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

Sleep Loss and Weight Gain — How It Works

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One of the hallmarks of a good theory is that it defines a mechanism that makes the theory work. Understanding the “why” is critical.ben_franklin

If you ask most nutritionists, you’ll probably hear about how important good sleep habits are to health. You might hear that sleep is important to managing weight and that people who are well rested aren’t as hungry.

Now we are starting to get the rest of the story. A team of researchers at Upsala University (Sweden) have developed a body of research about the impact on short and interrupted sleep on the body.

The behavioural data reveal that metabolically healthy, sleep-deprived human subjects prefer larger food portions, seek more calories, exhibit signs of increased food-related impulsivity, experience more pleasure from food, and expend less energy.

How does this happen? Sleep loss . . .

  • Shifts the hormonal balance from hormones that promote fullness, such as GLP-1, to those that promote hunger, such as ghrelin.
  • Increases levels of endocannabinoids, which promote appetite.
  • Alters the balance of gut bacteria, which has been widely implicated as key for maintaining a healthy metabolism.
  • Reduces sensitivity to insulin (management of blood sugar levels).

The researchers want to conduct longer duration studies to assess long term effects of sleep loss. In the mean time, they’ve given us an initial assessment of what happens.

If you’re in a situation in which you can’t get adequate sleep, then you need to control carefully what you eat to offset these effects to the extent possible. You may want to consult a doctor or nutritionist about specific steps you should take.


Sources:  European Society of Endocrinology. “Sleep loss affects your waistline.” ScienceDaily. ScienceDaily, 22 May 2017. <www.sciencedaily.com/releases/2017/05/170522081109.htm>.

Childhood Weight, Adult Depression and . . . Bullying? Time to Connect the Dots?

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Being narrow-minded affects people in a broad range of occupations, including ben_franklinacademia. Most people working in one field don’t see what people in related field are doing. Truth literally “falls between the cracks” separating different areas of work.

The people to whom we ascribe brilliance, like Steve Jobs, are those who are able to gather information from a broad array of sources and disciplines and connect the dots to form a coherent picture that others can’t see. Others fail to see the same because they don’t look. They limit what they see to the portion of the world in which they live and work.

Now for an example . . .

In an earlier blog, I reported on research linking being a victim of bullying to depression and health issues in high school. (1) The theory is that the impact of bullying can last well into adulthood.

A new study by Deborah Gibson-Smith from VU University Medical Center in the Netherlands and colleagues reports on a link between being overweight as a child and adult depression. The study doesn’t explain how extra pounds as a child effect adult emotions; it simply reports a statistical relationship. (2) The premise is that it has something to do with self-image.

My theory: Overweight children get bullied, and that bullying causes negative attitudes and behaviors that can linger into adulthood. It’s a simple idea, testable, and provides a concrete mechanism for converting excess weight as a child into adult depression.

However, because we have one group studying the effects of weight, and a different group studying the effects of bullying, apparently no researchers have tried to connect these dots.

Does that make sense?


Sources:

  1. Crain, “Bullying and Depression.”
  2. European Association for the Study of Obesity. “Being overweight in childhood may heighten lifetime risk of depression.” ScienceDaily. ScienceDaily, 18 May 2017. <www.sciencedaily.com/releases/2017/05/170518221006.htm>.

 

 

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/

 

 

Diabetes and Domestic Violence

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Diabetes is an ugly disease, affecting the physical health of those who have it.  It may also imagesaffect the mental health of victims.  Anecdotal evidence suggests that it may be the cause of some verbal and physical violence in the home.

What we know.

  • 29.1 million Americans have diabetes, according to a 2014 study by the Centers for Disease Control.
  • Of these, 8.1 million are undiagnosed.
  • Another 86 million are pre-diabetic, meaning they are at risk for development of the disease.
  • Diabetes results from a hormone imbalance (insulin) that results in excessive glucose (sugar) in the bloodstream.
  • Diabetes places a person at risk for heart disease, kidney disease, blindness, risk of amputation, and death.  It was the seventh leading cause of death in 2010 in the US.
  • Diabetes may develop at birth or occur in adults.  Risk factors include poor diet and obesity. (1)

What we’re not sure about and need to know

Excess sugar in the blood is anecdotally associated with mood swings and “irrational” behavior.  Most researchers have focused on eating disorders and the willingness of those suffering from diabetes to make the necessary behavior changes to control the disease.  However, that may not be the whole story.

  • The American Diabetes Association apparently considers “diabetic rage” to be a reaction to the diagnosis.

Diabetes is the perfect breeding ground for anger. Anger can start at diagnosis with the question, “Why me?” You may dwell on how unfair diabetes is: “I’m so angry at this disease! I don’t want to treat it. I don’t want to control it. I hate it!” (2)

  • However, there is both research on children and anecdotal evidence among adults that mood swings and rage behavior  occur independent of diagnosis.
    • A mother talks about a child with Type 1 Diabetes and how poor behavior is linked to low or excessive blood sugar levels. (4)
    • Joslin researchers reported a link between high levels of glutamate (a neurotransmitter produced by glucose) to symptoms of depression in people with type 1 diabetes. (5)
    • “Behaviors such as aggression, delinquency, and hyperactivity In children with type 1 diabetes, are associated with high blood glucose (sugar) levels.” (6)
    • There is a blog thread on people who have direct experience with violent behavior associated with abnormal glucose levels. (7)

Gonder-Frederick and colleagues comment on the lack of research on the social and behavior impact of hypoglycenia (abnormal blood glucose levels).(8)  Balhara points to the existence of a relationship between diabetes and psychiatric disorders, and also to the lack of research focused on this link.(9)

Mary de Groot and her colleagues focus on the relationship between diabetes and depression, anxiety disorders and more severe forms of mental illness (e.g., bipolar disorder).(10)

In my own family, my grandmother was apparently prone to verbally abusive outbursts as a young woman.  These outbursts apparently stopped when she was diagnosed as diabetic and placed on an insulin regimen.

