• Halbig and the individual mandate

    In what is perhaps the strangest rhetorical move in the Halbig litigation, the challengers maintain that they’re trying to protect people from the individual mandate. They point out that ACA exempts families from the mandate penalty if, after taking tax credits into account, they would have to spend more than 8% of their income to get health coverage. Eliminating tax credits in states with federal exchanges would mean that many more people would exceed that 8% figure.

    For the challengers, that’s a good thing. In Michael Cannon’s words, “a victory for the Halbig plaintiffs would free more than 8.3 million residents” from the mandate. The pending Supreme Court petition makes the same point:

    [B]y purporting to make a credit “allowable” in states served by HealthCare.Gov, the IRS Rule reduces the number of people in those states exempt from the individual mandate penalty. Now ineligible for exemptions, those individuals are no longer free to forgo coverage … .

    The argument is tailor-made for Justice Kennedy, who cares so deeply about personal liberty that whole books have been written about it.

    But it’s an odd argument. To see why, think about who would be exempt from the mandate penalty if Halbig is upheld. It wouldn’t be everyone. The average cost of a bronze plan is $3,468 per year. That’s more than 8% of income only for those families making less than $43,350 per year, which for a family of four is about 180% of the poverty line.

    So in most states, for families making between about two and four times the poverty line, a victory in Halbig wouldn’t eliminate the mandate. It would just wipe out tax credits and effectively increase the price of insurance. That’s not exactly a blow for liberty.

    What about those lucky people—those who make too much to go on Medicaid but still less than twice the poverty level—who would be exempt from the mandate penalty? To make it concrete, imagine for a minute that you don’t have coverage through your job and you’re trying to support your family on an annual income of $35,000 (about 150% of poverty). You want insurance, especially for your kids, but even a bronze plan costs almost $3,500 per year, or 10% of your total earnings. You just can’t afford it.

    With a tax credit, however, coverage would be in reach. Your credit would be worth about $2,740, so you’d only have to pay $760 for a bronze plan—about 2% of your income, or $63 a month. (These figures aren’t outliers. CBO estimates that the average tax credit in 2014 will be $2,400.)

    Would you really have more freedom if you lost the tax credit and, because you could no longer afford insurance, you were exempt from the mandate? No doubt, some people would say yes. They bristle at the mandate and don’t value insurance very much—even cut-rate insurance. They’re also pretty cavalier about asking the rest of us to pick up the tab if they fall ill or have an accident.

    Many near-poor families, however, would find it liberating to get cheap coverage, even if they were required to do so. As Bill has eloquently observed, health insurance offers a kind of freedom, too. It’s the freedom to quit that stultifying desk job that you stay in only because of the health benefits. It’s the freedom not to have to choose between making rent and buying your kid’s asthma medication. And it’s the freedom not to fear that a car accident or a cancer diagnosis might bankrupt you.

    Yes, if the Halbig challengers prevail, millions of people would be exempt from the mandate penalty. But that just means they would be free to decline coverage that, without tax credits, they could have afforded anyhow. What kind of freedom is that?


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  • You have not become who you will always be

    I did not expect my children to express sadness around their birthdays. As they’ve aged they’ve been better able to articulate why. “I don’t want to grow up,” they’ve told me, crying. Crying!

    Their emotions are mixed. Birthdays are exciting, and they have a good time too. But the sense of the gradual, inexorable chipping away at their youth is palpable, even to them, as it is to me.

    I’m 42. I get it. I don’t want to age anymore either. This is a common feeling among adults. I guess kids feel it too, or my kids anyway. Maybe it’s genetic, because I was the same when I was young. I recall trying to hang on to what it felt like to be five as I turned six, then seven, then eight, …

    Despite my attempts, I could not do it. My brain aged with my body, and my mind changed with it, as it should. Not only did the memories fade, but so did the feelings. At some point I could not conjure up the sense of fiveness. It was gone.  Completely gone. And I was sad. I could never go back, not even in my imagination, and this inevitable irreversibility is not what I wanted.

