Relevant and even prescient commentary on news, politics and the economy.

Wanna balance the budget? Eat real food.

‘Food desert’ is not a common idea on people’s minds, but we also tend to say “Let them eat cake” when it comes to obesity.

Michael Pollan suggests:

Stay out of the middle of the supermarket; shop on the perimeter of the store. 

It is not just what you eat but how you eat.  “Always leave the table a little hungry,”

Families traditionally ate together, around a table and not a TV, at regular meal times. It’s a good tradition. Enjoy meals with the people you love.   In the U.S., 20% of food is eaten in the car.

Wanna balance the budget? Eat real food in the NYT.

In the United States — the world’s most obese country — the most recent number for the annual cost of obesity is close to $200 billion. (Obesity-related costs are incalculable but could easily exceed $1 trillion annually. Wanna balance the budget? Eat real food.) The amount the National Institutes of Health expends for obesity-related research is less than $1 billion annually, and there is no single large, convincing study (and no small study will do) that proposes to solve the underlying causes of obesity. If the solution were as simple as “salt, fat, sugar” or the increasingly absurd-sounding “calories in, calories out,” surely we’d have made some progress by now.

 

Fast food messes with your bank acount?  University of Toronto

“Fast food represents a culture of time efficiency and instant gratification,” says Chen-Bo Zhong, who co-wrote the paper with colleague Sanford DeVoe to be published in a forthcoming issue of Psychological Science. “The problem is that the goal of saving time gets activated upon exposure to fast food regardless of whether time is a relevant factor in the context. For example, walking faster is time efficient when one is trying to make a meeting, but it’s a sign of impatience when one is going for a stroll in the park. We’re finding that the mere exposure to fast food is promoting a general sense of haste and impatience regardless of the context.”

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What is Wrong with “Our” VA

This was an answer in the local Weekly Reader to a couple of others who insisted VA healthcare should be disassembled and handed over to the private sector. I guess I could have said “nuts; I did say “nonsense.”

“All right, they’re on our left, they’re on our right, they’re in front of us, they’re behind us…they can’t get away this time.” You figure out who said this.

Senator Bernie Sanders bill failed by 4 Republican votes to get out of the Senate. Within that bill there were several sections dealing with meeting the needs of veterans.

Section 327 would require VA to develop and transmit to Congress a strategic plan for improving access and quality of health care services for veterans in rural areas. This plan would include goals and objectives for: the recruitment and retention of health care personnel in rural areas; ensuring timeliness and improving quality in the delivery of health care services in rural areas through contract and fee-basis providers; implementation, expansion, and enhanced use of telemedicine services; ensuring the full and effective use of mobile outpatient clinics.

Section 501 would direct VA to reorganize the Veterans Health Administration (VHA) into geographically defined VISNs. In addition, it directs the Secretary to ensure that each VISN provides high quality health care to veterans, increases efficiency in care delivery, implements best practices, enhances collaboration with partner entities, among other management functions. Finally, this section requires the Secretary, at least every three years, to review and assess VISN structure and operations and submit review results to the Committees on Veterans’ Affairs.

Section 502 would require VA to establish not more than four regional support centers within VHA to assess how effectively and efficiently each VISN conducts outreach to veterans who served in contingency operations; administers programs for the benefits of women veterans; manages programs that address homelessness among veterans, and consumes energy. In addition, the regional support centers would assess the quality of work performed within finance operations, compliance related activities and such other matters concerning the operation and activities of each VISN as the Secretary considers appropriate. “Comprehensive Veterans Health and Benefits and Military Retirement Pay Restoration Act of 2014”

Here is what some of those needed four Republican Senators said:

“I don’t think our veterans want their program to be enhanced if every penny of the money to enhance those programs is added to the debt of the United States of America,” Senator Jeff Sessions Republican Alabama.

“Greatly expanded spending without any realistic offset,” as he dickered with Reid over sanctions on Iran. Republican Senator Mitch McConnell, Kentucky

“I think the decision we got here, as we debate this legislation, is whether we are going to commit to a promise that is bigger than what our kids can fulfill.”It costs more than our kids can afford (with a little sh*t-eating grin on his face). My colleagues pointed out most of the veteran organizations support this bill in fact correct. Senator Richard Burr Republican North Carolina

As far as the bill, the chairman has offered here, this bill has already been debated and there are problems with this bill that is an extensive piece of legislation that has many good elements in it. It also has a cost issue at a time when our nation owes $18 trillion and that was the reason why so may on my side of the aisle objected to it and that is why I would object as to the motion made here today by the Senator from Vermont.” Republican Senator Mario Rubio, FLA.

