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

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.

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.

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.

 

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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
   

Emergency Pain Management

A newly reported study from Australia finds that

1. Acupuncture is a viable alternative to drugs such as opioids for pain management for patients coming into ERs in severe pain. The researchers believe that ER personnel should be trained in acupuncture and have this available as a resource.
2. However, the authors report that neither drugs nor acupuncture provide immediate, adequate pain relief. They urge the need for research into development of tools for immediate pain management.

In a previous post, I talked about tai chi as a recommended treatment for depression for individuals resistant to Western psychotherapy. Now we have a recommendation for incorporating  acupuncture with Western medicine. Taking the best elements from different traditions seems to make sense.

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Marc M Cohen, De Villiers Smit, Nick Andrianopoulos, Michael Ben-Meir, David McD Taylor, Shefton J Parker, Chalie C Xue, Peter A Cameron. Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non-inferiority trial. The Medical Journal of Australia, 2017; 206 (11): 494 DOI: 10.5694/mja16.00771

Autism and Eye Contact

In theory, autistic individuals shun eye contact with others.

According to a new study, that’s not a voluntary or learned behavior. Eye contact can cause excessive stimulation of a section of the brain, and that in turn can be felt as pain by the individual.

That makes sense. If something causes pain, you usually try to avoid doing it.

Unfortunately, lack of eye contact is also interpreted by some as a sign of dishonesty. With the autistic person, that interpretation simply doesn’t apply.

Bottom line: you have to get to know someone in order to understand what their physical cues mean.

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Sources:

1. Nouchine Hadjikhani, Jakob Åsberg Johnels, Nicole R. Zürcher, Amandine Lassalle, Quentin Guillon, Loyse Hippolyte, Eva Billstedt, Noreen Ward, Eric Lemonnier, Christopher Gillberg. Look me in the eyes: constraining gaze in the eye-region provokes abnormally high subcortical activation in autism. Scientific Reports, 2017; 7 (1) DOI: 10.1038/s41598-017-03378-5

The Mechanics of Concussion

A new study from a research team at Ohio State University provides insight into how concussions work. The research is based on a laboratory experiment with mouse tissue, but the effects are quite similar to what is seen with human patients with neurological disorders.

Source: Washington Univ.

Cells contain axons, which transmit signals (messages) to other parts of the body and brain through the nerve system.

Concussions activate a protein “called TRPV4, which causes a chain reaction that prompts a pause in content exchange along the axon.” (1) When the pause occurs, the axon swells, which is the physical sign of the problem. Similar swelling occurs in patients with Alzheimer’s and Parkinson’s.

This research also indicates that the swelling can be reversed with prompt reduction of stress to the brain. Further, if the protein is suppressed, the swelling does not occur. However, we don’t know exactly what that means for humans, at least not yet.

Knowing how something works is key to developing fixes for problems.

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Sources:

1. Yuanzheng Gu, Peter Jukkola, Qian Wang, Thomas Esparza, Yi Zhao, David Brody, Chen Gu. Polarity of varicosity initiation in central neuron mechanosensation. The Journal of Cell Biology, 2017; jcb.201606065 DOI: 10.1083/jcb.201606065
2. Picture source: https://faculty.washington.edu/chudler/cells.html

Parenting and Risky Sexual Behavior in Teens

It may sound obvious, but parents matter. Both parents matter.

However, when it comes to risky sexual behavior in teen daughters, the spotlight is on the father.

A new study from the University of Utah relates the “quality of fathering” with teen behavior.

• High quality fathering is associated with setting standards for behavior and consistent monitoring of how the teen spends her time and money. It affects with whom the teen associates and reduces the likelihood of risky behavior.
• Low quality fathering does just the opposite.

The study strongly suggests that having a low quality father out of the home may be better for daughters than keeping the family intact.

The study may in fact underestimate the negative effects of low quality fathering. In some cases, parents or other family members are the source of risky behavior.

