Public Health and Pediatrics

Obamacare vs. Econ 101- there ain't no free lunch

When I was in high school, our sports teams traveled throughout southern Arizona to games and meets.  This travel often necessitated stopping at some fast food establishment for some after-competition sustenance, usually at the local McDonalds since the Golden Arches were the end-all and be-all of the fast food culinary arts in the mid-70’s.  I distinctly remember the coach standing outside the bus as we filed off, handing each one of us two crisp (or maybe not so crisp) $1 bills.  With this bounty in hand, I found out quickly that my two dollars would typically buy two cheeseburgers, a small side of fries, and a chocolate shake.  Every sports trip I took would end up with the same order; a bounteous feast to be sure. 

What strikes me now, after the passage of so many years and so much nasty McDonald’s burger consumption, is that neither I nor my teammates ever once presented ourselves to the counter and expected food to flow from the back of the restaurant into our ravenous mouths without the exchange of currency of some sort.  If we wanted another tasty Mcshake, or had a desire to top off the meal with a scrumptious apple pie, then we would be expected to produce even more of those little green bills with pictures of prominent Americans on them.  Apparently there was a mechanism in place to compensate the makers of the feast for their hard work and expense.  I suspect that otherwise this benevolent burger purveyor would soon have ceased to do business.  As we all know, that certainly didn’t happen.  Ronald McDonald (or at least his descendants) is still alive and well.

I’m reminded of this episode when I see recent news about what is lovingly known in some circles as Obamacare.  It would appear that insurance premiums are increasing yet again, while the Affordable Care Act was supposed to rein this in.  There are myriad reasons why, I suppose.  Might insurance companies be jacking rates in anticipation of future constraints to this sort of practice? 

Possibly. 

Might there be an increase in healthcare costs independent of the ACA? 

Perhaps. 

However, when a piece of legislation specifically prohibits insurance companies from actuarially accounting for pre-existing conditions, when the bill provides for the automatic inclusion of all children up to the age of 26, when the law states that no lifetime caps for benefits are to be instituted, then something has to give.  Did anyone expect that a business would be able to absorb such a mandate?  These increases were a foregone conclusion when the bill was passed, despite assurances to the contrary.  Someone will have to pay for this largess.  Will the insurance companies decide to pick up the slack?

It ain’t gonna happen.  It was never gonna happen.  As I found out years ago at the counter of Mickey D’s, there’s indeed no such thing as a free lunch. 

Dr. K

 

Medical marijuana- the Arizona scam

There appears to be a public health disaster looming of epic proportions, one that apparently will dwarf the impact of smallpox, HIV/AIDS, heart disease, or even bed bugs.  The statistics are startling, yet the American public seems to be blithely ignorant of the problem.  As a public health official in Arizona, I consider it my duty to warn folks of the impending catastrophe that may befall us if we do not take measures soon.  According to the Arizona Department of Health Services website, this concern afflicts fully 89% of the 33,633 successful applicants to the Arizona Medical Marijuana program.  I, for one, was not aware of the enormity of the problem.

What might this scourge be?  A horrible infectious disease?  An environmental health disaster?  Nah, nothing so prosaic.

Chronic pain. 

You got it. 

Chronic pain.

What is even more interesting from an epidemiological standpoint is that most of these afflicted with this dreaded chronic pain fall in the younger set; 46% of the applicants are 40 years old or younger.  A full 26% are younger than 30 years of age.  According to these figures there are seemingly hordes of young adults running around acutely suffering from chronic pain.  I would have thought that chronic pain would be something that increases with age.  Apparently not.  Well, color me skeptical, but I suspect that this set of numbers probably coincides with the percentages of each age group that light up marijuana currently.  Prior to the passage of the medical marijuana act in Arizona, the 18-40 year old demographic was far more likely to be smoking weed than your cuddly old grandmother-type with cancer.  Methinks this same group has just been transplanted onto the medical marijuana rolls, with a likely huge increase in the “chronic pain” diagnosis.  All this “new” chronic pain among our younger population is going to be such a heavy burden for society to bear!   