After causing Senator Bernie Sander’s bill to fail by 4 votes, these same 4 Senators are now trying to get to the bottom of why there are delays in getting care for veterans. The VA has always had a degree of issues with it in waiting for the benefits offered and this has been the case for decades. Too often and too late much of the delay is the result of the lack of funding to meet the influx of newly discharged and veterans (disabled and healthy). The issue extends to the Vietnam Veterans who are now arriving at the VA installations with issues resulting from age. Old Mr. Invincible has seen a few instances of physical vulnerability.

To answer to the insistence on leaving Veteran healthcare to the free market, we pretty much have done so with everyday people over the decades. What have we experienced?

– Since the proposal of Hillarycare in the nineties, we have seen the cost of providing healthcare quadruple. There are no controls or incentives to stem the persistent and ever-increasing cost of healthcare by the industry as it is a service- for- fees- cost- model, which makes it money by selling you more. The US has one of the most expensive healthcare systems in the world without the benefit of the best care globally.

– We have left the training of doctors and the supply of them to the free market. Increasingly we are experiencing a shortage of primary care doctors not only at the VA; but, it is being experienced in the private healthcare market today. Only 20% of the students hoping to be doctors are going into primary care and the shortage is growing. “The US is short ~16,000 Primary-Care Doctors. The PPACA attempts to solve the problem by skewing funding and salary to primary care except Congress is cutting PPACA funding “Congress, for example, already has chopped about $6.25 billion from the ACA’s new $15 billion Prevention and Public Health Fund, which pays for programs to reduce obesity, stop smoking and otherwise promote good health. In addition, federal support for training all types of physicians, including primary care doctors, is targeted for cuts by President Obama and Congress, Republicans and Democrats, says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges, who calls the proposed cuts “catastrophic.” Nurse Practitioners are coming on line; but, the time table is long and they will not be abundant for years yet Some of this is a contrived shortage as cited by PNHP:

“(Nursing schools are trying to produce more Nurse Practitioners (NPs) to deal with the crisis in primary care, but have been consistently attacked by MDs who insist that NPs are not well enough educated to provide even routine primary care.)” “Lack of funding is the Real VA scandal”

– Try getting in to see a Cardiologist or specialist or primary care doctor in 2-3 weeks in the commercial market. You can not and the wait times extend outward from 1-3 months in private medical care clinics (my experience). This is typical. Phillip Longman the author of The Best Care Anywhere most recently pointed to the wait for a private clinic doctor’s appointment.

patients who already have good private insurance have trouble scoring an appointment with a primary care physician. Which is why, (Philip Longman interview at Vox) , wait times for an appointment in Los Angeles are on average up to 59 days and in Boston up to 63. Newspaper reports like that in the New York Times spotlight vets who have been able to get immediate appointments in the private sector.

Well I congratulate them.

Most people I know, even those with good health insurance have a pretty hard time finding a PCP whose practice is even open to new patients and have to wait a good long time for specialist care as well. How will the nation’s overtaxed primary care doctors suddenly be able to accommodate millions of vets when they can’t handle the patients they already have, plus the influx of patients who will now be insured thanks to the Affordable Care Act?”

And the acting VA Chief is planning on dumping thousands of veterans into the commercial market? The placing of Veterans in the commercial market will start an erosion of VA benefits for those who have earned it serving the “4 chicken-hawks” I named above who sent them to war.

– The VA offers more to veterans than what the private healthcare clinics can. As one Livingston Daily Veteran (Jim Pratt) pointed out: “The VA system has major advantages over private hospitals in some things- such as electronic medical records, coordinated care, and early screening and detection of issues that of are particular need for military veterans. U of M medical center does not screen for PTSD, or for titanium dust (Camp Victory), depleted uranium exposure (All our engagements since the 1980’s), or exposure to ionizing radiation. The VA can do those, and more.

Another veteran, Jack Samples points to the efforts of the Ann Arbor VA in handling its patient workload. Having been there myself, I can vouch for it also. Guarantees two-week maximum waits for primary care appointments, Provides 24-hour emergency care, provides daily urgent care for anyone who does not have an appointment but needs or wants to see a doctor, etc.

– VA Primary Care doctors are underpaid and making less than their commercial counterparts do. It is difficult to attract more primary care doctors to the VA when more can be made in commercial hospitals.

