Google Flu Trends - take with salt

Google has a service called Flu Trends which attempts to predict influenza outbreaks based on people's search behavior. The theory is that during outbreaks, people do more searches for particular terms or items.

As any investor can tell you, past performance is no predictor of future returns. Any algorithm Google can come up with can correlate very nicely with past data from the CDC, but may not be as useful for forward predictions. Still, it's a nice idea, and one more bit of information to add to the mix.

Just don't bet your house on it.

Healthy School Lunches

My family has really enjoyed Jamie Oliver's Food Revolution, a television show centered on changing the food available for school lunches in an American town, Henderson West Virginia. As much as I appreciate our Houston Independent School District, the food vendor we've been acquainted with, Aramark, has provided absolutely unpalatable food for the student lunches. My kids pack a lunch every day, so they don't have to eat school food.

I'd love to find a group of like-minded parents at my kids' schools, who would be willing to work on changing the food in HISD. My kids would benefit greatly from a warm, healthy lunch, especially one with a vegetarian option. I'm worried, though, that HISD is too huge for a small group of parents to move; it would take a very dedicated set of individuals to take on this effort. In the mean time, maybe what we need to do is help pass federal legislation to provide incentives to schools to experiment with providing healthier meal choices to students.

If any parent or group is interested in coordinating a district-wide effort to improve school lunches at HISD, please let me know; I'd be willing to be a liaison to the schools my kids attend.

HOWTO: Houston Flu

The City of Houston has a resource dedicated to information about the H1N1 and seasonal flu viruses, including a list of places where the vaccines (shot and spray) are available at no charge. Google has a map facility where you can put in your zip code and find commercial sites which have stocked, are stocking, and will stock the various vaccines. Houston ISD is opening campuses to provide vaccines this weekend; check back because they're likely to continue the program for a while.

And finally, Google Trends is predicting flu severity by tracking geographically-identified searches for flu related terms. Their methodology is interesting; they basically look for search terms whose temporal frequency matched historical outbreak data from the Center for Disease Control (CDC) for particular locations, and then use those terms to predict forward what CDC trends will be based on current searches. It's an interesting approach, especially since CDC data is only available after a lag of two weeks or so. It's just a correlation, and may be useful to provide earlier warning of outbreak. But it all depends on how well current and future search terms match ones used in the past, and depends on how representative Google searchers are of the population, etc. YMMV.

Stay healthy and safe this flu season!

Death Panels

In 1999 Texas governor George W. Bush signed into law the Texas Futile Care Law, now part of Chapter 166 of the Texas Health and Safety Code, which "allows a health care facility to discontinue life-sustaining treatment against the wishes of the patient or guardian ten days after giving written notice if the continuation of life-sustaining treatment is considered medically inappropriate by the treating medical team." The law could be described as an improvement over the previous regime which allowed a hospital to "simply" receive a court injunction to withdraw treatment without notifying the family.

Contrast that to what's being described as "death panels" in the current health care reform proposals: a requirement for caregivers to discuss (and presumably memorialize in signed documents) the wishes of the patients themselves, so ordinary people can express their preferences ahead of time in case they are put in such a position of incapacitation. Could that not be considered an improvement over what currently exists in Texas, where the treating medical team can make that decision for the patient and the family?

More support for a single payer system

Here's an article from the Houston Chronicle, written by the inimitable Helen Thomas, exhorting President Obama and the Congress to extend Medicare coverage to all as the most effective way to reform health care in America.

Keep your eye on the ball

the public option is only a means to that end...

In his speech before a joint session of Congress, President Obama dismissively described the so-called "public option" of the proposed health care reforms as a "means to an end". I get that. It's hard to argue with such broad goals as "... provid[ing] more security and stability to those who have health insurance. ... provid[ing] insurance for those who don't. And ... slow[ing] the growth of health care costs for our families, our businesses and our government. ..." In a way, it's like saying "we're in Chicago right now, we want to get to Washington, DC, and there are more than one way to get there from here."

