.

Health insurance

In 1993, when the Clinton administration was just getting started, Senator Moynihan urged them to start work on welfare reform immediately. Clinton said no, he needed to take care of health insurance first, because how could you expect low-income parents to give up the guarantee of health insurance from Medicaid for jobs that didn't provide health insurance. Well, as everyone knows, the health insurance proposal died, and by the time Clinton turned to welfare reform, the Republicans controlled Congress.

With that history, I'm reluctant to say that the health insurance problem needs to be solved before we can try to address work-family issues. But the linkage of health insurance to employment is probably the single largest barrier to high-quality part-time jobs. As the cost of health insurance doesn't go up with the number of hours someone works, it makes sense for employers to want to get as much possible work out of their current workforce rather than to hire more people for fewer hours each.

Kerry supports a number of changes that would expand access to health insurance, but doesn't propose to break the basic link between employment and insurance. He would address the problem that Amy raised -- that states aren't enrolling all the eligible children under SCHIP -- by providing incentives to states that expand enrollment.

The statistic that I've heard is that it costs the automakers over $1,000 more per car to build a car in Detroit than to build the same car in Canada, because of health insurance. I don't understand why employers aren't demanding that government take over their health insurance costs.

Walking the walk...

The new issue of Working Mother hit my mailbox yesterday, containing their new list of the 100 best companies for working mothers. I'm more than a little dubious about these lists, because there's often a big gap beween the official company policies that are captured in these formulas and practice on the ground, especially around part-time work and non-standard schedules.

My sense is that if you have a supportive boss, you can often get flexible arrangements even if they're not company policy, and if you don't, you're out of luck, regardless of what the manual says. I'd love to see data on what fraction of the workforce is taking advantage of these policies, broken out by gender (are they just creating a mommy track?), and on the career outcomes for people who work part-time or take extended leaves. I work for the federal government, which is overall reasonably family-friendly (with the glaring exception of ZERO paid parental leave), but I know people's experiences vary dramatically from department to department and even office to office.

If any of my readers work at one of these 100 best companies and want to comment on what it's really like, I'd love to hear your point of view.

Amy pointed out that in my discussion of flexibility on Monday, I didn't talk much about stable flexible arrangements, especially shifted schedules. She's right, and that's ironic, as such schedules are very common in the Federal government. People love them, especially people who drive to work and want to avoid the utter craziness of DC-area traffic during rush hour. Working Mother reports that flexible hours are among the most common family friendly benefits, with 57 percent of companies offering flextime, and 34 percent offering compressed workweeks.

Of the benefits discussed in the study, the most common offered nationwide are dependent care flexible spending accounts, offered by 73 percent of all companies and mental health insurance, offered by 72 percent. (These figures are attributed to a Society for Human Resource Management survey, which I think means that it's mostly large companies who were asked.) The least commonly offered benefits are take-home meals (3 percent), business-travel child care reimbursement (3 percent) and emergency/backup elder care (2 percent).

I'd also like to call attention to Corporate Voices for Working Families' efforts to increase flexible working options for low-wage and hourly workers.

Many companies -- even those that have very enlighted policies for their professional workforces -- offer much less flexibility to their production and support workforces. The National Partnership for Women and Families reports that only 47 percent of private sector workers have ANY paid sick leave. At a conference I attended, one woman explained how her company, a large food industry corporation, had just changed their policies so it was possible for production line workers to take less than a WEEK of leave at a time (but only if they could find someone to substitute for them on the line). I'm embarassed to admit that such a possibility had never occurred to me in my privileged professional position.