    As a teenager, perhaps 15, I recall discussing something like this with my wonderful and wise step-father. When he realized what I was getting at he asked me what was so special about being young. My answer was paradoxical, “Because you change a lot when you’re a kid. Your mind changes, and that’s fun. It’s interesting.” I wanted to stay young precisely because I enjoyed the rapid change of growing up. Perhaps fiveness was exciting to me because there was so much newness, so much change. But to experience it also ment gradually becoming not five.

    Then my step-dad said something important that I will never forget. “You think adults don’t change?”

    “Well, once you grow up, you’re kind of done, right?” I said.

    “Oh no! Anybody can change. Personal growth does not stop when you’re a grown up.” I believed him because I had learned that he’s usually right. And now I know from experience that he spoke the truth.

    Without knowing it, my step-dad and I were discussing the end of history illusion. This is the phenomenon that when one contemplates the future—the next decade, say—one tends to imagine very little change in one’s personality, values, and preferences. However, when one thinks back over the past decade, one recognizes considerably more change. The amazing thing is that, according to work by Jordi Quoidbach, Daniel Gilbert, and Timothy Wilson, this discrepancy between the predicted change in the future and the recognized change in the past exists at every age.

    Throughout their lives, people “regard the present as a watershed moment at which they have finally become the person they will be for the rest of their lives.” There is no more growth, we think. But we’re always wrong. This is the end of history illusion.

    In a sequence of studies, Quoidbach, Gilbert, and Wilson compared people’s predictions of change in personality, values, and preferences over the next ten years with recollections of people ten years older about the prior ten years. For example, they compared how 20 year olds thought they’d change (or not) to how 30 year olds had actually changed over the same decade of life, 20-30. They did this for every age between 18 and 68 years old. The charts below, based on metrics of changes in personality, values, and preferences, summarize their findings.

    end of history

    As the chart shows, reported changes were above predicted changes for all ages except after age 55/65 with regard to preferences. This suggests that we change as we age a lot more than we expect to, which is what my step-father was telling me. The charts also show that we do change less over time, just not as much less as we think.

    “Time is a powerful force that transforms people’s preferences, reshapes their values, and alters their personalities,” the authors wrote.

    When I get sad about aging, this insight brightens my mood. It’s not over! Of course I will never be five or even feel fiveness, but I’m not done experiencing the very thing I cherished about youth: change.

    My kids aren’t either, despite what they may think.

    If you are sad at birthdays because it means the end of the personal growth you’ve been enjoying, you’re wrong. You have not become who you will always be.

    Watch Dan Gilbert explaining the end of history illusion in his TED talk:


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  • Healthcare Triage: Systematic Reviews

    Healthcare Triage covers systematic reviews:

    You’ve probably heard of “evidence-based medicine”. It’s the idea that we practice based on research and data. There’s another way of practicing called “eminence-based medicine”. It’s the idea that we listen to the person who’s been around the longest or who has somehow managed to be labelled the expert.

    It used to be that such a person would periodically get to write a review article in some journal, and that would be how everyone learned what to do in medicine. That’s a problem. We’ve got a solution. Systematic reviews!

    Here are some references from the video:


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  • Gluten free

    Via Bill Gardner and in honor of Aaron’s Healthcare Triage video on the subject, which I had requested:

    gluten free2


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  • Healthcare Triage News: Pot, Foul Language, and Pain

    This week’s HCT news:

    What are people talking about this week? Better yet, what should they be talking about? We’re talking about marijuana and obscene language.

    Enjoy! Tell your friends to watch!


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  • Best in the world my a$$!

    Readers of the blog know of my many, many, many problems in trying to get my prescriptions filled. And I’m an expert in the health care system! Today, Charles Ornstein (also an expert) relates his difficulties in trying to fill a prescription for his son. The story is maddening. He has some advice at the end:

    If you find yourself in such a predicament, what should you do? First, be prepared. Sign up for an account online with your health insurance company, review your benefits and review your claims. You’ll be amazed by how much — and sometimes how little — your health insurer pays for various treatments and drugs. Second, if you encounter a problem, ask questions. While you may have to pay the bill at the pharmacy if you want to leave with the prescription, you should follow up with your health plan and ask to speak with a supervisor.