Is this a diatribe against the use of medical marijuana?  Not really.  I only decry the use of the rubric “medical” to promulgate the legal use of marijuana in my state.  I have somewhat more respect for those who were recently advocating the legalization of marijuana in Colorado, as there was a modicum of honesty in their presentation. 

Where will this end?  I have no idea.  However, given the likely rise in consumption of munchies in Arizona, I feel my portfolio could use a strategic Frito-Lay buy...

 

 Dr. K

 

 

An Arizona gunfighter and Dengue fever

I admit it.  I have a fondness for the history of my home state of Arizona.  The trick is to figure out a way to work this penchant for history into a blog about public health and pediatrics.  It’s not always easy, but it can be done with a bit of imagination and ingenuity.  And thus I will regale the reader with the story of one Jefferson Davis Milton.  How this has anything to do with public health? 
 

Wait for it…. 

Jeff Milton was born in 1861 on the Florida estate of his father, the Confederate (thus the name Jeff Davis) governor of Florida who committed suicide towards the end of the Civil War.  Jeff left home when he was 15 to seek his fortune as there appeared to be no future on an estate with no slaves and little prospects.  He landed in Texas and at 17 joined the Texas Rangers (lying about his age to qualify).  Four years later he moved west and spent the 1880s and 1890’s throughout Arizona, Texas and New Mexico working as a deputy U.S. marshal, sheriff’s deputy, customs inspector, police chief and in other law enforcement roles.  One of his more famous escapades as the police chief in El Paso involved backing down the infamous John Wesley Hardin.  As Hardin rode into town, Milton met him face to face in the street and asked him for his weapons.  For one of the few times in his life, Hardin decided against drawing against a man who had developed a reputation for a fast draw.  Hardin meekly gave up his guns to the police chief and was killed a short time later in an El Paso gambling saloon.  Milton famously stated once that "I never killed a man who didn't need killing, and I never shot an animal except for meat." 

By 1900 Milton had moved into Arizona and was working as a railroad guard when the Burt Alvord gang attempted a train robbery in the Cochise County train stop of Fairbank.  Not expecting Milton to be working that day, the gang opened fire on him in the railroad car and received a blast from Milton’s shotgun for their efforts.  One outlaw eventually died from the wounds delivered by that firearm.  Even still, Milton was shot in the left shoulder and left for dead.  He did have the foresight to hide the keys to the safe, however, and the gang left with a total of 17 Mexican pesos.  His left arm was never the same and it left him with a significant disability the remainder of his life. 

His story doesn’t end here in Fairbank, though, and we find out that he was hired
as an agent for the federal government under the Chinese Exclusion Act.  He spent the next 28 years traipsing all over the Arizona-California border with Mexico looking for smuggled Chinese aliens and others who might be fleeing the law.  He retired in 1932 at the age of 71 and is remembered today by officers of the U.S. Border Patrol as “America’s First Border Patrolman.”  He was 85 when he died in Tombstone, Arizona.

Well, with all this as preamble, our border with Mexico remains today a hot-button issue as well as a political minefield.  What people may not realize is that not only are there gripping stories and human tragedies along the border counties, but public health issues as well.  Should county, state, or federal monies be spent on immunizations for children who may be illegal aliens?  Should illegal aliens be treated with U.S. taxpayer dollars for conditions such as tuberculosis?  What of the emerging diseases that are creeping up from Mexico, such as Dengue fever?  We know the border to be a very fluid place.  We might think to vigilantly patrol the border as did our friend Mr. Milton, but communicable diseases, sadly, do not lend themselves to being controlled by an arbitrary line drawn across a multicolored map.  

No matter how tough the lawman.  

 

Dr. K

Teenage pregnancy prevention redux

My last post regarding the New York City school system and its provision of Plan B contraception was met with a number of replies that took issue with my characterization of the problem. Perhaps I have been less than artful in my explanation of this issue.

