US Immigration: the Curiosity of Numbers that Don’t Add Up

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The chart below shows data for population growth pulled from the Census Wonder data system. A positive number in the “Missing” column means that the population grew by more than the net of births, naturalizations and deaths. A negative number means it grew by less than the combination of births, naturalizations and deaths.

Here’s the problem. Say you want to assume that there are 1 million illegal immigrants entering the US in 2015. To make the numbers work, you have to have more than 800,000 people living in the US leaving.

  • Possible explanation 1: That’s the American Diaspora, and it appears to be quite real.
  • Possible explanation 2: There’s less illegal immigration than most people think.

In 2011 and 2012, we appear to have had more people leaving the US than entering.

In fact, if Explanation 1 is true, then were we to stop illegal immigration, we would have a steady population drain and slower economic growth. Without major changes in productivity, economic growth is directly linked to the size of the workforce. 

This is just a preliminary analysis. I’m looking for additional data.

You may also notice from the table that the death rate is edging upward. That’s probably just the natural result of the aging US population.

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How Americans Drive Up Their Own Health Insurance Costs (UPDATE)

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This is not a defense or excuse for the exorbitant pricing or profits in the health insurance industry in the US.  As with most social issues, there is no single cause of a problem. The industry owns part of the issue, Congress owns a major part, but consumers also own a piece. It’s time to recognize that and do what you can do about it.

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I grew up in an advertising era touting “rugged individualism.” The icons of that era included John Wayne, the TV character Palladin, and the advertising “Marlboro Man,” all part of a mythology that people could cut their own path regardless of others.

Unfortunately, that’s not how life works. If your reading this, someone else probably had provided the electricity for  you. If you also write, the court system protects your intellectual property. If you have a retirment account, you depend on financial regulators to protect your assets. If you eat (and you’d better be doing that), there’s the farmers and fishermen who provide what you consume. We are a connected network of people, whether on the grid or not. Whether you like it or not.

That’s blatantly the case in health insurance. There was a time when health insurance didn’t exist and didn’t matter. There were relatively few doctors in the 1850s, medical knowledge was relatively crude, and life expectancy was short.

  • In the Americans, life expectancy from birth was only 35.1 years in 1850. Life expectancy for slaves was less, with estimates ranging from 22 to 30 years of age.
  • The shortness was due to childhood deaths. If one could make it to age 10, there was a reasonable prospect to live to age 60.

ourworldindata_life-expectancy-cumulative-over-200-years-768x548

Life expectancy has  increased dramatically in the last two years, as you can see from the chart above, from an excellent article by Max Roser. (1)

In most geographies, the major gain in life expectancy came after World War II.

Exponential-PHE-Growth-Irfan

However, the increase in life expectancy comes at a substantial cost. One estimate says that each day of additional life expectancy adds $1.6 billion to medical costs just in the US. (2) However, living longer is just one component of the story of rising health costs.

Behavior matters. Certain things some of us do add substantially to medical costs for each and every one of us. How does that work? It’s in built into the concept of insurance as conceived by Benjamin Franklin.

  • People — healthy and sick — pay into a fund that in turn pays people in their time of need.
  • The required size of the fund is determined by the number of claims and the size of claims. The required size of the fund determines what people who participate have to pay.

That might seem unfair to healthy people, but we have to remember that no one stays healthy forever. Everyone dies. Everyone gets a turn with illness, sometimes more than one turn.

What might be considered unfair is when people do things or allow things to happen that cause illness. For example,

  • The CDC estimates that 36.5 million Americans smoke cigarettes, and 16 million currently have a smoking-related illness. Not everyone who smokes gets sick, but a larger percentage do, and that adds $170 billion to total medical expenses in the US. (3, 4)
    • According to a recent Gallup survey, more than 28% of adults in Ft. Smith, Arkansas, Layfayette, Louisiana, Erie, Pennsylvania and Bristol, Tennessee smoke. The national incidence is 18.2%, down from more than 40% in the 1960s. (9)
  • Obesity is estimated to add $147 billion to national healthcare spending (2008 dollars). (5) That figure may be low due to the large number of undiagnosed diabetics in the US.
  • Alcohol and drug abuse adds another $64 billion to healthcare spending (7)
  • Distracted driving (there are no separate estimates of direct medical costs), but medical bills have been rising even as the severity of injuries has been declining. (6)

The medical expenses that result from these behaviors hit every consumer:

  • Rising healthcare charges (remember the principle of “supply and demand”?)
  • Rising insurance premiums to cover the rising healthcare costs
  • Rising taxes to cover the proportion of expenses the government pays

High spending doesn’t mean better medical results.