According to an The Atlantic article from 2013,

One in three-to-four girls, and one in five-to-seven boys are sexually abused before they turn 18, an overwhelming incidence of which happens within the family. These statistics are well known among industry professionals, who are often quick to add, “and this is a notoriously underreported crime.” (2)

Another review of the research literature suggests a 40% rate of molestation among girls and 30% among boys in the US. (4) In all cases, the figures are subject to some disagreement about definitions.

For those of us who know victims  of family abuse, this incidence is quite plausible. In my own conversations, I’ve been flabbergasted by the people who reveal histories of abuse — people I would never have suspected. It comes out in conversations after a certain level of trust is in place. And it surfaces too many times with too many people.

Ultimately, the statistics we have are unreliable, because too many people won’t talk about this. The statistics are incomplete, as they tend to focus on father-daughter abuse and not on mother-son or sibling relations (or on abuse by authority figures other than priests).

Traditional studies have focused on “broken” families and the importance of having two parents in the home. The truth seems to be a bit more complex. There are many cases in which the “intact” family is broken and dysfunctional, and breakup represents improvement.

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Sources:

1. Danielle J. DelPriore, Gabriel L. Schlomer, Bruce J. Ellis. Impact of Fathers on Parental Monitoring of Daughters and Their Affiliation With Sexually Promiscuous Peers: A Genetically and Environmentally Controlled Sibling Study. Developmental Psychology, 2017; DOI: 10.1037/dev0000327
2. Mia Fontaine, “America Has an Incest Problem,” The Atlantic, 24 January 2013. https://www.theatlantic.com/national/archive/2013/01/america-has-an-incest-problem/272459/
3. Margaret Ballantine and Lynne Soine, “Sibling Sexual Abuse — Uncovering the Secret,” Social Work Today Vol. 12 No. 6 P. 18. http://www.socialworktoday.com/archive/111312p18.shtml
4. Rational Skepticism.org. “Just how common is incest?” 11 July 2010. http://www.rationalskepticism.org/social-sciences/just-how-common-is-incest-t9841.html

Brain Tumor Options

Brain tumors are pernicious. How do you know when a headache is just due to stress or a sign of something more serious? Right now, 1 in every 161 cancer diagnoses involves a brain tumor, but these tumors can be a natural follow-on to other cancers. Glioblastoma is the most deadly form of brain tumor, killing 83% of the youngest patients it infects within five years.

Medicine is changing rapidly, and that brings both benefits and problems. Obviously, new treatment methods can improve outcomes for patients. However, it is a challenge to keep up with developments and know what’s best. It’s a challenge for doctors, and worse for patients.

The traditional approach has involved surgery, chemotherapy and radiation therapy to remove and kill cancer cells.  These approaches have met with varied success. The five year survival rates for various brain tumors are shown in the chart below:

Five-year survival rates, selected brain tumors (2)

Five-year survival rates	Age of patient
Tumor type	20-44	45-54	55-64
Low-grade (diffuse) astrocytoma	65%	43%	21%
Anaplastic astrocytoma	49%	29%	10%
Glioblastoma	17%	6%	4%
Oligodendroglioma	85%	79%	64%
Anaplastic oligodendroglioma	67%	55%	38%

New research is finding that radiation treatment can affect brain function, possibly producing the cognitive impairment seen in many patients after treatment. (3,4)

There are a number of options, but your local doctor may or may not know what they are, or have access to them.

The NIH National Cancer Institute highlights three categories of research under way:

• Therapeutic vaccines
• CAR T-cell therapy (taking patient cells, re-engineering them, and reinjecting them in the patient)
• Checkpoint inhibitors that allow the patient’s immune system to attack tumor cells (5)

These approaches fall under the broad label of immunotherapy.

Where are clinical trials happening?