Public health is at its core a preventative specialty. As many know, prevention can be of a primary, secondary, or tertiary nature. In most areas of medicine, primary measures of prevention are lauded as the most beneficial, and tertiary measures are considered a failure in a population context. As a simple example, hypertension and its complications can prevented in a primary fashion by proper diet and exercise, in a secondary way through medications, and finally, the complications of hypertension, such as heart disease, can be treated in a tertiary manner through more invasive means such as surgery. Traumatic brain injury due to firearms is another example. Tertiary means of prevention such as treatment of brain injury by the neurosurgical crowd is certainly not the ideal. Secondary prevention such as gun safety education is not considered adequate by some segments of the population.  The true primary preventative intervention would be to ban guns altogether, and, again, certain voices in and out of medicine advocate for that as well.

Why should prevention of teenage pregnancy be any different? Would it not be better to facilitate a primary prevention model for the problem? Because it doesn’t work? The same thing could be said for the obesity problem, yet millions of dollars are spent in figuring out how to provide the health education necessary to convince millions of us to adjust our diets and eating habits (including the banning of certain sizes of sodas in a particular jurisdiction), clearly a primary prevention model. If the current model of primary prevention of teenage pregnancy is ineffective, then it would seem that there should be a push to find a model of primary intervention that does work and not be satisfied with secondary and tertiary results. Our profession doesn’t accept this in most other areas of medicine.

The point is, this continuum of preventative measures is found all throughout medicine, and in my opinion, the New York City school system’s move to provide Plan B is an example of secondary or even tertiary prevention, and could be construed as a failure in the public health context as outlined above.

Dr. K

 

 

 

 

Trolls, Obamacare and the land of make believe

Make believe.  It has a nice ring to it.  Living in such a land can be fun.  Enjoyable.  Enchanting even.  We all wish we had a visa to this country.  Because if we did, we would want to stay there forever.  However, the hard truth is that when we visit this land, eventually we have to go back to the reality of everyday life.  Where things do not always happen for the best.  Where things we want must be worked for and paid for. 

 

Such as some of the goodies that were promised in the euphemistically named Obamacare.  They tend to be the most popular of the provisions in the bill.  We all like the idea of our kids being carried by our insurance until they are 26.  We mostly seem to be amenable to the idea that pre-existing conditions should be covered.  What we tend to miss is that both of these are essentially a de facto expansion of the insurance rolls that will need to paid for somehow, by someone.  And this has already occurred; it isn’t one of the provisions that will strike in 2013, 2014 or beyond.  We also neglect to notice that these items don’t come cheaply.  The reason that pre-existing conditions typically aren’t covered is because these types of policies are so expensive that insurance companies couldn’t sell them anyway.  So now they are magically added to the insurance pool?  One of the major touted benefits of Obamacare was the money savings that would be found.  Adding these sorts of patients to the rolls of the insurance companies has to mean that premiums will of necessity rise for all.  I don’t believe this aspect was explained very well to the country, if at all.  Or maybe there was a willful blindness to the cost of these goodies.  Because they sounded so...good.  We wanted to make believe they wouldn't carry any cost.      

It must be nice to live in the land of make believe.  But we should realize that this land is not always just a frolic with fairies and unicorns; sometimes there is a big hairy troll.  With a club.  And sometimes, just sometimes, we could get hit over the head with it, which would bring us back to reality.  That certainly hasn't happened yet.  Some say that we'll cross that bridge when we get to it.  But you all know what might be lurking beneath that bridge...

Dr. K  

Medicare cartoons!