The list goes on, on how Congress has failed the veterans of this nation with some lame excuses for not funding the last two wars and preparing adequately to receive veterans. Much of this is not the fault of the VA. The generalities expressed by two readers do not hold up to a close examination and there is no economic reason to give veteran healthcare over to a failed private healthcare system which abandoned millions of people.

“The Architect of the VA’s Quality Transformation Under Clinton Speaks Out”, Phillip Longman

“VA Care: Still the Best Care Anywhere? Part II”, Phillip Longman

“How to Beat the Doctor Shortage”, Marsha Mercer

“The Best Care Anywhere”, Phillip Longman

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Thanks, But We Still Hate Obamacare!

Greg Sargent gets a great nugget from Democratic pollster Celinda Lake, who “recently conducted a statewide poll in Kentucky for an unnamed client and found that Kynect polls very positively, in contrast to Obamacare, which is underwater.”

Kynect is the Kentucky version of the Affordable Care Act exchange. To the extent the polling is correct, these results are another example of people loving the ACA but hating Obamacare.

 

Which just isn’t very surprising. People still don’t really know what “Obamacare” is. Why should they? There’s nothing labeled “Obamacare” that anyone has to deal with; almost nothing labeled “Affordable Care Act;” and there aren’t even all that many noticeable parts of the new system. Of course, Kynect is one of those new things, but there’s no reason for anyone in Kentucky to know that it has anything to do with the national law.

 

Hat Tip: Jonathan Berstein Thanks, But We Still Hate Obamacare!, Jonathan Bernstein

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Waldmann V Waldman

I was reluctant to read this post by Paul Waldman Obama must fix VA scandal to redeem liberal vision of government. In general, I think very highly of him and think he does our [n]name proud. The post is OK, but I will criticize it.

My reaction to the Veterans’ Administration scandal was first to recall the claim that the VA provides better care than other US systems and second to suspect that the scandal doesn’t prove this claim false. I was pleased that my fellow Waldman[n] noted the claim (which was based on solid evidence) here

In 2007, Phillip Longman wrote a widely-praised article, later expanded into a book, documenting how the VA health care system had transformed itself into a model of excellent care, using creative problem-solving and early adoption of electronic records.

Exactly. But then the next sentence is

So what happened since then?

This assumes that something has changed. But the scandal doesn’t prove that the VA care is worse than any other care in the USA. Longman’s article compared the VA to the rest of the US health care non system. The fact that VA care is scandalously bad and a violation of our contractual obligation to our veterans does not mean that it isn’t much better than the rest of the US health care system. The post contains a catagory error (or maybe Longman’s article did) contrasting relative evaluation of VA vs non VA with relative evaluation of actual VA vs promised VA.

Waldman’s hypothesis is that something has changed since 2007 (sic) (or rather since the data Longman discussed in 2005 were collected). I think he is wrong. Steve Benen noted “In 2012, RAND Corp. found in nearly every category, “VA patients received consistently better care across the board, including screening, diagnosis, treatment, and access to follow-up.” ” Benen linked to this post by Jon Perr which is extremely convincing (just click there it’s too good to excerpt)

I didn’t know that, but I know the scandal doesn’t tell us two things. First it doesn’t tell us how the VA performs on average. Second it doesn’t tell us anything about the VA vs anything else in the world.

I think there are four problems here (and I don’t mean to pick on Waldman).

The first is that the data based response that things are worse in the rest of the US healthcare non system is not considered acceptable, because it suggests a lack of outrage or respect for the victimized veterans. I think in a discussion of horrible consequences of misconduct, reporting the fact that worse things have happened is not accepted. This means that there are facts which must not be mentioned. This is always a problem.

The second is a strong tendency to discount the not so distant past. Waldman should have looked for solid relevant evidence before guessing that something changed dramatically in the past decade. In fact, more recent studies comparable to the New England Journal of Medicine study which he indirectly cites reach the same conclusion.

A third is that there is (and must be) a legal and is (but shouldn’t be) a pragmatic distinction between making a promise and breaking it and not making the promise. The veterans were not given the care to which they were contractually entitled. Non veterans are not contractually entitled to (non emergency) care. At most, you are insured which means that you don’t have to pay for the care. There is no scandal related to secret waiting lists kept separate from the official public waiting lists by doctors with office practices. They don’t have official public waiting lists and you might be told to go elsewhere and not put on a waiting list at all. If there are no rules, there are no broken rules. A bureaucratic system will have scandals, because there are ruled to break and written records which can contain proof that they were broken.