    Finally, if the stakes are high enough, consider a health advocate like Ms. Gardner. Some advocacy firms are run by former health insurance executives, who help navigate the roadblocks that their former companies have erected.

    But, ultimately, you may well end up doing what I did: paying the higher fee with gritted teeth and gaining a new appreciation of how confusing our health care system really is.

    It’s the last sentence that grates on me.

    By the way, I still own the site bestintheworldmyass.com. I just haven’t figured out what to do with it yet!


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  • System pressure

    It was this Freakonomics podcast episode that persuaded me to read Allan McDonald’s book Truth, Lies and O-Rings, which I finished on my flight home from DC yesterday. I’m sure you can already guess what it’s about: the Space Shuttle Challenger disaster.

    McDonald was in a unusual position and did a difficult thing. He knew more about the solid rocket booster’s O-rings than just about any other engineer on the planet. Because low temperatures degraded their ability to keep hot gas from escaping the booster’s joints, he did not approve of launching the Challenger in the extremely cold conditions on January 28, 1986. He was in the room when the decision was made to do so anyway, over his objection. And in the subsequent investigation into the cause of the explosion of the Challenger, he was one of the few who spoke the full truth without attempts to paper over the flawed decision-making process.

    What gave NASA cover to launch—but in the full context of the situation was inexcusable anyway—was a signed blessing of the O-ring’s adequacy from the solid rocket booster’s manufacturer, Morton Thiokol. Despite the low temperatures, McDonald’s superiors at Morton Thiokol decided the O-rings would be fine. This was what drew me to the story.

    Why did Morton Thiokol executives make the go-for-launch call when their engineers and the data strongly argued the risk of failure was high?

    I imagine it was a tough call. I sure hope it was! Try to put yourself in their position. On one side, you’ve got engineers telling you the O-rings can’t handle the conditions, and they have some data to support that position, though it’s not an air tight argument. There’s always room for some doubt, some probability things will be fine.

    On the other side you have what? “System pressure,” as David Newman would call it, also known as “conflicts of interest.” The pressure to please the client, NASA, was high. NASA was, at that time, considering Morton Thiokol’s next contract. A lot depended on keeping the money flowing. Jobs were at stake. It’s no small thing to displease a client, lose a contract, and have to lay off hundreds of workers who are counting on you. NASA had its own form of system pressure, in wanting to maintain a tight schedule of launches to show Congress—which controls the purse strings after all—it could perform as promised.

    System pressure should never have ratcheted up so high that it created strong incentives to launch on January 28, 1986. That was NASA’s fault. Perhaps overly politicized “oversight” by Congress can and did play a role as well. (This is not unique to NASA and the Shuttle.)

    But even in much less vital circumstances—ones even you and I face—there is some system pressure. We become invested in our positions, feeling our reputations ride on them. We have some responsibility to maintain our salaries and even grow them. Some of us are responsible for creating revenue that others and their families rely on. There are professional and cultural norms that we are loath to cross.

    Sometimes, though by no means always, these forces push against doing the right thing. We are conflicted, at least somewhat. And sometimes they do so when there’s some ambiguity as to just what the right thing is. Here’s where it’s easy (or easier) to shade, to lean, to allow those system pressures to tip the scales so we can have it all. We find a way to justify doing the thing that doesn’t disrupt the status quo, even when without those system pressures we would not do that thing.

    It’s very hard to be fully in tune to when this is happening. Most of the time it doesn’t matter much. Few decisions are anywhere near as important as whether or not to launch the Space Shuttle in temperatures below those at which its components have been tested. But sometimes a decision matters just enough that one is risking one’s integrity and credibility (if not worse) by succumbing to system pressure when it opposes what is empirically the (more) right call.

    McDonald did a hard, brave thing by resisting system pressure. He paid a price for it, though his career seemed to have gone quite well anyway. It’s no small feat, what he did, and some of his colleagues couldn’t do it. Is it so clear you or I could in the same circumstance? In what ways do you or I allow system pressure to chip away at our credibility and integrity, if only imperceptibly? I find it disturbingly interesting to ponder these questions.