But as anyone who looks at a map can tell, some paths will get you there more quickly than others. A single payer plan such as HR 676 would be the fastest way; it clearly would provide stability and security to the insured, provide coverage to those who don't currently have it, and would control the growth of health care costs and decouple them from employment, reducing their burden on employers. A "public option" could work as well, if all health care providers are require to accept its payments (preserving your ability to choose a doctor) and if the plan has open enrollment (allowing everyone to access its benefits). The tepid "reform" proposals included in the President's speech, with no public low-cost competition for private carriers, are like walking from Chicago to California, then hoping you can hitchhike from there to DC. The byzantine regime of proposed regulations may be effective in controlling costs and keeping people healthy if they are coupled with aggressive enforcement and penalties for breach. Of course, this will inevitably add to the amount our country spends on "health care", without actually using that amount for providing care.

Let's also not lose focus on the main item insurance companies want to get from the current proposals: a mandate that everyone be required to purchase coverage in a "health plan". The insurance companies will benefit greatly by having 47 million new premiums paid (many or most subsidized by our tax dollars), and they will fight hard to make sure they can capture that revenue without onerous regulation or meaningful competition from each other or a public entity. If all we end up with is a "mandate" without a public plan to compete with private insurers, we will end up with a situation worse, not better, than what we have now.

Deeper in

I'm reading Karl Llewellyn's lectures collected in The Bramble Bush, the 2008 Oxford University Press edition, and thought I'd share another quote: this one is about assuming institutions are just so because that's the only way they could be arranged. This quote is preceded by a description of what courts and judges do, which I omit.

... I take time to say this because I deem it important that early, very early in this game you meet some counterweight against what I may call the unconscious snobbery of social institutions: against the touching faith that the current rationalizations of an institution, first, fit the facts, second, exhaust the subject, third, negate other, negate better possibilities. Nowhere more than in law do you need armor against that type of ethnocentric and chronocentric snobbery -- the smugness of your won tribe and your own time: We are the Greeks; all others are barbarians. ...

I offer the above quote to those who argue that a market based or private insurance solution to our health care crisis is important because the United States has a "tradition" of such things (a very recent one, to be sure). If that were not enough, Paul Krugman shares this report by Kenneth J. Arrow, excerpts of which are available from the World Health Organization web site; it's an economist's analysis of the factors which contribute to the observation that a market based approach does not provide optimal solutions to the pricing and provision of health care.

Question everything!

Costs: Medicare vs. private insurers

I don't like to simply copy and paste from other peoples' articles, but I thought this meme was important enough to echo. From Paul Krugman's blog, a discussion of the assertion by the Heritage Foundation that the lower administrative costs of Medicare (less than 2% of expenditures) are actually higher than the administrative costs in private plans if measured on a per-capita basis. According to Heritage, the key is realizing that the expenditures in Medicare are higher per capita (they're a population which requires more care), so the percentage ends up being lower.

The key to rebutting this assertion comes from their own framing of the issue. If the two populations are not comparable (necessary to their argument) then it helps to find two populations which are. Luckily, we have the Medicare Advantage program, which serves a population comparable to Medicare, and which is run by private insurers. From Jacob Hacker:

These administrative spending numbers have been challenged on the grounds that they exclude some aspects of Medicare’s administrative costs, such as the expenses of collecting Medicare premiums and payroll taxes, and because Medicare’s larger average claims because of its older enrollees make its administrative costs look smaller relative to private plan costs than they really are. However, the Congressional Budget Office (CBO) has found that administrative costs under the public Medicare plan are less than 2 percent of expenditures, compared with approximately 11 percent of spending by private plans under Medicare Advantage. This is a near perfect “apples to apples” comparison of administrative costs, because the public Medicare plan and Medicare Advantage plans are operating under similar rules and treating the same population. (And even these numbers may unduly favor private plans: A recent General Accounting Office report found that in 2006 Medicare Advantage plans spent 83.3 percent of their revenue on medical expenses, with 10.1 percent going to non-medical expenses and 6.6 percent to profits—a 16.7 percent administrative share.)

