Topic: Health Care & Welfare

The Costs of War

With 103 American fatalities, October was the fourth-bloodiest month since the beginning of the Iraq War. But the focus on the number of battle deaths may understate the true costs of the war for the American soldier. Due to innovations in battlefield medicine, we’re getting much better at saving soldiers’ lives. In WWII, 30 percent of those injured in combat died. In Vietnam–and even in the Gulf War–it was 24 percent. Now it’s around 10 percent. That is unquestionably a positive development. But it also means that many of those we save are horribly maimed. As this article from the New England Journal of Medicine describes:

One airman with devastating injuries from a mortar attack outside Balad on September 11, 2004, was on an operating table at Walter Reed just 36 hours later. In extremis from bilateral thigh injuries, abdominal wounds, shrapnel in the right hand, and facial injuries, he was taken from the field to the nearby 31st CSH in Balad. Bleeding was controlled, volume resuscitation begun, a guillotine amputation at the thigh performed. He underwent a laparotomy with diverting colostomy. His abdomen was left open, with a clear plastic bag as covering. He was then taken to Landstuhl by an Air Force Critical Care Transport team. When he arrived in Germany, Army surgeons determined that he would require more than 30 days’ recovery, if he made it at all. Therefore, although resuscitation was continued and a further washout performed, he was sent on to Walter Reed. There, after weeks in intensive care and multiple operations, he did survive. This is itself remarkable. Injuries like his were unsurvivable in previous wars. The cost, however, can be high. The airman lost one leg above the knee, the other in a hip disarticulation, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question….

[F]or many new problems, the answers remain unclear. Early in the war, for example, Kevlar vests proved dramatically effective in preventing torso injuries. Surgeons, however, now find that IEDs are causing blast injuries that extend upward under the armor and inward through axillary vents. Blast injuries are also producing an unprecedented burden of what orthopedists term “mangled extremities” — limbs with severe soft-tissue, bone, and often vascular injuries. These can be devastating, potentially mortal injuries, and whether to amputate is one of the most difficult decisions in orthopedic surgery. Military surgeons have relied on civilian trauma criteria to guide their choices, but those criteria have not proved reliable in this war. Possibly because the limb injuries are more extreme or more often combined with injuries to other organs, attempts to salvage limbs following the criteria have frequently failed, with life-threatening blood loss, ischemia, and sepsis.

Even with all the efforts made to save limbs, “the amputation rate in Iraq is double that of previous wars,” as the LA Times reported earlier this year, in its three-part series on wounded American soldiers. 

That war is a bloody business is hardly a novel point.  And, of course, it is not by itself an argument against any particular war. If these men incurred similar injuries charging Al Qaeda positions at Tora Bora, that would have been terrible, but far easier to justify.  However, it is becoming increasingly hard to justify the costs of our open-ended commitment in Iraq, where our mission becomes ever murkier, and victory, however defined, continues to recede over the horizon.

Health Care Involves Non-Monetary Costs, Too

The Fraser Institute of Vancouver, B.C., has released its 16th annual “Waiting Your Turn” report on waiting times for health care in Canada’s state-run Medicare system.  The median wait for surgical and therapeutic services increased slightly over the 2005 median to less than one day shy of their all-time high of 17.9 weeks in 2004.  Throwing more money at the system doesn’t seem to make a difference; the Frazer Institute has documented that waiting times often increase with increased spending on Canada’s Medicare program.

This year’s report had special significance for me.  Four Sundays ago, I tore my ACL playing soccer.  The following Tuesday, I saw an orthopedic surgeon.  On Wednesday, I had an MRI.  (As a cash-paying patient, I had people offering to cut their MRI list price in half.)  The next Tuesday, I saw the orthopedist again.  He diagnosed the torn ACL and recommended surgery, which he could schedule as early as November 9th.  That’s 4.6 weeks after injury, 3.3 weeks after diagnosis. 

Nadeem Esmail, the lead author of the Fraser report, helped me work out how I would have fared in Canada.  Esmail estimates that, “not counting issues actually getting the referral to a specialist from a GP in the first place,” a typical Canadian could expect to wait:

  • 16.2 weeks to see an orthopedic surgeon,
  • 10.3 weeks for an MRI, and then another
  • 16.5 weeks for ACL reconstruction surgery.

All told, that’s 43 weeks; I could expect to have my ACL reconstructed in early August 2007.  And with a six-month recovery time, I’d be good as new by February 2008.

As it turns out, I’m not having the surgery done on the earliest possible date.  I’m able to walk without too much pain, so I’m taking some time to strengthen my knee, and to research procedures, surgeons, and prices.  Not all waits are problematic. 

But it’s nice to have the choice.  Were I forced to wait until next August for surgery, that would impose significant costs on me and on others.  I would be living in pain, with limited mobility, and might further injure my much-weakened knee.  My wife would have to endure nine additional months of complaining.  Plus, think of all the games my soccer team might lose. 

