Half Changed World

Last week, the federal Advisory Committee on Immunization Practices recommended adding a new vaccine, Gardasil, to the standard immunization schedule for 11 and 12 year old girls.  Gardasil immunizes against several strands of the Human Papilloma Virus (HPV), which causes genital warts and cervical cancer.

As Rivka at Respectful of Otters explained, the conservative groups that had initially responded to the prospect of such a vaccine in a hysterical snit ("How are we going to stop people from having sex if we can’t threaten them with deadly disease?"  — no that’s not a literal quote, but the real ones aren’t far off), have moderated their message, and are now saying that they’re glad the vaccine is available, but it shouldn’t be mandatory.  This change is rhetoric seems to have been effective: the NYTimes says that "a few religious groups have expressed mild reservations about the vaccine."  But Rivka argues that there will always be exceptions available for religious objectors, and if the vaccine isn’t made mandatory, states may not pay for it.

If I understand the issue correctly, assuming that HHS accepts the ACIP recommendations, the new vaccine will be covered under Medicaid and the federal Vaccines for Children program.  So really poor kids should get it (as long as they have access to the documents to prove their citizenship, but that’s a topic for another day).  And most private insurance will cover it as well.  The problem is the state programs that provide vaccines for kids who aren’t poor enough to qualify for Medicaid, but don’t have insurance.  Gardasil is expensive — $120 per shot, with a series of three shots required — and covering it would nearly double the cost of some states’ immunization programs.

However, on the parenting lists that I’m on, most of the discussion has been from parents who aren’t sure that they want to give their daughters a new vaccine, especially if they’re not sexually active.  I’m not going to quote anyone without permission, but what I’ve been hearing is pretty similar to the parents quoted in this article about the vaccine.  My kids are way too young, and the wrong gender (although eventually Gardasil or another similar vaccine is likely to be available for boys and men as well), so it’s not a decision I’m personally facing.  But I tend to be pretty pro-vaccine in general.

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I saw a poster on the metro over the weekend, seeking healthy volunteers to participate in clinical trials for a malaria vaccine.  I don’t remember the URL and google has failed me in digging it up, but I’m going to look for the poster again.  Obviously, I want to learn more about both the vaccine and the study protocol, but I’m seriously considering doing it. 

AP had a depressing story this week on the increase in "moderate to middle-income" Americans who were uninsured for at least a part of last year.  It’s not particularly surprising, though, since fewer employers are providing insurance, and buying individual insurance is out of reach for most lower-income families.

A couple of people have asked me what I think of the new Massachusetts health insurance law, which requires everyone in the state to have health insurance (or face fiscal penalties) and provides subsidies for low-income individuals and families.  I’m a little dubious about whether it will work, but it’s certainly worth trying.  No one else is even making a serious attempt at achieving universal coverage, and I have to admit that the Massachusetts model is a lot more politically feasible that my preferred choice of a single payer model.  And I’ve got a lot more confidence in this approach than in Health Savings Accounts as the solution to the uninsurance problem.

If you want to know the details of the argument for an individual mandate system, check out the New America Foundation, which has been pitching this approach for a while.  But in brief, the argument is that there are a significant number of young healthy people who could (theoretically) afford to pay for insurance, but gamble that they won’t need it.  They know that if they really get sick, they can show up at a hospital, and won’t be turned away for inability to pay.  An individual mandate therefore both makes them pay their fair share, and reduces the costs of uncompensated care, freeing up funds to pay for insurance for those who really can’t afford to pay.

The reason I’m skeptical is that I haven’t seen anything that explains how the Massachusetts approach deals with the problem of the small minority of people who have major health problems, people like Annika.  Unless you have some way of putting such people in a risk pool with a large number of mostly healthy people (as in the typical employer-provided plan), there’s no way they can afford an insurance plan that charges their actuarial costs.  As soon as people are choosing their own plans, anyone who is healthy will keep their costs down by staying out of insurance plans that are attractive to very sick people.  And so the costs of those generous plans spiral up and up.  If anyone knows how Massachusetts is dealing with this problem, I’d love to hear about it.

My dad sent me two articles that he thought I’d find interesting in light of the ongoing discussion here about work hours.

The first is an article on The Relationship between Specialty Choice and Gender of US Medical Students, 1990-2003.  It debunks the idea that the increase in the fraction of doctors who are women is responsible for the decreasing interest of medical students in specialties where hours are considered "uncontrollable," especially internal and family medicine, pediatrics, ob/gyn and general surgery.  In fact, in every time period examined, women were more likely than men to be planning on uncontrollable specialties.

The second is an article from the Johns Hopkins Medical School alumni magazine about the changes involved in implementing the 80-hour/week restrictions on interns’ and residents’ working hours.  On the one hand, it’s a little surreal to read about a world in which 80-hour work weeks are considered virtually part-time.  But, it’s also a story about a place where people swore that it was impossible to limit working hours without destroying the experience, until they didn’t have a choice, and then they managed to do it.  And if law firms and game companies suddenly faced economic disincentives to working people huge hours (instead of strong incentives to do so), they’d change as well.

Tuesday book review is postponed, because I’m too sad and angry.

I’m sad because Mr. Badger died yesterday.  No, he’s not someone I know in person.  He’s the husband of an anonymous blogger, known to me only as Badger.   He was my age, with a young son.   And just under a year ago, he was diagnosed with liver cancer.  Her writings have been heartbreaking.