The CBO study suggests that even in the context of basic insurance reforms, such as guaranteed issue and renewability, private plans’ administrative costs are higher than the administrative costs of public insurance. The experience of private plans within FEHBP carries the same conclusion. Under FEHBP, the administrative costs of Preferred Provider Organizations (PPOs) average 7 percent, not counting the costs of federal agencies to administer enrollment of employees. Health Maintenance Organizations (HMOs) participating in FEHBP have administrative costs of 10 to 12 percent.

In international perspective, the United States spends nearly six times as much per capita on health care administration as the average for Organization for Economic Cooperation and Development (OECD) nations. Nearly all of this discrepancy is due to the sales, marketing, and underwriting activities of our highly fragmented framework of private insurance, with its diverse billing and review practices.

As I've said before on health care, if you want your premiums to be applied to improving your health and not to inefficiencies then you should support H.R. 676. Even a fully functional, national public insurance option may be acceptable as a compromise, as long as its ultimate goal or effect is to gracefully, gradually, but inexorably drive the inefficient health insurance companies out of the market. This is especially important if a large public investment will be made in the plan; I want my tax dollars going toward improving public health, not padding the profits of private corporations. In the end, given the facts, it's really that simple.

March 10: 4th National Call-In Day for Single Payer Health Insurance

Progressive Democrats of America are organizing a call in day in support of HR 676, the single payer health care plan. Please, call your representative on March 10, 2009.

Health care call in

February 12 is the National Call-in Day for HR 676, which is the House resolution implementing a national single-payer health care system. Please call the Congressional switchboard: 202-224-3121 and ask for your representative's office. You can also call (202-456-1414) or fax (202-456-2461) the White House.

Single payer health care is different from "universal health care" because it eliminates the need for private health insurance plans. This helps realize a few important effects:

• Eliminate the inefficiencies of private plans. The 25% - 30% of our premiums which go toward profit and marketing can be used instead to provide care to more individuals.
• Remove the mis-alignment between profit and health. Insurance companies, to make a profit, routinely deny care to their customers, in what often seem like arbitrary decisions. A governmental single payer plan will need to determine what procedures and items to pay for, but it will at least be nationally consistent, a single set of rules for everyone. Yes, there will be a public organization or committee responsible for those decisions - but such deliberations should take place transparently, with the potential for oversight from all of us who are affected. Compare that to the decisions now made by your insurer - who makes them? Are they in your best interests? Do you feel they are concerned to make sure you're healthy, or do they deliver just enough care so you don't leave, and they can maximize their profit?
• Improve doctor choice. Current insurance plans exclude doctors and hospitals, forcing you to choose providers "in the plan". With a single payer, everyone is in the plan.
• Improve the competitiveness of American firms. Firms employing American workers have to pay inflated premiums (see the inefficiencies point above) for health care for their workers. Firms in almost every other developed country have their workers covered under some state-organized plan. Sure, health care has to be paid for somehow; payroll or per-worker taxes are the most likely tool to use. But when everyone's covered, and inefficiencies are squeezed out of the system, it should end up that the cost per worker, for the same level of care, is less under a single-payer plan than in our current environment.
• Potentially mitigate billing errors and issues. I'm on thin ice here because I have no experience dealing with Medicare or Medicaid. Do they pay on time, and in full? Dealing with a single payer may make it unnecessary for a practice or hospital to have a large staff dedicated to collecting payment from insurers. The process may be streamlined, saving time and money for everyone involved.
• Implement a single formulary for prescription drugs, allowing the negotiation of reasonable prices for such a huge market commitment. Yes, this would set a single price for each drug; it would have to be reasonable enough for drug makers to be able to fund research into new drugs. It may end up that the market shifts a bit; drug research and drug manufacture may be split up under some compulsory licensing scheme. A drug researcher would take on the costs of developing new drugs, typically with access to federal funds; once a drug (or device) is developed and tested, the organization would recoup the costs from licensing the resulting patents to manufacturers. A robust market in manufacture could help drive the cost to the consumer down.

A health care market under HR 676 would potentially look dramatically different from what we have now; some companies and segments will be unnecessary and disappear, and others will change dramatically. That's fine with me, because it seems the system we have now is fundamentally broken, and is not delivering the care we deserve for the dollars we're pouring in.