Half Changed World

One of the joys of our system of employer-provided health insurance is that the odds are pretty good that if you lose your job, you'll also lose your health insurance. 

Well, you can continue your coverage with COBRA, but relatively few workers who have just lost their job can afford to pay 102 percent of their premiums for an extended period of time. The average COBRA payment eats up something like half of the average unemployment insurance benefit.

If you're young and healthy, you might be able to buy an individual plan for less than your COBRA payments, especially if you're willing to accept a high deductible and hope you don't get sick.  If you have children, they might qualify for public insurance, through SCHIP or Medicaid, but unless you were seriously living paycheck to paycheck and have no assets, you probably won't qualify.

The Economic Recovery bills moving through Congress attempt to deal with this problem in a couple of different ways:

• it would provide a federal subsidy for part of the cost of COBRA payments
• it would extend how long you could continue to participate in your former employer's plan if you were within 10 years of qualifying for Medicare, or had worked for your old employer for at least 10 years.
• At least on the House side (it may be in the Senate bill too, but I haven't found it), it would let states cover workers receiving unemployment benefits under Medicaid, without regard to income or assets.

I'm not an expert on health care policy, but this strikes me as a bit of a kludged together package.  For one thing, it leaves out the 60 percent of unemployed workers who don't qualify for unemployment insurance, most of whom probably didn't get employer-provided benefits in the first place, and so can't get COBRA either.  For another, COBRA is a pretty expensive way to cover people — Medicaid is  lot cheaper. 

I'm not really objecting to the proposal — it's better than doing nothing, and I recognize that health care reform isn't likely to happen in the next month.  But this really isn't a substitute for doing health care reform for real.

What does it say about me (or modern life) that when I read Judith Warner's column last week about the use of brain-enhancing drugs my first reaction was to wonder how one goes about getting some Provigil?  (It's an anti-narcolepsy drug, which apparently allows one to maintain brain functionality in spite of sleep deprivation.  And for the record, the only drug I'm actually taking is claritin.)

I'm not a scientist, and I don't know what the side effects of these drugs are.  But a few months ago, after being up most of the night with one of the boys, I went to work, and was pretty fuzzy around the edges.  And then I realized that I had spent a good two years or more in that kind of a fog every single day.  And if someone had offered me a drug to make it go away (other than caffeine), I'm pretty sure I'd have jumped for it.

If asprin were invented today, it would probably require a prescription — between its blood thinning action and the potential for Reye's syndrome, it's easy to make the case that it's too dangerous to be available without control.  Caffeine is ubiquitous, but I could argue that it's as much of a mind-altering substance as Provigil or Ritalin.  I think the editorial in Nature arguing for legalizing these drugs for people who aren't "ill" is pretty convincing.

*If you're wondering about the title, it's a reference to Nancy Kress' excellent sci-fi novel Beggars in Spain, where she explores what happens if some people are genetically engineered not to need sleep, and thus have an advantage over the rest of us.  Pills are certainly more egalitarian than genetic modification.

I knew that December 1 is World AIDS Day, but I hadn't realized that it was first observed 20 years ago.  

I'm young enough, and my friends are young enough, that I didn't lose anyone close to me to AIDS. But in 1990, I had a summer job working for a doctor whose practice was mostly AIDS patients  She was an internist in the West Village in the '80s, and was one of the first to notice that a bunch of people were coming in with diseases that were supposed to be incredibly rare.  She was always running really late, and gradually most of the healthy people stopped coming to her practice, but if you were sick, she was a great doctor to have on your side.  She spent hours dealing with the paperwork needed to get people enrolled in clinical trials, because that was the only way to get the drugs that might possibly help them.  And she'd visit her patients in the hospital and sit with them and read the riot act to the staff who were afraid to touch them.  (Me?  I answered phones and filed charts and entered data.)

I don't know what I'd have thought if a time traveler from 2008 had come with a news report.  So wonderful that HIV is a manageable infection, something you can live with, not an automatic death sentence.  But I don't think I ever imagined that 20 years later, there still wouldn't be a cure.  And if you had told me that gay rights groups would be focused on marriage equality, with hardly a mention of HIV/AIDS, I simply wouldn't have believed it.

An organ transplant — especially when it’s a repeat job — is never a simple operation, but all things considered, Annika seems to be doing pretty well.  I’m still keeping her and her family in my thoughts and prayers.

On one of the posts about her (not here, on another blog), someone posted a comment urging people to join something called LifeSharers.  Their stated goal is to increase the number of organs donated and reward the people who choose to donate, by giving people who commit to donate organs higher priority to receive organs themselves.  They’re doing this by creating a free membership organization, where the condition to belong is that you commit to a) donating your organs and b) specifying that other members should get priority for those organs.