With development, health outcomes generally improve, but the U.S. is an anomaly. The U.S. and the U.K. are both high-income, highly developed countries. The U.K. spends less per person ($3,749) on health care than the U.S. ($9,237). Despite its high spending, the U.S. does not have the best health outcomes. [Life expectancy, for example, is 79.1 years in the U.S. and 80.9 years in the U.K. And while the U.S. spends more on health care than any country in the world, it ranks 12th in life expectancy among the 12 wealthiest industrialized countries, according to the Kaiser Family Foundation, a non-profit organization focusing on health issues.] (8)

Europeans and the Chinese government understand the impact of individual behavior on costs. Americans have been more reluctant to understand and accept personal responsibility for how their behavior affects themselves and everyone else. It’s time to grow up and put the myth of rugged individualism away.

 


Sources:

  1. Max Roser, “Life Expectancy,” Our World in Data, undated. https://ourworldindata.org/life-expectancy/
  2. Sean Davis, “8 Charts that Explain the Explosive Growth of U. S. Health Care Costs,” Media Trackers, 1 October 2013. http://mediatrackers.org/national/2013/10/01/8-charts-explain-explosive-growth-u-s-health-care-costs
  3. US Centers for Disease Control and Prevention, “Economic Trends in Tobacco,” last updated 17 June 2017. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm
  4. US Centers for Disease Control and Prevention, “Current Cigarette Smoking Among Adults in the United States,” last updated 1 December 2016. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
  5. US Centers for Disease Control and Prevention, “Adult Obesity Causes and Consequences,” last updated 15 August 2016. https://www.cdc.gov/obesity/adult/causes.html
  6. Rocky Mountain Insurance Information Association, “Cost of Auto Crashes and Statistics,” undated. http://www.rmiia.org/auto/traffic_safety/Cost_of_crashes.asp
  7. National Institute of Drug Abuse, “Trends and Statistics,” last updated April 2017. https://www.drugabuse.gov/related-topics/trends-statistics
  8. NPR, “What Country Spends The Most (And Least) On Health Care Per Person?” 20 April 2017. http://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what-country-spends-the-most-and-least-on-health-care-per-person
  9. Samuel Stebbins, “Cities with the Most Smokers,” 24/7 Wall Street, 22 JUne 2017. http://247wallst.com/special-report/2017/06/22/cities-with-the-highest-smoking-rates/?utm_source=247WallStDailyNewsletter&utm_medium=email&utm_content=JUN232017A&utm_campaign=DailyNewsletter

ACA Repeal: Update

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I’ve been quiet about the recent AHCA legislation. Frankly, the House bill isn’t good for ben_franklinmost Americans, but the assumption is that the Senate will heavily revise the bill before it has a chance for passage. So it’s hard to say what the final legislation will be at this point.

Then it goes to conference committee and the result will return to each chamber for a vote.  So this is a long way from being done.

There are a number of articles enumerating the problems in the House bill. The major issues are

  • Loss of health insurance for millions of Americans
  • Impact on the solvency of hospitals and clinics serving rural areas — where most of the poor live
  • Reductions in Medicaid coverage, especially for children
  • Allowing states to reduce coverage standards in insurance (depart from the ACA’s Minimum Essential standards) — reducing what the insurance buyer gets for their money
  • Raising costs drastically for consumers between the ages of 50 and 64 (1)

With all of these issues, we are still expecting the repeal bill to result in sharply higher premiums for health insurance.

The only positives in this bill are tax reductions for the wealthy.

My major concern is with health screening and checkups. The ACA recognized that the main way to reduce health care expenditures is through early detection and treatment of disease. Removing access to doctors means later detection and much higher costs.

Example: breast cancer, cost of treatment by tumor stage

Stage

0                                         $71,909

I/II                                      $97,066

III                                      $159,442

IV                                      $182,655 (2)

Reduction is access to health care is a commitment to higher medical spending or to reduction of life expectancy.


Sources:

  1. Harris Meyer, “15 quick facts from CBO report on Obamacare repeal bill,” Modern Healthcare, 24 May 2017. http://www.modernhealthcare.com/article/20170524/NEWS/170529946?utm_source=modernhealthcare&utm_medium=email&utm_content=20170524-NEWS-170529946&utm_campaign=mh-alert
  2. Helen Blumen, Kathryn Fitch, Vincent Polkus, “Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service,” Am Health Drug Benefits. 2016 Feb; 9(1): 23–32.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822976/

The Intelligent Patient

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Medicine isn’t about just doing what the doctor tells you to do. Quality of life is ben_franklinsomething a doctor cannot determine. That’s a call that the patient has to make.

Let me explain by example. Prostate cancer is a difficult form of cancer, traditionally treated by removal of the prostate gland. The unfortunate side effects of that surgery are urinary incontinence, and erectile/sexual dysfunction.

A few years ago, it was discovered that some prostate cancers grow so slowly that the cancer would pose no meaningful threat to the patient. This led to an alternative approach to treatment called “watchful waiting” — basically, monitoring the growth of the cancer and doing nothing as long as the growth rate remains slow.