• Duke is a leader in brain tumor research and has a number of clinical trials underway testing treatments for brain tumors involving immunotherapy and the manipulation of T and B cells. (6)
• Other centers with clinical trials include:
  • The University of Florida
  • The University of Texas Southwestern Medical Center, also featuring clinical trials with imunotherapy
  • The Dana Farber Cancer Center, Boston, Massachusetts
  • Cedars-Sinai Medical Center, Los Angeles, California
  • University of California, Irvine, California
  • Mayo Clinic, Rochester, Minnesota
  • University of Alabama
  • MD Anderson Cancer Center, Univ. of Texas, Houston
  • Provident Cancer Center, Portland, Oregon
  • City of Hope Medical Center, Duarte, California
  • NIH Clinical Center, Bethesda, Maryland

The bulk of innovative work is happening on the east and west coast, leaving people in the North Central, Midwest, Plains and much of the South and Southwest without ready access to advanced medical treatment. Even with access, doctors in these areas will have little experience dealing with side effects, and that could be fatal for a patient.

This explains in part why, as discussed in prior blog posts, where you live in the US effects your life expectancy.

How prepared are you to relocate for three or six months for treatment?

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Sources:

1. American Brain Tumor Association. http://www.abta.org
2. American Cancer Society, “Survival Rates for Selected Adult Brain and Spinal Cord Tumors.” https://www.cancer.org/cancer/brain-spinal-cord-tumors-adults/detection-diagnosis-staging/survival-rates.html
3. University of California – San Diego. “Radiation therapy vital to treating brain tumors, but it exacts a toll: Researchers say treatment alters neural networks and may cause long-term cognitive impairment.” ScienceDaily. ScienceDaily, 9 June 2017. <www.sciencedaily.com/releases/2017/06/170609133810.htm>.
4. Carrie R McDonald et al. Altered network topology in patients with primary brain tumors after fractionated radiotherapy. Brain Connectivity, June 2017 DOI: 10.1059/brain.2017.0494
5. Duke Neurosurgery, “Research Initiatives.” https://neurosurgery.duke.edu/research/basic-research/duke-brain-tumor-immunotherapy-program/research-initiatives.
6. UT Southwestern Medical Center. “New approach to destroying deadly brain tumors.” ScienceDaily. ScienceDaily, 13 June 2017. <www.sciencedaily.com/releases/2017/06/170613102056.htm>.
7. Musella Foundation, “Clinical Trials and Noteworthy Treatments for Brain Tumors,” last updated 5 February 2017. https://www.virtualtrials.com/Immunotherapy_treatments.cfm

Health: Genetic Testing — Knowing Less than We Think We Know

Two papers appearing today raise interesting questions about genetic testing.

1. The first raises the question about insurer access to genetic testing records.
2. The second states that some people who are genetically disposed to breast cancer don’t in fact get it — due to another genetic factor not previously considered.

In the first case, health and life insurers want access to genetic information in order to estimate more precisely the claims they are likely to face in providing insurance for a specific individual.

In fact, that approach violates the original logic of insurance — that insurance is sharing risks among a group of individuals, not writing a custom policy for a particular person.

Be that as it may, the second paper shows that what we know about genetics is still incomplete. That paper shows that persons with the BRCA mutation that disposes them to breast cancer don’t necessarily ever develop that cancer. The absence of cancer in these people may be linked to a COMT genetic variation. Right now, all that is know is that people with BRCA who don’t develop cancer tend to have the COMT variation; how it works isn’t known.

So, were an insurer to raise rates based just on the BRCA factor, the insurer could be getting an unnecessary, windfall profit on people with COMT.

Prudence says that we don’t know enough about the relationship of certain genetic factors and disease to make a universal case for inclusion of genetics in underwriting (pricing insurance). For some illnesses, maybe.  For all, no. That begs the question of whether inclusion of these factors fundamentally changed the definition of what insurance is.

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Sources:

1. Mercedeh Movassagh, Prakriti Mudvari, Anelia Horvath. Co-Occurrence of COMT and BRCA1/2 Variants in a Population. New England Journal of Medicine, 2017; 376 (21): 2090 DOI: 10.1056/NEJMc1701592
2. European Society of Human Genetics. “Balancing rights and responsibilities in insurers’ access to genetic test results.” ScienceDaily. ScienceDaily, 25 May 2017. <www.sciencedaily.com/releases/2017/05/170525194817.htm>.