There’s an interesting logic here.  It gets around the primary objection to paying people for their organs (e.g. that the amounts involved could be coercive, and might motivate your next of kin to make decisions that were in their best interest rather than yours).  They explicitly don’t require that you be in good enough health for anyone to use your organs to join, so there’s no discrimination in membership.  (Although, as T points out, since they seem to be mostly recruiting through the internet, there’s a procedural bias towards the populations that are more likely to use it.)  And this doesn’t appear to be one of the predictably irrational cases where you make people less altruistic by offering an external reward.

But, in looking at their site, it seems like many of the people who are endorsing it are at least as motivated by a desire to show that incentives and free markets can produce a better outcome than government solutions as they are by they desire to have more organs transplanted.

Because there’s another very simple way to increase the number of organs that are available for transplant, that they don’t mention at all.  Make organ donation opt-out, rather than opt-in.  In other words, rather than having to specify that you want to donate your organs (and then have your next of kin confirm that intention), it would be assumed that you gave consent for donation unless you specified otherwise.  This sounds like a radical concept, but  a bunch of European countries do it, and they have donation consent rates between 85 and 99.9 percent*, compared to less than 30 percent in countries that have opt-in policies.

Fundamentally, these alternative approaches to increasing donation are based on very different hypotheses about why more people don’t donate.  LifeSharers is based on the hypothesis that there’s not enough of an incentive to donate.  Opt-out is based on the hypothesis that thinking about dying freaks people out and so they avoid doing it as much as possible.  I’d put my money on the latter.

The UK is considering moving to a system of presumed consent.  Does anyone think it has a chance in the US?

*Sweden is the outlier here, at 85.9 percent, with no other opt-out country at under 88 percent.  I wonder if there’s some cultural issue here against organ donation, or if they’re more aggressive than the other countries in making sure people know of their right to opt-out.  Either way 85.9 percent is a heck of a lot higher than 30 percent.

"Achoo!"
"Bless you."
"Achoo!"
"Gezundheit!"
"Achoo!"
"Damn it, you better not be getting sick."

Tomorrow evening, I’m attending a fundraiser in support of the Ohio Healthy Families Act, which would guarantee full-time workers 7 paid sick days a year (with part-timers eligible on a pro-rata basis).   The ability to take a paid sick day is something that professionals take for granted, but only about half of American workers have any paid sick days, and many of those that do, can only use them if they’re personally sick, not to care for a sick family member.

Paid sick days are good for workers, good for families, and good for public health.  Trust me, you don’t want restaurant workers coming to work sick, and you don’t want other families sending their kids to school sick because they can’t afford to keep them home.

I support federal legislation for paid sick days, but I also think it’s great that folks in Ohio are using the ballot initiative process to try to move the idea.  For one thing, it might well get passed before anything happens at the federal level.  For another, it helps mobilize low-income workers to vote in November.

Head over to www.everyonegetssick.org and join the online rally for paid sick days.

Because you shouldn’t have to choose between taking care of your sick kid and having the money to pay your rent.  And from a public health perspective, you really don’t want the people who are preparing and serving your food, or loading your groceries at the supermarket, to be dragging themselves into work even though they’re sick because they can’t afford to stay home.

If you live in DC, check out www.dcsneezes.org and give your city councilmember a call.  They’re voting on the DC Accrued Sick and Safe Leave Act on Tuesday.

And if you’re in Illinois, read this post to learn how you can help.

Here’s the NY Times editorial, Catching Up on Family Values, from earlier this week.

In honor of the Roe v. Wade anniversary, I’m highlighting the Hyde- 30 Years is Enough campaign to lift the restrictions on Federal funding of abortion services to poor women who receive health insurance through Medicaid.  Here are some of the reasons I oppose the Hyde amendment restrictions:

• I believe that the ability to control one’s reproduction should not be limited on the basis of income.  NNAF says it better than I can:

"We call for full public funding of abortion as a
part of comprehensive health care for all, and support for low-income
women to care for their children with dignity.  We stand for
reproductive justice, a world in which all women have the power and
resources necessary to make healthy decisions about their bodies and
their families."

• One of the main effects of the Hyde restrictions is to push abortions from the first trimester into the second.  This increases the health risks to the woman, raises the cost of the procedure, and pushes closer to the viability line.

• The logic of the Hyde amendment — and the related laws that prohibit coverage of abortion for federal employers, military personnel, and their dependents — is fundamentally flawed.  Supporters argue that even though abortion is legal, people should be able to avoid having their tax dollars support something that they consider immoral.  Well, I can think of a number of things that my tax dollars support that I consider immoral, and I don’t get to opt out. 

If you’re not poor, a federal employee, or a member of the armed services, these bans don’t affect you.  Now.  But if you hope to someday be covered by a public health insurance system, you should be paying attention.