    The book is long, both because it is so detailed, but also because it tells the history of the aftermath of the disaster linearly. It was investigated several ways: by Presidential Commission, by congressional committees, and in various lawsuits. In each part of the story some of the same arguments and episodes are covered. I found some parts of the book overly technical. But it’s easy enough to skim and skip. If you don’t read it, at least listen to the Freakonomics episode.


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  • A little bit of money means a lot to many, many people

    A couple of years ago, the tires on my wife’s car needed to be replaced immediately. She called me, concerned, because they were going to cost a couple hundred bucks, and we really didn’t have the time to shop around. I told her not to worry, and to buy them.

    I distinctly remember feeling immensely grateful after I got off the phone. This, really, was “wealth”. Not fancy vacations or expensive meals, but the comfort of knowing that it was nearly impossible for “small”, incidental charges like this to really affect our lives.

    I thought of that when I saw this story this morning in Time:

    On a recent San Francisco afternoon, I returned to where I’d parked my car, but it was gone. A “No Parking” sign indicated that parking was prohibited after 3:00 PM on weekends. It was 3:15. I called the telephone number on the sign and a clerk affirmed that my car had been towed to an impound lot.

    I took a cab and entered a single-story brick building where a few dozen people were crowded together in a scene that evoked Kafka; weariness, frustration and anger were palpable. Some stood in line, some paced and some sat hunched on the floor. A family huddled in a corner, an infant asleep on the father’s shoulder. A woman on a pay phone wept as she begged whomever was on the line to find money so she could get her car back–she said she needed $875. “I’m gonna lose my job if I’m not there at 5.”

    Clerks sat on stools behind Plexiglas. At a window, a man pleaded with an agent, “I have to pick up my kids in less than an hour. What am I supposed to do?” At the next window, another man railed loudly and furiously, yelling, “How the hell am I supposed to get my goddam money if I can’t get to goddam work?” The clerk said, “If you can’t get cash, you can pay by credit card or cashier’s check.” The man shouted, “And if I had a goddam limousine, we wouldn’t be having this conversation.”

    To many Americans, a towed car is a nuisance. A real one, yes, but in the scheme of things, no more than that. That’s wealth. That’s privilige. For many others, a couple hundred bucks is all it takes to destroy the fragile framework of what passes for security in their lives.

    Think about that the next time someone tells you that a $100 copay shouldn’t be a “big deal”. Or how a $25 premium is “insignificant”. Or how over-the-counter birth control is “cheap”.

    It may be to you. But not to everyone. Not to far more people in this country than you likely realize.



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  • Why can’t I look up my service history?

    I am in the waiting room at a Toyota dealership, getting service on my Prius. There is a loose panel underneath the car that’s making a noise. And while I am in, I thought I would catch up on the car’s routine maintenance.

    The problem, however, is determining what has and hasn’t been done. I haven’t had this car serviced at this dealership before. I’m in a commuter marriage, I’ve been living in two cities, and I seem to travel all the time. So the car has been worked on at several dealerships in several cities. And of course, I have no clear memory of what I’ve gotten done when.

    No problem. The car has a VIN number. Dealerships are independent enterprises, but Toyota has an international database that has all the service records from all the dealerships. The service manager and I are looking at the records in seconds and we quickly make a decision about the needed service.

    This is interesting only because I can’t do this for my body. I have a congenital arrhythmia and a pacemaker. Like my car, my heart needs a lot of routine maintenance. I have to get care in two cities, but neither site can access the other’s records. There is also the occasional semi-emergency, when the cardiologists always regret that that they can’t read the trace data that are (they hope?) stored at the other clinic. I get pdfs of some of my records, but collecting these things in my Dropbox has been, shall we say, a less than world class solution.

    The engineering and legal work required to make electronic health records interconnect is harder than the engineering required to connect Toyota dealerships. Nevertheless, it is seriously stupid that I can access complete service information on my car but not my heart.


    For previous TIE writing — and complaints — about the disconnected state of electronic health records, see here, here, and here; and listen to podcasts available here.

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  • Dash of Salt Does No Harm. Extremes Are the Enemy.