I'm going to step into this one gingerly. I have never seen a Medicare patient in my entire career. True, as a pediatrician, I never had the occasion to. I do feel sorry for my colleagues that do see Medicare patients, because they are going to be hit with a tsunami that is welling up right now and will hit them full force in January. There is a lot of talk bandied about currently regarding the estimated $700 billion in cuts Obamacare will make to Medicare, where it will come from, who it will affect. In a move likely designed to reassure nervous seniors about the status of their healthcare, the administration has stated that the majority of the cuts are meant to decrease payments to physicians and hospitals; that they wouldn’t think of cutting anybody’s benefits. This is the type of reassurance that Wile E. Coyote gave the Roadrunner just prior to the anvil dropping from the sky,

 or that given by Snidely Whiplash to Nell just before tying her to the railroad tracks.

 

This stance begs a very fundamental question. What does the administration think that Medicare benefits are made of, if not mostly payments to physicians and hospitals? If you think it is hard to find a doc who accepts Medicare now, just wait until they see a 31% cut in January.  If we can’t have a substantive conversation about the sustainability or the viability of Medicare without resorting to silly assertions such as the above, then this debate needs more than an astute politician to turn the tide. It will take a hero the like we haven’t seen in a long while:

The administration’s thinking on the Medicare cut issue is almost sophomoric. Cartoonlike comes to mind.

 

Dr. K

A fairy tale about WIC and illegal immigration

Once upon a time in a country that shall remain unnamed (but it rhymes with Barizona), there was a federal program known as WIC that provided foodstuffs for women who were pregnant or had small children.  This program, with origins dating back to at least 1972, had been a resounding success in the state as numbers of clients steadily increased over the years.  However, a lady was elected queen in 2010 and knights of the legislative round table came to her and suggested that there be placed guards around the kingdom to prevent people from other lands coming and stealing from the citizens.  She indeed did agree and a decree was made that such guards be placed and thus they were.  In time this resulted in many of the people from other lands leaving and going back to their home kingdoms. 

When this happened the lords of the WIC realm realized that the numbers of citizens petitioning for WIC benefits dropped precipitously.  Faced with this calamity, there was much weeping, wailing, and gnashing of teeth amongst the WIC minions as this was interpreted as a failure of epic proportions.  Much of the WIC treasure was then spent urging all citizens of the land to sign up for WIC if they possibly could, since it made no sense that a benevolent government organization should LOSE clientele.  And the loss of clientele meant possible loss of employment for WIC workers. 

Lost in the swirling controversy was the point that the decree had unearthed the fact that many of the previous WIC clients had indeed been citizens of other kingdoms, and had been stealing treasure from the good country of Barizona and the Empire to which she belonged. 

After this episode, the good citizens of Barizona were left to ponder the following:

1. Is it wrong for people from other lands to rob from our treasure?
2. If there is less demand for a government service, is that necesarily a bad thing?

And they all lived happily ever after…

 Dr. K

A law primer for Obamacare- Mark Twain said it best

When I think of Congress, I am reminded of the Mark Twain quote: “Suppose you were an idiot. And suppose you were a member of Congress. But I repeat myself.” 

After the Robert’s decision from the Supreme Court, there has been talk of repealing Obamacare by many members in Congress.  This repeal may have a chance of passing, especially if the November elections result in a Republican Senate and President.  I don’t think this is likely, but perhaps…  Even so, Congress will not likely be able to repeal the one immutable law that still might be the downfall of Obamacare, that is, the law of unintended consequences. 

The Affordable Care Act (ACA) stipulates that those who don’t have insurance must obtain such or be faced with a fine or a penalty or a tax or a…whatever.  My take on this is that whenever the government extracts money from us it could be construed as a tax. 

But I digress.  Millions will now be pouring onto the insurance rolls, together with millions more who will be added to the Medicaid registries.  With the wave of a wand the government has decreed that these folks will have insurance and this likely means that this huge influx of patients will likely use their benefits at a rate not seen previously.  This is especially probable since the bill mandates that insurance coverage for everyone provides goodies heretofore not seen in many insurance products.  Given the law of supply and demand (another one of those pesky laws that fall outside the purview of Congress),

I envision that these millions of new patient visits will have to be seen by somebody.  Did the ACA also provide an infusion of physicians to take care of these patients?  Unlike the U.S. treasury, a medical school can’t just print more doctors when ever more are needed.  Couple this concern with the likelihood that many physicians will likely leave medicine altogether or retire early, rather than have their medical practice dictated to them by a top-heavy bureaucratic system that will probably substitute the patient-doctor relationship with a “new age” medical ethic that values the supremacy of the good of the society over the need of the individual.  This all in the name of saving health care dollars.

