The Individual Mandate is radical alteration of the social contract

The Individual Mandate is radical alteration of the social contract

Part of the health care reform bill currently being debated by the House of Representatives is the  individual mandate.  By this provision, everyone would be required — by law — to have health insurance, or else be charged with a criminal offense and face fines or possible imprisonment.

This would be a radical and unprecedented change in relationship between citizens and government.  The government would be saying, “you must be part of the system — our system — or we’ll fine or imprison you.”  That violates your basic freedom as a human being.

At face value, the arrangement seems no different than mandated car insurance, which already exists.  But there’s an important difference.  Nobody has to drive a car.  If you don’t want to be forced to buy car insurance, walk or take the bus.  You aren’t compelled.  You retain your freedom to participate or not.

Similarly, everyone is required to pay income tax – but only if you have income.  If you really don’t want to pay income tax, you can, in theory, quit your job and just live off the land.   Few do this, but the possibility of choice has a major implication.  Since you’re free to opt out of the system, your participation is voluntary.  That’s the essence of the social contract, and the basis by which governments are accountable to citizens.  Without the voluntary aspect,  there is no social contract, because a contract cannot be compulsory.  If you’re forced to participate, your condition is that of slavery and servitude to the state.

A further implication is that you’d be effectively forced to have a job so that you can pay for health insurance.  True, nominal programs would help the unemployed buy insurance, but these would likely be inconvenient and complicated.  Most Americans would feel it necessary to work and to buy insurance.

People should work because they want to, not because they have to.  When they have to work, it affects the workplace: companies then don’t need to supply good benefits or working conditions to retain employees.  So with the individual mandate, not only would you be a slave to the state, but to the corporate system as well.

The individual mandate’s closest analogy is military conscription.  But at least the draft — itself controversial — applies to a dire emergency — war.  The individual mandate is, at best, a convenience of the government, not a social necessity.

Thus, as with 9/11 and the ensuing Patriot Acts, the government is trying to use problems in the health care system to justify an expansion of power – at the cost of your freedom.

What we have in the United States is a health crisis, not a health insurance crisis.  Legislators seem unable to comprehend the difference.  The problem is not that many Americans lack health insurance, but that health-care costs are too high. We should be focusing on new ideas for reducing costs – based on technology, innovation, competition, and  individual initiative –  not trying to expand the current insurance-based system that has produced the crisis.

<!–[if !mso]> <! st1\:*{behavior:url(#ieooui) } –>

Part of the health care reform bill currently being debated by the House of Representatives is the <i>individual mandate</i>.  By this provision, everyone would be required — by law — to have health insurance.  Otherwise you’ll be charged with a criminal offense and face fines or possible imprisonment.

This is a radical and unprecedented alteration of the fundamental relationship between American citizens and their government.  The government would be saying, “you have to be part of the system — our system — or we’ll fine or imprison you.”  This violates your basic freedom as a human being.

At face value, the arrangement seems no different than mandated car insurance, which already exists.  But there’s an important difference.  Nobody <u>has</u> to drive a car.  If you don’t want to be forced to buy car insurance, walk or take the bus.  You aren’t compelled.  You retain your freedom to participate or not participate.

Similarly, everyone is required to pay income tax – but only if you have income.  If you really don’t want to pay income tax, you can, at least in theory, live off the land.   Few do this, but the possibility of choice has a major implication.  Since you’re free to opt out of the system, your participation is voluntary.  That’s the essence of the <i>social contract</i>, and the basis by which governments are accountable to citizens. Without the voluntary aspect,  there is no social contract, because a contract cannot be compulsory.  If you’re forced to participate, your condition is that of slavery and servitude to the state.

Moreover, by legislating the individual mandate, the government is saying, “we have the right to pass a law that will require your participation in any program we dream up.”

A further implication is that you are effectively forced to have a job so that you can pay for health insurance.  True, nominal programs will help the unemployed buy insurance, but these will likely be inconvenient and complicated.  Most Americans will feel it necessary to work and to buy insurance.