Now we have new research that  both documents the the impact of prostate surgery and raises questions about the value of it.

A paper presents follow-up research with prostate cancer patients, some of whom had undergone prostate cancer surgery. The follow-up was conducted approximately 19.5 years after the surgery. The key findings are:

  • Those who had the surgery reduced their risk of death from all causes by 5.5%. That is, 66.8% of those under watchful waiting died, as did 61.3% of those who had the surgery.
  • A separate analysis determined that patients characterized as “high risk” or “low risk” at the time of the decision about surgery saw no reduction in the risk of death. The entire benefit accrued to those in the “intermediate risk” category. However, due to complicating issues, there’s a debate about how much benefit even they received.

The question for the patient (not the doctor): is the surgery worth the pain and side effects for a 5.5% decreased risk of dying?

The recommendation of the doctors presenting these results is the separation of diagnosis and treatment decisions. A specific course of treatment should not be an “automatic” follow-on to a diagnosis.

My point in writing this is that the cost/benefit analysis you have to apply to this decision is true for other diseases and treatments as well. Ultimately, you as the patient need to decide what’s right for you. And, as always, consult other independent medical professionals for second and even third opinions.

CAVEAT: As always, I’m not a doctor. I’m a researcher. My role is to make you aware of items you should know or consider in making decisions, but I’m not making the decision for you, or providing medical, legal or financial advice. Your life is yours to control and manage.


Sources:

  1. Roger Li, MD, Ashish M. Kamat MD, and Wayne B. Duddlesten, Professor, MD Anderson Cancer Center, “AUA 2017: Radical prostatectomy versus observation for early prostate cancer: follow-up results of the prostate cancer intervention versus observation trial,” conference presentation, 2017 AUA Annual Meeting – May 12 – 16, 2017 – Boston, Massachusetts, USA

NIH on COPD: Missing the Point, Too

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When you politicize science — or try to — you create new opportunities to waste taxpayer ben_franklinmoney.

The NIH has announced a new “National Action Plan” to combat COPD, the third leading cause of death in the US.

The third leading cause of death in the United States, chronic obstructive pulmonary disease, or COPD, affects 16 million Americans diagnosed with the disease and millions more who likely do not know they have it. The disease, which costs Americans more than $32 billion a year, can stifle a person’s ability to breathe, lead to long-term disability, and significantly affect quality of life. (1)

In building the action plan, NIH assembled workshops involving patients, medical professionals, academics, and pharmaceutical industry representatives.

That’s the problem.

COPD isn’t curable, but it may be preventable. However, to prevent it, you have to focus on causes, not treatments after the disease has developed. What are the causes?

  • Smoking — 20 to 30% of smokers develop COPD according to the Mayo Clinic, although others may have reduced lung function (4)
  • Long term exposure to industrial dust and chemical fumes (e.g., the famous “black lung” of coal miners)
  • Long term exposure to air pollution
  • Premature birth with lung damage
  • Genetics

Some authorities try to put the entire blame for COPD on the cigarette industry. That’s a simple answer, and as usual with simple answers, it’s probably not correct. Mayo’s analysis is probably more prudent, splitting blame between cigarettes and environmental factors.

Here’s the issue:

  • The workshops didn’t include representatives of the industries creating the pollution that causes COPD. Where are reps for the auto, power, chemical or cigarette industries?
  • Further, the current administration has made a clear statement that environmental issues don’t matter.

We can anticipate that this initiative will focus on more expensive treatments instead of prevention. That simply drives healthcare costs higher without solving anything.


Sources:

  1. National Institutes of Health, “COPD National Action Plan aims to reduce the burden of the third leading cause of death,” press release, 22 May 2017. https://www.nih.gov/news-events/news-releases/copd-national-action-plan-aims-reduce-burden-third-leading-cause-death
  2. WebMD, “COPD (Chronic Obstructive Pulmonary Disease) – Causes,” undated. http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-cause
  3. Ann Pietrangelo, “Everything You Need to Know About Chronic Obstructive Pulmonary Disease (COPD),” Healthline, 25 October 2016. http://www.healthline.com/health/copd
  4. Mayo Clinic, “COPD – symptoms and causes,” undated. http://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/dxc-20204886

Your Health: The Right to Life?

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The US was founded on the promise of “the Right to Life, Liberty and the Pursuit of ben_franklinHappiness” in Jefferson’s Declaration of Independence.

From the start, the relationship between the country and this promise has been at best inconsistent and sometimes ironic. After all, the principal writer of the Declaration, Jefferson, was a slave-owner.  So for whom was this promise made? Everyone? Or the wealthy, the planters, the slave-owners and the merchants? (Remember, there were no factories — that was before the industrial revolution.)

