walkitout (walkitout) wrote,

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:


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 (http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEffects/default.htm) 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).

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