People should work because they want to, not because they have to.  When they have to work, it affects the workplace: companies then don’t need to supply good benefits or working conditions to retain employees.  Not only do you become a slave to the state, but to the corporate system as well.

The individual mandate’s closest analogy is military conscription.  But at least the draft — itself controversial — applies to the dire emergency of war.  The individual mandate is only a convenience of the government, not a necessity.

Thus, as with 9/11 and the ensuing Patriot Acts, the government is trying to use problems in the health care system to justify an expansion of power – at the cost of your freedom.

What we have in the United States is a health crisis, not a health insurance crisis.  Legislators seem unable to comprehend the difference.  The problem is not that many Americans lack health insurance, but that health-care costs are too high. We should be focusing on new ideas for reducing costs – based on technology, innovation, competition, and  individual initiative –  not trying to expand the current insurance-based system that has produced the crisis.

Hi Mischa

Hi Mischa!  It’s hard to keep ones nerve standing in a crowded grocery store line in a new town, at least for me.

Please send me your email address.

Seven arguments against a doctor’s office visit for flu

Seven arguments against a doctor’s office visit for flu

1. Unless the patient has *serious* pre-existing conditions the flu will pass by itself.

2. After two days of symptoms, pharmaceutical treatments (i.e., Tamiflu or Relenza) will probably have little or no benefit.

3. The best treatment for flu in any case is to stay in bed.  A trip to the doctor’s office places serious and potentially unnecessary stress on the patient and his/her immune system.

4. The patient exposes others to flu virus.

5. In principle, a prescription for Tamiflu or Relenza could be made without a physical examination.  Patients can accurately take their own temperature and report their symptoms by phone.

6. The best reason for an office visit is indirect:  to take a throat or nose swab/sample for flu virus confirmation, either via a rapid (immediate) test or by sending it to a lab for culturing and more accurate testing.  This has public health value, because it helps track flu in the community, but does not benefit the actual patient.

7. There’s no logical reason not to sell rapid influenza test kits in pharmacies (without a prescription) and to let patients use these at home.  Note that these tests have relatively low diagnostic sensitivity (50-70%): they produce many false-negative results.  However the tests have diagnostic specificities of more than 90%:  they produce few false-positive results; thus, if a positive result occurs, the patient probably has flu and Tamiflu or Relenza can be prescribed.  This could be done by phone or fax based on a patient’s self-test.  Thus, for 50-70% of patients with flu, an unnecessary and counterproductive office visit could be avoided by means of a self-administered rapid test.

The above just outline some of the obvious considerations.  The main point is that this subject needs to be examined at the level of public health policy and some sensible guidelines established.

More information on flu testing:
http://www.cdc.gov/flu/profesionals/diagnosis/labprocedures.htm

Prioritizing Flu Vaccine: Individual Patient vs. Aggregate Rules

This is a fairly big issue and I’ll probably devote more than one post to it.

In recent days newspaper headlines have made misleading statements that relate to how to ‘prioritize’ swine flu vaccine (potentially demand will exceeed supply).

For example, one headline today ran “Flu vaccine to pregnant women first“. What the study in question actually showed (or, rather, suggested) is that pregnant women may, on average and as a group, be at greater risk for swine flu and swine flu complications.

But to keep in mind is that each person’s circumstances are unique. Assessment of flu vaccine candidacy, assuming there’s a vaccine shortage, must consider all relevant factors of a person: medical history, age, risk of exposure, health status, risk of complications, risk of infecting others, etc.

While being pregnant is a factor to consider, so are others. It’s not as simple as putting all pregnant women ahead of all non-pregnant women in the ‘queue’, as the headline seems to suggest.

Another headline this week similarly suggested “Antiviral drugs for swine flu patients may be wasted on the elderly.” Again this is an incorrect and misleading statement. On average, elderly people perhaps respond less well to antiviral flu medicine (they do show somewhat lower immunoresponse to flu vaccination on average than younger people) ; they areprobably less likely, again on average, to have a lot of contact with children .

