May 31st, 2011

Ryan Thinks He's Churchill; other strategies for saving money on health care

I haven't posted very much about Ryan's "Premium Support" proposal for Medicare. I've been incredulous all along that the Republican party would really pursue this idea. The Democratic talking point is that "premium support" is a "coupon" or "voucher". Ryan insists that it is not a coupon or voucher but is rather "premium support" that will be tied to inflation. Critics point out that health care inflation is much higher than core inflation, and thus anyone currently 55 or younger will be paying way more out of pocket since all the added costs will be going to the user rather than the government. Given that Republicans also want to roll back health care reforms that no one can be refused health care, the net effect would be to change Medicare from a you-get-it-when-you-turn-65 to only-if-you-can-afford-it-and-someone-will-sell-it-to-you. In other words, the elimination of Medicare in a form that anyone would want it.

I want to reiterate: I've been incredulous that the Republican party would really pursue this idea. A Democrat winning NY-26 by running on her opponent saying she would have voted for Ryan's plan would seem to argue in my favor _if and only if_ you assume the party would like to see their candidates (re)elected. Which I have been assuming.

It's possible I've been wrong.

In particular, when describing the many Republican freshman in the House in the wake of the massive unpopularity (<-- understatement) of his proposal, Ryan is quoted as saying:

"These new people, the 87 freshmen, they are cause people, not career people. They are all more about the cause than their career."

The Republicans suffered a series of very negative elections, culminating in 2008. Ryan and company are the people who turned it around in 2010. The party is poised to behave in a way completely incompatible with (re)election.

It's a bit of a headscratcher, really.

In the short run, I hope that the desire to be a little less associated with the increasingly apparent toxicity of the Medicare plan will lead to what the Republicans promised when they got elected: Jobs Jobs Jobs. Or at least some legislative maneuvering intended to look like promoting Jobs Jobs Jobs. I _expect_ however that the focus will simultaneously be on the deficit, and that's a combination that tends to not increase jobs or reduce the deficit.

We really _do_ need to do more about health care costs in the US. Doing something about health care costs in the US will help all of us in a lot of ways, but most notably, if we do it sensibly, it'll both save us money and improve our health. Two items in the news that show how this can work:,0,3913823.story

Niaspan is a time-release niacin supplement intended to help raise HDL (aka "good" cholesterol). It has been pushed by its makers as a supplement to statin therapy (intended to lower cholesterol, in particular LDL, "bad" cholesterol). People don't like to take niaspan; it has really awful side effects and they are inherent in niacin, not an artifact of the "drugification" process.

Reducing cholesterol in general is a proxy for other desirable attributes (not having heart attacks, strokes, dying, etc.). Niaspan's impact on HDL numbers was detectable but small (especially compared to the impact of statins on LDL and total cholesterol). A recent NIH study was stopped because the niaspan group was having more strokes. Noticing that Niaspan does not improve outcomes and may be doing harm means that we don't need to be spending any more money on Niaspan -- and we can feel _good_ about not spending any more money on Niaspan. This isn't rationing. This is informed decision making.

Essentially: Dr. Russ Altman's team mined AERS ( and some other digital medical records databases looking for patterns. They produced a paper describing one: Paxil and Pravachol in conjunction led to a jump in blood sugar (enough to potentially push someone from "prediabetic" to "diabetic"). They were able to reproduce this response in an animal model.

In this case, the probable outcome will be to shift patients to, say, a different statin. No money is likely to be saved in terms of the drugs, however, substantial savings would occur by not causing that jump in blood sugar that might in turn trigger more drug therapy designed to deal with the newly diagnosed diabetes.

In an ideal world, we'd be much, much more sensible and rearrange our world to better support walking and biking and generally being more physically active in the course of our daily lives. But until then, we can keep doing what we're doing (taking pills and doing studies) but by doing a bit more loop closure (more studies _after_ the drugs are OK'd after the FDA), we can make sure those pills work as well as they can and do as little damage as possible. And electronic medical records are the current strategy for making this possible.

Ryan has a very simple model of the world. He's a hero because he's reducing the size of government and its commitment to provide services. That helps business and that helps the country. In his eyes, the best way to reduce the cost of services is through competition, and by triggering "refusal to buy": if people cannot afford something so they don't buy it, then the price will come down until they do buy it. But Ryan appears to have forgotten that the reason we created insurance schemes (public and private) is because generally speaking, if you cannot afford health care, you suffer more than if you could (there are exceptions to this rule see above). We started with private ones and added public ones because there was a social justice thing that just kind of rankled.

So while Ryan is thinking of himself as some weird zombie amalgamation of Churchill and Thatcher, he's being mean to future old people. This puts us squarely in a debate about how best to manage future health care costs: lots of science-y analysis leading to new guidelines/rules/regulations designed to encourage "best practice" or make old people pay for their own healthcare (possibly by purchasing private health insurance) starting with people who are currently about 55.

You can see why I'm a little incredulous that the Republican party would pursue this idea.


New York Times article on how doctors mostly work for big practices/hospitals on salary, rather than running their own or being a partner in a small practice. As a result, doctors are no longer reliable Republicans.

Current and past presidents of the AMA and state chapters there of don't necessarily agree either that the change is happening or that it will last.

I love Denial. Almost as much as I love predictions of DOOOOOOOMMMM.


CNN really decided to run with this polypharmacy thing (<-- they aren't calling it that. They've taking "medication multiplication" out for a spin).