The fourth is that in politics perceptions are reality and it is very hard to keep discussions of politics and policy separate. The public won’t be convinced by Rand studies. Stories beat statistics. A vigorous and severe response to the VA scandal isn’t needed just to make the VA as good as it must be, but also to refute the argument that the private sector works better, which is appealing to normal people outraged by the scandal even though the scandal provides almost no relevant evidence.

Waldman’s main argument is based on the fourth issue. His post explicitly focuses on the politics. I actually agree with his conclusion. But the post included the bolded sentence which is not supported by any evidence he presented and is contradicted by available evidence (which I didn’t personally find either).

update: back to the source. Ezra Klein interviews Phillip Longman here. He stands by his story.

the big question with these stories about the VA is, “compared to what?” This scandal wouldn’t exist if the VA didn’t have performance metrics on its employees. If it didn’t measure or care whether veterans get prompt appointments it could just do what the rest of the health-care system has done and not hold people responsible for these metrics. Now, certain people seem to have cheated on this metric. But that’s far better than what goes on in the rest of the health-care system where no one is accountable for this at all.

[skip]

PL: The metric here is they tried to get vets in for non-urgent appointments for care within 14 days. Compare that to a survey done in 2009 on average wait times outside the VA to see a family physician. [skip] The average wait time in major metropolitan areas is about 20 days.

Oh just click the link and read the interview.

i

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A Patient’s Story–How Much Can or Should– Your Doctor Tell You About Potential Risks?

AB Introduction: For a while now, Angry Bear has been featuring some of Maggie Mahar’s articles about Healthcare, the PPACA, and costs. Besides being a former 20th Century Foundation Fellow Maggie’s has also written as a financial journalist for Barron’s, as well as articles for Time Inc., The New York Times and other publications. Her first book, “Bull: A History of the Boom and Bust 1982-2003” (Harper Collins, 2003) was recommended by Warren Buffet in Berkshire Hathaway’s annual report and her latest book “Money-Driven Medicine: The Real Reason Health Care Costs So Much” touches on the squander and the waste found in delivering healthcare in the US. For more on her books, click here.

Besides writing at Angry Bear, Maggie has her own blog The Health Beat from which this article was originally published.

Below a non-fiction story from Pulse: Voices from the Heart of Medicine, “an online magazine of personal experience in health.” Pulse is both a magazine and an online community that provides a chance for patients, doctors, nurses, social workers to come together, and share their experiences.

The magazine’s founders write: “Despite the large numbers of health magazines and medical journals, few openly describe the emotional and practical realties of health care. We at Pulse believe that our stories and poems have the power to bring us together and promote compassionate health care. “ Pulse was launched by the Department of Family and Social Medicine at Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx, New York, with help from colleagues and friends around the state and around the country (Subscriptions are free: You will find the home page here.

At the end of the story, see my note, asking HealthBeat readers: “What Do You Think: Should the patient have sued the doctor?” Would she even have a case?

Collateral Damage

By Brenda Scearcy

Dr. Robert’s office felt right to me, with a musical birdsong soundtrack, soft lighting and fresh green tea, and I had my best friend in tow: piece of cake. In this serene atmosphere, I was sure that I’d find out what to do next to finish treating my endometrial cancer.

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Longevity and Long-Term Care: The Medical Crisis of the 21st Century : Part 2 Update: Maggie Mahar will be doing a radio interview at 12:30 PM The Attitude with Arnie Arnesen 94.7 FM WNHN Concord NH

Maggie Mahar at The Health Beat Blog discusses Alzheimer’s care and the alternatives.

Throughout the 20th century, most Americans saw “longevity” as a goal. If we took care of our bodies, we reasoned, we could “live longer and better.”

But in the 21st century, I suspect that some of us will learn to fear “longevity” the way we now fear cancer.

This is the second in a series of posts that will explore the anguish that some experience when they live into their late eighties and nineties–and how we, as a society, can address the hardships of “old, old age.”

Senile Dementia

Thanks to better diets, exercise, and advances in medical knowledge, more and more of us are living to four score and seven. But the downside is that in too many cases, our bodies are out-living our minds. As I note in the post below, since 2011, 40% of the increase in Medicare’s outlays can be attributed to spending on Alzheimer’s patients.

Why is the incidence of Alzheimer’s (AHD) spiraling? Because we are less likely to die of heart disease or strokes, millions of Americans are living long enough to be diagnosed with senile dementia. One could say that longevity is the proximate cause of Alzheimer’s.