And I’m angry because of the mess that passes for a health care system in this country.  I’m angry because one of Badger’s friends had to pass the virtual hat to raise money to pay for Mr. Badger’s hospice care.  I’m angry because Cubbiegirl has a tooth infection and is puking from the pain and can’t afford to have it extracted.

And the scary thing is that neither Mr. Badger nor Cubbiegirl is one of the 45.8 million Americans without health insurance, as reported today by the Census Bureau.  Mr. Badger had health insurance, but he ran through the $100,000 annual limit and it only covered a portion of the cost of hospice care anyway.  And Cubbiegirl is a veteran, but the VA health system doesn’t cover dental care, unless it’s service related. 

This week’s New Yorker has a nice article by Malcolm Gladwell on the problems caused by lack of insurance and under insurance, and how the current Administration is full of people "who regard health insurance not as the solution but as the problem."  It’s worth a read.  But it will make you angry too.

D. had a full blown asthma attack (his first) yesterday afternoon and spent the night in the hospital.  He’s doing well now, and we hope he’ll be home later today, but I’m obviously not going to have a chance for a while to respond to the very thoughtful posts on Warner’s articles.  I will second the recommendation to check out the dicussion at Chez Miscarriage.

One thought before I shower and head back to the hospital.  I have a job where I can take leave on short notice, with pay and without risk of losing my job.  I have an extremely involved spouse.  And I have good health insurance.  And this is still really hard.  Lots of people are missing at least one of these, and there’s a significant number of parents who don’t have any of them.  And poor kids are disproportionately likely to have asthma, probably due to environmental factors.

Update: We’re all home, and D is breathing easily (although with regular nebulizer treatments).  We need to meet with his regular pediatrician next week to figure out where we go from here with identifying the trigger and deciding whether he needs ongoing maintenance treatment.  But the immediate crisis is over.  Thanks for the good wishes.

In 1993, when the Clinton administration was just getting started, Senator Moynihan urged them to start work on welfare reform immediately. Clinton said no, he needed to take care of health insurance first, because how could you expect low-income parents to give up the guarantee of health insurance from Medicaid for jobs that didn’t provide health insurance. Well, as everyone knows, the health insurance proposal died, and by the time Clinton turned to welfare reform, the Republicans controlled Congress.

With that history, I’m reluctant to say that the health insurance problem needs to be solved before we can try to address work-family issues. But the linkage of health insurance to employment is probably the single largest barrier to high-quality part-time jobs. As the cost of health insurance doesn’t go up with the number of hours someone works, it makes sense for employers to want to get as much possible work out of their current workforce rather than to hire more people for fewer hours each.

Kerry supports a number of changes that would expand access to health insurance, but doesn’t propose to break the basic link between employment and insurance. He would address the problem that Amy raised — that states aren’t enrolling all the eligible children under SCHIP — by providing incentives to states that expand enrollment.

The statistic that I’ve heard is that it costs the automakers over $1,000 more per car to build a car in Detroit than to build the same car in Canada, because of health insurance. I don’t understand why employers aren’t demanding that government take over their health insurance costs.

The new issue of Working Mother hit my mailbox yesterday, containing their new list of the 100 best companies for working mothers. I’m more than a little dubious about these lists, because there’s often a big gap beween the official company policies that are captured in these formulas and practice on the ground, especially around part-time work and non-standard schedules.

My sense is that if you have a supportive boss, you can often get flexible arrangements even if they’re not company policy, and if you don’t, you’re out of luck, regardless of what the manual says. I’d love to see data on what fraction of the workforce is taking advantage of these policies, broken out by gender (are they just creating a mommy track?), and on the career outcomes for people who work part-time or take extended leaves. I work for the federal government, which is overall reasonably family-friendly (with the glaring exception of ZERO paid parental leave), but I know people’s experiences vary dramatically from department to department and even office to office.

If any of my readers work at one of these 100 best companies and want to comment on what it’s really like, I’d love to hear your point of view.

Amy pointed out that in my discussion of flexibility on Monday, I didn’t talk much about stable flexible arrangements, especially shifted schedules. She’s right, and that’s ironic, as such schedules are very common in the Federal government. People love them, especially people who drive to work and want to avoid the utter craziness of DC-area traffic during rush hour. Working Mother reports that flexible hours are among the most common family friendly benefits, with 57 percent of companies offering flextime, and 34 percent offering compressed workweeks.

Of the benefits discussed in the study, the most common offered nationwide are dependent care flexible spending accounts, offered by 73 percent of all companies and mental health insurance, offered by 72 percent. (These figures are attributed to a Society for Human Resource Management survey, which I think means that it’s mostly large companies who were asked.) The least commonly offered benefits are take-home meals (3 percent), business-travel child care reimbursement (3 percent) and emergency/backup elder care (2 percent).

I’d also like to call attention to Corporate Voices for Working Families’ efforts to increase flexible working options for low-wage and hourly workers.

Many companies — even those that have very enlighted policies for their professional workforces — offer much less flexibility to their production and support workforces. The National Partnership for Women and Families reports that only 47 percent of private sector workers have ANY paid sick leave. At a conference I attended, one woman explained how her company, a large food industry corporation, had just changed their policies so it was possible for production line workers to take less than a WEEK of leave at a time (but only if they could find someone to substitute for them on the line). I’m embarassed to admit that such a possibility had never occurred to me in my privileged professional position.