America’s health care sector is full of waste, but when people say that Canada’s system is cheaper, they’re leaving out some very real non-monetary costs.  Canada’s Supreme Court acknowledged those non-monetary costs in a 2005 opinion that struck down Quebec’s ban on private insurance:

Dr. Eric Lenczner, an orthopaedic surgeon, testified that the usual waiting time … for patients who require orthopaedic surgery increases the risk that their injuries will become irreparable… . [He] also stated that many patients on nonurgent waiting lists for orthopaedic surgery are in pain and cannot walk or enjoy any real quality of life.

The ban on private health insurance effectively kept people from spending more money on health care to reduce health care costs.  (The story of the man who defeated that ban can be found here.) 

Only the individual patient can tally those non-monetary costs and weigh them against the cost of treatment.  If we’re really interested in lowering health care costs, we need to give the patients the money, and let them choose the lowest-cost option.

Lovely Hospital, Doc — Be a Shame if Anything Were to Happen to It…

I recently came across a transcript of National Economic Council director Al Hubbard’s remarks to a hospital trade group back in March.  In it, Hubbard discusses Bush administration policy regarding price transparency in health care.  That policy was later fleshed out in an executive order, which mandated that federal health programs furnish beneficiaries with information on prices, etc.  The administration stopped short of imposing a similar mandate on the private sector.

But Hubbard’s comments to the hospitals let us know where the president is headed.  And it was Hubbard’s…shall we say…rhetorical agility that I find priceless:

The president’s approach has been…that through persuasion we can get the [health care] providers of this country to start providing accurate, easy-to-use information and we don’t have to go to legislation, because, you know, legislation is a very crude tool to accomplish things and we would much rather let the free market, and you all individually, com[e] up with the best way of approaching transparency as opposed to Congress and the federal government telling you how to do it. But the president has also made it clear that if the provider community is not receptive to providing transparency that we will turn to Congress and ask them to support transparency.

When is persuasion not persuasion?  When it’s a threat.  Later, in an answer to a question, Hubbard dispensed with the subtleties:

And by the way – and I hate to use this blunt club as a threat – if you don’t, it’s going to be imposed upon you. It is going to be imposed upon you.

In other words, Pres. Bush thinks that the market should do whatever it wants, so long as it’s exactly what he wants.

Which is exactly the same as not being for a free market at all.

I Ain’t Sayin’ Nuttin’

I attended a briefing today, by certain representatives of a certain governor of a certain state who has a certain health care proposal.  I already blogged certain details of the proposal, and my thoughts on the proposal. 

But after the briefing – and only after the briefing – I was told that the contents of the briefing are to be kept confidential.  So we had to pull down that blog post.

Believe me, though, somewhere out there in America, there is a governor.  Who has a health care proposal.  About which I have thoughts.  I just can’t share them now.

Until then, all I can say to you is this.

The FDA’s Record on Folic Acid

However the kerfuffle over the Food and Drug Administration’s handling of Vegemite pans out, my passionate Australian colleague Sallie James is right to be suspicious. The FDA’s record regarding folic acid has been anything but sensible – or humane. As I wrote in 1998:

[I]n 1992, the federal Public Health Service (PHS) recommended [that] all women of childbearing age consume 0.4mg of folic acid daily. The PHS estimated this could lead to a reduction in spina bifida, a crippling birth defect that partially exposes the infant’s spinal cord through a hole in the backbone, of about 50 percent (i.e., about 1,250 cases per year).

However, the FDA would not let producers of foods rich in folic acid (oranges, leafy green vegetables, etc.) inform expectant mothers of this preventive medicine until 1996. From PHS estimates, it may be reasonably postulated that the FDA’s four-year suppression of this health claim caused as many as 5,000 infants to be unnecessarily stricken with spina bifida.

The federal government itself recommended that women of childbearing age consume more folic acid, yet the FDA refused to let food manufacturers get the word out for four years. As if to shine a beacon on its prior stupidity, in 1998 the FDA required manufacturers to fortify enriched cereal grain products with folic acid.

If the FDA can tolerate 5,000 preventable cases of spina bifida, it’s reasonable to conclude that the agency wouldn’t bat an eye over severing one’s emotionally crucial link to the motherland.

That is, unless Australians have a more powerful lobby than newborns do.

A Democratic Congress, Scary? Compared to What?

The office of House Majority Whip Roy Blunt (R-MO) has produced a document titled “Pelosi’s House.”  It is a list of 

out-of-the-mainstream bills introduced by Democratic Members [that] deserve particular attention because the principle [sic] advocates are the very individuals who would be in a position to schedule committee markups and move the legislation through the Congress should the Democrats take control. 

The list includes bills that would nationalize health care, create an adult diaper benefit under Medicare, reduce mandatory minimum sentences for crack cocaine, etc.

The list is less scary than its authors seem to think.  Reducing jail time for selling crack cocaine is actually a good idea.  And most of the bills have little support even among Democrats.  A bill that would nationalize health care has only 19 cosponsors, which is less than 10 percent of Democratic House members and less than 5 percent of the full House.

I mean really.  If the Democrats were to take control of the House, probably the worst they could do is add an expensive new prescription drug entitlement to Medicare. 

Oh, wait.  The Republicans already did that.  So the Democrats would have to shoot for something else, like a new adult diaper entitlement.  At least the GOP would go back to opposing such things.  Right?