The inconsistency continues to this day.

We have groups concerned with whether babies or born, but not with what happens to them after they are born. How long do they live? What’s their quality of life? As Ed Cara notes, in some areas of the US, children will now have shorter lives than their parents. (2)

A new study in the Journal of the American Medical Association talks about discrepancies in life expectancy. I’ve blogged about this before, but it’s nice to see authoritative sources recognizing the issue.

The new statistical analysis shows that there is a difference in life expectancy of up to 20 years based on the county in which you live. In this analysis, the issues affecting life expectancy are

  • Income and poverty
    • The wealthy live longer
  • Race/ethnicity
    • Both Native Americans and African Americans have a shorter life expectancy
  • Regular exercise
    • Those who do live longer
  • Obesity, Diabetes and Hypertension
    • Shorten life expectancy
  • Education
    • Each level completed adds to life expectancy
  • Quality of health care
    • Higher quality is associated with living longer
  • Having health insurance
    • Having health insurance promotes longer life
  • Access to physicians
    • Having more physicians in an area helps

These factors translate into differences in life expectancy in the US based on where one lives:

  • Residents of central Colorado, coastal California and the New York Metro area live longer
  • Residents of eastern Kentucky and much of the Old South, especially along the lower Mississippi River, have a shorter life expectancy
    • The Old South in this case includes Alabama, Arkansas, Georgia (outside of Atlanta), Louisiana, Mississippi, Oklahoma and Tennessee (outside of Nashville)
    • The two metro areas, Nashville and Atlanta, offer much better life expectancy than the rest of their states

The states with the lowest life expectancy are those with the lowest spending on public health and health education.

One limitation of this study is that the analysis is at a county level, and there is only selected data available at that level regarding health. In particular, suicide is now one of the top 10 causes of death in the US. Suicide isn’t reported accurately or consistently, and there is limited data available on the causes of suicide.

A second limitation is the inter-relationships between some of the factors measured. For example, wealth is associated with having health insurance, with less use of cigarettes, and with living in an area with better access to medical professionals. By breaking the analysis into this much detail, does the report understate the role of wealth in life expectancy?

By the way, I use the image of Ben Franklin on some of these posts for the following reasons:

  • His brilliance
  • His common sense
  • His skill at negotiation
  • And among the Founding Fathers of the US, he became a profound opponent to slavery

Sources:

  1. Laura Dywer-Lindgren, et. al., “Inequalities in Life Expectancy Among US Counties,1980 to 2014,” JAMA Intern Med. Published online May 8, 2017. doi:10.1001/jamainternmed.2017.0918. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2626194
  2. Ed Cara, “Kids Will Die Younger than Their Parents in Some Parts of the US,” Vocativ. 9 May 2017. https://www.aol.com/article/news/2017/05/09/kids-will-die-younger-than-their-parents-in-some-parts-of-us/22077174/

 

 

More on Diabetes

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The US is seeing modest, steady growth in the incidence of diabetes among children and teens. A new analysis of data from 2012 to 2012 shows

  • An increase in Type 1 Diabetes of 1.8% per year and
  • An increase in Type 2 Diabetes of 4.8% per year.

While there’s a genetic component, diabetes risk is associated with

  • Family history
  • Immune system issues
  • Diet and weight (and exercise)
  • Blood pressure

Europeans understand that how you care for yourself affects health care costs and health insurance rates for everyone around you. It’s not just about you. Teaching a child to veg in front of a computer or TV simply shortens the child’s life.

However, one of the frustrations with public health data is lack of currency. Has the situation gotten better or worse in the last five years?  My guess is worse, but we simply don’t know.


Sources:

  1. Elizabeth J. Mayer-Davis, Jean M. Lawrence, Dana Dabelea, Jasmin Divers, Scott Isom, Lawrence Dolan, Giuseppina Imperatore, Barbara Linder, Santica Marcovina, David J. Pettitt, Catherine Pihoker, Sharon Saydah, Lynne Wagenknecht. Incidence Trends of Type 1 and Type 2 Diabetes among Youths, 2002–2012. New England Journal of Medicine, 2017; 376 (15): 1419 DOI: 10.1056/NEJMoa1610187
  2. NIH/National Institute of Diabetes and Digestive and Kidney Diseases. “Rates of new diagnosed cases of type 1 and 2 diabetes on the rise among children, teens: Fastest rise seen among racial/ethnic minority groups.” ScienceDaily. ScienceDaily, 14 April 2017. <www.sciencedaily.com/releases/2017/04/170414105821.htm>.
  3. International Diabetes Foundation, “Risk Factors.” http://www.idf.org/about-diabetes/risk-factors
  4. Mayo Clinic, “Diabetes.” http://www.mayoclinic.org/diseases-conditions/diabetes/basics/risk-factors/con-20033091