    The following originally appeared on The Upshot (copyright 2014, The New York Times Company).

    For years, we have known that diets high in salt can be bad for people with high blood pressure. A study published recently in The New England Journal of Medicine confirmed this fact. It monitored more than 100,000 people in 18 countries and found that people who consumed more sodium generally had significantly higher blood pressures than those who did not.

    Another manuscript in the same journal looking at the same study population went even further. It found that people who consumed more than 7 grams of sodium per day had a significantly higher chance of death than people who ate 3-6 grams per day. People consuming high levels of sodium had higher rates of heart attacks, heart failures and strokes as well.

    These results confirm that people who eat too much salt should eat less of it. The problem with the way we respond to such information, though, is that we often run too far and too fast in the other direction.

    Americans consume, on average, 3.4 grams of sodium per day, or about the equivalent of three and a half tablespoons of soy sauce. This is on the low end of the “safe zone” of 3-6 grams in the study. The United States Food and Drug Administration thinks that’s not low enough. It recommends 2.3 grams per day. The World Health Organization says it should be 2.0 grams. The American Heart Association goes even further and recommends we consume no more than 1.5 grams.

    Upshot Salt

    Why? There’s surprisingly little rationale for this belief. Last year, experts convened by the Institute of Medicine assessed the evidence concerning sodium intake around the world. They agreed that efforts to reduce excessive sodium were warranted. But they cautioned that no such evidence existed to recommend a very low salt diet. They hoped that future research would assess the potential benefits of a diet where sodium intake was 1.5 to 2.3 grams per day.

    The second New England Journal of Medicine study did just that. In addition to looking at high sodium diets, it compared the health outcomes of those who had very low sodium diets. What they found was worrisome. When compared with those who consumed 3-6 grams per day, people who consumed less than 3 grams of sodium per day had an even higher risk of death or cardiovascular incidents than those who consumed more than 7 grams per day.

    This result would be shocking if we in the medical community hadn’t seen it before. But we have. In 2011, researchers published a study in the Journal of the American Medical Asssociation after following 3,681 people over almost a decade. They, too, found that excessive salt intake was associated with high blood pressure. They also found that a low-sodium diet was associated with higher mortality from cardiovascular causes.

    Why experts and organizations feel the need to go from one extreme to the other is unclear. But it’s unfortunately something we do far too often in medicine.

    Take cholesterol. Initially, people believed that the evidence was pretty compelling that high cholesterol was bad for you. But instead of focusing on those who are really at high risk, or those at the very highest ranges of cholesterol levels, we saw recommendations emerge that told us that all cholesterol was bad. We began to eliminate it from our diets completely. Eggs were shunned.

    But later research showed us that egg consumption had no relationship to cardiovascular disease for most people. In fact, a majority of people’s serum cholesterol level has little to do with how much cholesterol is in their diet.

    Today we use medications to lower our cholesterol levels. Once again, though, our sights keep shifting lower. Instead of focusing on those who are most at risk, we’ve decided cholesterol is so unhealthy that a 60-year-old African-American man with a total cholesterol of 150 might be placed on therapy. Just two years ago, a total cholesterol level of 200-239 was considered to be a definition of “intermediate” cardiovascular health. Theaverage total cholesterol value in America is 200.

    This problem doesn’t run solely in the direction of eradication, though. It’s well understood that vitamin deficiencies can lead to significant diseases. Our response has often been to take them in ever increasing megadoses. There’s no evidence that this does any good, and some vitamins can actually harm usif we consume too much of them.

    More often than not, though, the body can’t use the extra vitamins, and just gets rid of them. The truth is that vitamin megadoses mostly just createvery expensive urine.

    Too many calories are bad for us. That doesn’t mean we should consume none. Too little exercise can lead to bad outcomes. That doesn’t mean you exercise to the point of hurting yourself. Too much sun can cause cancer. That doesn’t mean we should never go outside.

    It’s a cliché but true: In so many things moderation is our best bet. We have to learn that when one extreme is detrimental, it doesn’t mean the opposite is our safest course. It’s time to acknowledge that we may be going too far with many of our recommendations.


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