The Washington Post website has an interactive "choose your candidate" tool that purports to show you which candidate you should be supporting, based on their public statements on a variety of issues, and how important you say these issues are.  I spent some time playing with it, and it mostly demonstrated to me how close the Democratic candidates are on most of the issues that I care about.  If you can parse the differences between what they’re all saying on Social Security or immigration, you’re doing better than I am.  And while the tool lets you say how much you care about the issue in general, it doesn’t have any way for you to indicate how much you care about the differences in the candidates’ positions.  I think I gave up on it about halfway through, when it was saying I should be supporting Chris Dodd.

Precisely because the candidates are so close together on policy, the areas where they disagree, even a little, are getting a lot of attention, perhaps excessive.  One of the areas where some differences have shown up is on health care.  Kucinich is the only one standing up for a true single payor system, while Obama has criticized Edwards and Clinton for requiring everyone to get health insurance.  He’s dead wrong on this — both because you really do need to get everyone into the insurance pool in order to avoid people freeloading until they actually get sick, and because the attack on "mandates" is likely to come back and haunt him if he actually gets elected.  (I don’t have the energy to go hunting for a full set of links right now, but this has been exhaustively discussed in the wonkosphere. )

So, on one of the few areas of substantive difference, I think Obama’s wrong.  But I still think he’s my pick.  I’m embarrassed by that.  I’m a self-proclaimed policy wonk.  But he makes me want to believe. 

***

On a related topic, this week you’ll see an ad in my sidebar from the fine folks at One.org, who have asked all the candidates about what they’d do to fight international poverty and disease. Spotlight on Poverty and Opportunity is a similar exercise focused on domestic poverty.  Check them both out.

A month or so ago, I got an email from FlavorX, asking if I’d be interested in a sample of FlavorIT, their new home kit for adding flavorings to medicine.  I responded with an enthusiastic yes.

I’d heard of FlavorX a couple of years ago, but at the time, they only had products for use by pharmacies.  Pharmacies add the flavorings either free or for a nominal charge, but generally only for prescriptions that they fill — it’s a way to stand out from other companies, in what is basically a saturated market.  But because we have a HMO, we have to get our prescriptions filled at the HMO’s pharmacy — and they don’t do flavorings.  So after much calling around, we finally found a kindhearted pharmacist (at Alexandria Medical Arts, for anyone in the area) who was willing to do it.  (We had our cat’s prescriptions filled there, so they did make some money off of us.)

So, I was thrilled to hear that these flavorings were now available for home use.  But, I didn’t want to post about it until we had actually tried it, and D has been relatively healthy of late.  But the other day, he complained of a stomach ache until we broke out the Zantac, and gave it a try.  The kit comes with a bottle of sweetener and four different flavorings.  I think we did a drop of the sweetener and one of the bubblegum.  He still grimaced at the taste — but he drank it. 

So, if you have a kid who resists taking medicine, I’d definitely give this a try.  The one thing that I wish they did differently is provide a medicine syringe for mixing the flavorings in, rather than a spoon.  The syringe wastes less medicine, and is good for shooting the medicine into the back of the mouth, so there’s less opportunity to taste it.

The good news is that the House passed the SCHIP reauthorization bill.  The bad news is that the 265-159 vote margin is not going to be enough to override a veto.  Congress will presumably include SCHIP in the continuing resolution that it will need to pass by September 1, and it will continue at current levels until at least sometime next year, probably until 2009.  That’s going to mean real cuts in some states.

Here’s the roll call.  What immediately jumped out at me is that my representative, Tom Davis, is one of the Republicans who voted against the original House bill but for the compromise bill.  I had been wondering about that after getting his response to my email plea for SCHIP last week, which said, in part:

"H.R.
3162 was not SCHIP.  It was an excessive expansion of a good program, an expansion that could undermine
the program’s effectiveness and a backdoor effort to move toward government run health care….   

Given
the wide range of problems with this legislation I voted against it when it came before me in the House.
It passed, however, by a vote of 225-204.  The Senate passed a narrower expansion of the SCHIP program.
I am hopeful that as we proceed to a conference we will return to the core principles established in
the original SCHIP."

I assume that Davis is going to run for the Senate seat that John Warner is vacating.  I think this vote will hurt him in the Republican primary, but help him in the general election if he gets nominated.  Or maybe I’m being too cynical — many Republican voters support health care for kids too.

Added: I heard this afternoon that there’s been another recall of Thomas trains for lead-based paint.  Unlike the first go-around, we do have some of the affected pieces, and will send them in for an exchange.  But I still wish that the American public was half as outraged about SCHIP as it is about lead in toys.  Nick Anderson got it right a month ago.