My wife’s first husband was verbally and physically abusive.  He was also diagnosed late in life (after their divorce) as diabetic, and was about to remarry when he died.  Could earlier diagnosis have put a stop to the abuse?  There’s just no way to know.  Hindsight only goes so far.

What you need to consider:

  • If you know someone who is abusive to family or  coworkers, does the person have characteristics that might suggest they are diabetic?  For example, are they overweight?  Does their demeanor change before and after meals? 
  • Have they been tested for diabetes?  Are they willing to be tested?
Caveat:  I am a researcher, not a doctor.  If you think there is an issue in your family, you need to consult with a medical professional and determine whether diabetes might be a factor in what you are seeing.  If it is, it needs to be managed.  It’s not something you can ignore and hope it goes away.
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Sources:
  1. Centers for Disease Control and Prevention, “National Diabetes Report 2014.” http://www.cdc.gov/diabetes
  2. American Diabetes Association, “Anger”, http://www.diabetes.org/living-with-diabetes/complications/mental-health/anger.html
  3. Liberty Medical, “How does elevated blood sugar affect a person’s behavior and mood?” https://libertymedical.com/diabetes/question/how-does-elevated-blood-sugar-affect-behavior-and-mood/
  4. Insulin Nation, “Bad Behavior or Blood Sugar Swings?”  http://insulinnation.com/living/bad-behavior-or-blood-sugar-swings/
  5. Joslin Diabetes Center, “Emotions & Blood-Sugar Levels: How Diabetes Can Affect Your Mood,” 8 July 2014.  http://blog.joslin.org/2014/07/emotions-blood-sugar-levels-how-diabetes-can-affect-your-mood-2/
  6. “Sugar Levels Affects Behavior of Children With Diabetes,” 9 October 2007. http://www.diabetesincontrol.com/sugar-levels-affects-behavior-of-children-with-diabetes/
  7. “High Blood sugar and irrational behavior,” Blog discussion, 24 March 2006. http://www.ourhealth.com/conditions/diabetes/high-blood-sugar-and-irrational-behavior
  8. Gonder-Frederick LA, Clarke WL, Cox DJ. “The Emotional, Social, and Behavioral Implications of Insulin-Induced Hypoglycemia,” Semin Clin Neuropsychiatry. 1997 Jan;2(1):57-65.
  9. Yatan Pal Singh Balhara, “Diabetes and psychiatric disorders,” Indian J Endocrinol Metab. 2011 Oct-Dec; 15(4): 274–283.
  10. Mary de Groot, Sherita Hill Golden, Julie Wagner, “Psychological Conditions in Adults With Diabetes,” American Psychologist, 2016, Vol. 71, No. 7, 552–562.

Obesity and Coed Grades

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Female students who are obese get lower grades than their peers in non-science subjects.(e.g., English).  That’s true even if standardized test scores for the obese and non-obese female are identical. Coeds who are overweight but not obese get grades that are comparable to their more svelte peers.

That’s the finding of research from the University of Illinois (Chicago).

“The study found obesity to be associated with a penalty on teacher evaluations of academic performance among white girls in English, but not in math. There was no penalty observed for white girls who were overweight but not obese.” (2)

The researcher goes on to hypothesize that teachers in subject associated with female gender stereotyping exhibit prejudice in grading obese female students.  Certainly, that’s a possible explanation.  Other studies have concluded that obesity can affect brain function including memory and concentration.

“Obesity subtly diminishes memory and other features of thinking and reasoning even among seemingly healthy people, an international team of scientists reports.” (3)

However, in Branigan’s defense, there is a substantial literature showing that teacher expectations of students affect the grades students receive. Stipek is but one of a large number of references discussing the impact of teacher bias on student achievement. (4)

Bias exists in both positive and negative forms.  If a teacher expects a student to do poorly, the student is likely to get a lower grade.  If the teacher expects a student to do well, the student is likely to get a better grade.

If I may hazard a guess, the same prejudices exist in the workplace with similar results.


Sources:

  1. Amelia R. Branigan. (How) Does Obesity Harm Academic Performance? Stratification at the Intersection of Race, Sex, and Body Size in Elementary and High School. Sociology of Education, 2017; 90 (1): 25 DOI: 10.1177/0038040716680271
  2. University of Illinois at Chicago. “Teachers may be cause of ‘obesity penalty’ on girls’ grades.” ScienceDaily. ScienceDaily, 7 February 2017. <www.sciencedaily.com/releases/2017/02/170207191854.htm>. https://www.sciencedaily.com/releases/2017/02/170207191854.htm
  3. Janet Raloff, Obesity messes with the brain,” Science News, Vol. 179 #9, April 23, 2011, p. 8. https://www.sciencenews.org/article/obesity-messes-brain
  4. D. Stipek, “How Do Teachers’ Expectations Affect Student Learning,” Education.com, 20 Juy 2010.  https://www.education.com/reference/article/teachers-expectations-affect-learning/
  5. Tim Lobstein et. al., “Child and adolescent obesity: part of a bigger picture,” Lancet. 2015 Jun 20; 385(9986): 2510–2520.