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Scott Brown says no one should work at a minimum-wage job in the U.S. forever. Instead they should move to Canada. Or Germany. Or France. Or …

I’m encouraged any time government functions. We’re a very philanthropic society. We always want people to have safety nets. Medicaid is meant to be a temporary measure to provide benefits for people who are in difficult circumstances. It’s not meant to be going on forever.

— Scott Brown, when Politico reporter Kyle Cheney asked him whether he supports New Hampshire’s Medicaid expansion.

So if he’s elected to the Senate he’ll propose a really large increase in the minimum wage. Expect Walmart and McDonald’s to make sizable donations to Jeanne Shaheen’s reelection campaign committee.  Luckily for us Dems, they’re people and can do that.

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Michael Hiltzik: “‘If I had to guess, this case won’t go well for retirees,’ [U. Mich. law prof. Nicholas] Bagley writes.”

In an era in which corporations have been trying every possible stratagem to cut employee benefits (see our look at the Obamacare employer mandate earlier today), a new threat to retirement benefits has just arisen.

The source of the threat is the Supreme Court, which earlier this month agreed to rule on when or whether employers can unilaterally end retiree healthcare benefits, even when they’re negotiated as part of a union contract.

– The Supreme Court saddles up for an attack on retiree benefits, Michael Hiltzik, LA Times, May 12

The article, which explains the situation and includes the quote in the title of this post, links to Bagley’s post about the Supreme Court case at issue on his Bagley’s blog.  The blog is called The Incidental Economist, and is devoted to discussion of healthcare reform.

The case has already been decided, of course, 5-4, at the Court.  All that remains are the formalities: the briefing, argument, and the opinion written by Samuel Alito.

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Krugman: If you don’t like the mandate, why not support single payer?

Bill Gardner at The Incidental Economist offers a rather decorous, mild reply to the people making [the argument that guaranteed health insurance is an assault on America’s freedom]. I’d put it more forcefully: the pre-ACA system drastically restricted many people’s freedom, because given the extreme dysfunctionality of the individual insurance market, they didn’t dare leave jobs (or in some cases marriages) that came with health insurance. Now that affordable insurance is available even if you don’t have a good job at a big company, many Americans will feel liberated — and this hugely outweighs the minor infringement on freedom caused by the requirement that people buy insurance. (Also, if you don’t like the mandate, why not support single payer?)

— Paul Krugman, Insurance and Freedom, NYTimes.com, today

I’ve said now here at AB too many times to count, but most recently five days ago, that the highlighting of Obamacare horror stories–real or fabricated–is really an argument for single payer. Every single horror-story problem–real, fabricated, or predicted down the road–would be cured by single payer.  But, to my knowledge, no one else was writing this in print for public consumption.  Now, Paul Krugman has done that.

But why aren’t the Dems pointing out that what the Repubs appear to actually be complaining about is the absence of a public option, or that the ACA didn’t establish single payer?  Maybe sometime before the election, they will–if others who have a wide readership make the point, as Krugman did there.

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The Hill – “GOP struggles to land punches at ObamaCare insurance hearing”

HT :Washinton Monthly, Ed Gilgore: “House GOPers Face to Face With Unfriendly Facts on Obamacare”

Democratic lawmakers were emboldened to defend the Affordable Care Act with renewed vigor and levity, creating a dynamic rarely seen in the debate over ObamaCare.

Adding to the irregularity, exits on the Republican side at a subcommittee hearing led by Rep. Tim Murphy (R-Pa.) allowed multiple Democrats to speak in a row and let heavy Democratic criticism of Republicans go unanswered, a contrast with the heated exchanges of last fall.

The discussion was not always favorable to the healthcare law, as it touched on health plan cancellations, the potential for premium increases in 2015 and problems that still plague the back end of HealthCare.gov.

Witnesses from the insurance industry were also careful in their comments and promised to submit several answers to the committee at a later date.

But Republicans were visibly exasperated, as insurers failed to confirm certain claims about ObamaCare, such as the committee’s allegation that one-third of federal exchange enrollees have not paid their first premium.

Four out of five companies represented said more than 80 percent of their new customers had paid. The fifth, Cigna, did not offer an estimate.

That is absolutely terrible, the PPACA might be working and people are paying their premiums? What is this world coming to? All the critics said the PPACA would never work, people would not sign up, and if they did they would not pay their premiums . . .

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