A Bit More About Sookie and Cataliades

Recently, someone asked me to expand a bit upon this part of my review of _Dead Reckoning_.

"I like the sense that is slowly building over the course of the series that while a lot of supes have low (or no, or not recognizably human) morals, that is not universal, and Cataliades and Diantha actually agree with Sookie on a number of moral points that she can't seem to get across to some of the other people in her life."

(1) Adele, Sookie's grandmother, and Fintan, Sookie's biological fae grandfather, had sex several times while Fintan wore his customary appearance, overlapping with Adele's marriage to the man Sookie believed was her grandfather but who was unable to father children due to measles. Adele wanted children, and while she felt what she was doing was wrong, she really wanted children. Adele's husband never asked any questions. Sookie discovers, through Dermot, Fintan's twin, that Fintan _also_ had sex with Adele while wearing Adele's husband's appearance. This _really bothers_ Sookie, and Dermot can't understand why. He figures she'd already consented. Sookie feels that this kind of deceit was very wrong. Mr. Cataliades agrees that it was wrong. Sookie is articulating (possibly on behalf of the author, but possibly not) an idea of consent that is very contemporary and American. Dermot is articulating an idea of consent that is less contemporary American.

Here are other examples of this consent distinction: Jane and John go out to dinner. They go back to Jane's place. They have sex using condoms (consensual, and Jane didn't bring up the condom thing, John did). After Jane falls deeply asleep, John has sex with Jane without waking Jane up. He does not use a condom. Sookie would think that this is wrong. Dermot might not. You could take this several steps further: John plied her with alcohol to make sure she was deeply asleep. John put something in her food and/or drink so she wouldn't wake up. Etc. Dermot would say (presumably): hey, she consented. She went to bed with him willingly. Sookie would go, no that's wrong. And we're not even into territory of Jane rescinding consent.

The situation might be a whole lot worse, however. There's been a lot of evidence over multiple books that supes plan way ahead when they're trying to get a human to "consent" to something. Fintan wanted women with a particular "spark" which Adele had. Cataliades and Fintan put some of Cataliades' blood in wine for Adele in hopes that the kids would have Cataliades' telepathy. Then they monitored not just the kids, but the grandkids for that telepathy. What's to say that Fintan didn't do something to Adele's husband to make sure he couldn't have kids, to put Adele in such a desperate situation that she would have sex with him just to have kids? Adele was hugely troubled by her decision and once she had the kids she wanted, Fintan must have suspected she'd have less to do with him -- this was a strong motivation for him to get in the habit of wearing her husband's appearance.

If Fintan made the husband unable to father children so that Adele would have sex with Fintan, Adele's "consent" is so compromised it's basically non-existent. We don't know that that happened -- it's not in the books. But there is _nothing_ in the books incompatible with Fintan having done this and Cataliades' may have even suspected this happened and that was his issue with the situation.

So. Enough about consent/fraud issues between Adele and Fintan.

(2) Sookie has become very accustomed to solving certain of her problems, usually but not always involving supernaturals, by engineering blood baths. The supes think this is a completely reasonable way to solve problems, and one of the things they like about Sookie is that she comes up with much better ways to engineer blood baths than they do. She's devious. Sookie does this in order to survive; the books are very clear on this point. She doesn't like what she's doing. It makes it difficult for herself to live with herself and even harder for her to live with other people. Other people either reflect her judgment of herself, which is intolerable, because survival trumps other concerns. Or they can't figure out why she has such a problem with violence -- they expect her to enjoy it in, revel in it, be turned on by it, go looking for more of it whenever possible, etc. Mr. Cataliades' attitude towards violence is closer to Sookie's than it is to many of the other supernaturals in her life. They differ, however, on the appropriate use of telepathy. Mr. Cataliades' is relentlessly practical about survival in a way that Sookie has not yet become; telepathy lets you figure out who's going to do you so you can do them first. Sookie still has a lot of privacy hangups. It would be interesting to see more back-and-forth between them, because I think at a moral level, they are in agreement.

Having done sex and violence, last would probably be appetite/impulse control.

(3) Sookie has other issues with supes: in general, a lot of them are impulsive in a way that Sookie finds repulsive (Amelia would be an extreme example of this behavior). She also perceives them as being very carnal or base or driven by desire. Sookie finds grooming and structure and routine calming; they make her feel better about herself and her world. She also likes participating in social rituals in her small community, and providing service to others. Again, this is an area of low to no overlap with most of the supes -- but Mr. Cataliades and Diantha display a service ethic, an emphasis on routine and control that is conspicuously lacking among supes. To the extent that Cataliades is driven by base desire, it's all about the food. And in this most recent outing, Cataliades is being pursued relentlessly by unknown adversaries, yet he takes a break to simultaneously refuel AND bring Sookie (who he has "sponsored", whatever that might ultimately mean) up to date on some important information that she has finally figured out to ask about. Before that, he meticulously supplied needed protection when an attack on Sookie was imminent.

Here's what I think Cataliades and Sookie have in common, that Sookie does not have in common with many, if, indeed, any of the other supes (or many humans, for that matter) in her life:

Sex should involve informed, ongoing consent and communication.
Violence may be necessary, but it should be avoided where possible and contained when necessary.
Basic needs must be met, but beyond basic needs, our resources should be devoted to serving the community of people we value.

It's quite possible I'm reading _way_ more into the books than is actually there. The interactions between Cataliades and Sookie are brief, even glancing, and are open to multiple interpretations. I look forward to future entries.