So who will take care of all these people?  I can see there being huge shortages of doctors to take care of them on the one hand, or patients being seen by a new cadre of physician’s assistants or nurse practitioners on the other.  Either way the manner in which patients receive health care will be changed forever.  Either way, the pie-in-the-sky promises and expectations by some of Obamacare will eventually meet with another one of those laws, the law of gravity. 

As Blood, Sweat &Tears might have put it- What goes up must come down.   

Dr. K

Shhhh, don't tell New York about milk...

I went grocery shopping the other day and was cruising through the dairy section when I was hit by an epiphany.  This is one of my favorite sections, what with all the yogurt, sour cream, milk and the like in abundance. 

What I realized at that moment was that I had a gallon of no-fat milk in one hand and a gallon of 1% in the other.  I also noticed that 2% and whole milk cost the same per gallon as well.  What?  No tax on the richer, fat-laden milk options?  How could this be?  I thought that the best way to effect health behavior change was to tax something to death, or outright prohibit its existence.  In spite of this relatively new propensity to want to use the force of government mandate to determine what is eaten or imbibed, there has been a change in milk consumption over the decades that has occurred without coercion or browbeating.  Why?  I suspect that simple health education has resulted in many folks changing their milk-drinking behavior to a point where I would suggest that most people prefer 1% milk to whole milk these days.  To be sure, it has been a gradual decline, but a decline nonetheless.

   

 In a previous post, I commented on the silly aspect of Mayor Bloomberg’s war against soda.  I continue to be amazed at how governments at many levels are trying to regulate what and how much is eaten by the populace.  Maybe we can all take a lesson from the dairy industry experience.  If not, then I fear that my chocolate shake will be the next in a long line of trespassers to make the long walk towards extinction.  I sure hope not.  And miss out on this?   

   

Dr. K

Too fat or starving? Which is it?

I’m confused. 

On one hand I read that there is an obesity epidemic that threatens our very way of life, or at least our life expectancy.  Predictions abound that the “bulk” of us will be overweight in a few years.  Public health experts warn that this concern is reaching down into the pediatric age group as well.  This article states that “fully” one out of seven low income kids is obese.  Clearly this would appear to be a public health problem.

On the other hand, there also appears to be a hunger epidemic in America.  The news is replete with stories wherein children are going hungry on a daily basis.  Some estimates are that one in five children is struggling with what is known as “food insecurity” (however that is defined…).  Is this a true representation of the state of nutrition in our nation’s children, or does it imply something else?

Can both of these epidemics be true?  I don’t pretend to be able to provide an answer to the obesity problem, but I do know that if the hunger epidemic truly exists, then federal programs such as free school lunches, SNAP (food stamps), and WIC are monumental failures.  Digging into the weeds of the statistics of hunger, one finds that it is more likely that the true “hunger rate” is between one and two percent. 

It is interesting that two avenues of progressive thought seem to be vying in a paradoxical battle for control or dollars.  There are the forces that dutifully preach that the obesity epidemic must be curbed, and some of the means to curb it could mean dictating what may or may not be eaten or what medical care will be paid for.  Then there are the opposing groups that bemoan the fact that millions of children are going to bed hungry every night, and that we must pony up for even more governmental food programs.  I wonder who is going to win this one.

So which is it?  Can both scenarios be true?  Are too many poor kids too fat?  Or are too many poor kids starving?  Maybe if the fat kid would split his milkshake and Whopper with the hungry kid, then both problems would be solved…

 Dr. K