But there are plenty of people above age 65 who vary from the average. Some respond well to vaccines, some have a lot of contact with children, etc.

Decisions to administer antivirals or to give swine flu vaccinations have to be made on a case-by-case basis, considering all relevant aspects of the person and their circumstances.

It can easily be shown that approaching vaccine allocation by a blanket rule like “only young people and pregnant women should get the vaccine” would be extremely suboptimal. The degree of suboptimality associated with such rules — or what could be technically termed marginal prediction — can be estimated; in this case such faulty prediction would likely produce considerable excess mortality and morbidity,  reduced overall quality of life, and unnecessary loss of many millions of dollars.

One alternative is to construct a simple statistical decision tool that  would compute a score for each person (e.g., 1 = lowest priority to 100 = highest priority) based on the person’s individual data. This could be put online for people or doctors to use, for example.

The data to construct such a tool exists in various places, but would need to be collated and analyzed. At present I’m tentatively planning to develop a prototype tool, hopefully in the next couple of weeks.

Protect Yourself from the Flu – Video

Protect Yourself from the Flu

A leading flu vaccine producer, GlaxoSmithKline (GSK), has generously released this audio-visual presentation, originally developed for their employees, to the public:

GSK flu prevention video

When the new window opens, press the “Next” button on the lower right to continue.

This is the best presentation of its kind available today. Watch it yourself and show it to your family and friends.

If enough people follow the simple, common-sense steps outlined here, it can have a significant effect on reducing the swine flu pandemic. Because pandemic disease transmission follows an exponential pattern, even minor preventive steps like those explained here can have a major impact on total disease incidence.

College Tuition: Inflation or Hyperinflation?

As promised, here is a graph showing the disparity between general cost-of-living inflation and inflation associated with college tuition and fees (if the student I promised this to reads this, please let me know if the post is clear):

Source: Bureau of Labor Statistics and the College Board.

The figure compares inflation over the last 30 years associated with (1) the general cost of living, (2) the cost of medical care, and (3) college tuition and fees.

Inflation factors were computed to answer the question: in each year, how many dollars would be needed to have the same buying power as $1.00 had in 1978? The calculations made use of published data on the Consumer Price Index for all urban consumers (CPI-U), the medical costs component of the CPI, and historical data on inflation of college tuition and fees.

As is well known, medical care costs have grown faster than the general cost of living — by 2008, nearly twice as much. This receives a lot of public attention and many complaints.

Yet college tuition and fees inflated at a much faster rate: nearly three times that of general inflation. Thus while it took $3.30 in 2008 to buy the same general commodities purchasable for $1.00 in 1978, for college tuition and fees nearly $10 in 2008 was needed to buy what $1.00 got in 1978.

This excess inflation has, incidentally, occurred across the board: for both private and public 4-year colleges, and for public 2-year colleges.

This is why students are being forced to take out exorbitant loans.

In short:

• After adjusting for inflation, college tuition and fees are roughly three times more expensive now than in 1978. Why? What has intrinsically changed about college education so that this is the case?

• Excess inflation of healthcare costs is a prominent issue and receives much attention; but excess inflation of college costs is even greater. Why is this not a major social issue?

Shouldn’t we be making a college education easier to obtain instead of more difficult? We claim to rely on young people to make a better world in the future. How are they supposed to do that when they step into adulthood already burdened with debt?

Reading and Resources

• The College Board. Trends in College Pricing. Princeton, NJ: 2008.

• The Education Sector. Drowning in Debt: The Emerging Student Loan Crisis. July 2009

• Ronald Ehrenberg. Tuition Rising: Why College Costs So Much. Harvard University Press, 2002.

• The Project on Student Debt

• Paul Streitz. The Great American College Tuition Rip-Off. Oxford Institute Press, 2005.

• Richard K. Vedder. Going Broke by Degree: Why College Costs Too Much. American Enterprise Institute, 2004.

• Penelope Wang. Is college still worth the price? Money Magazine. August 20, 2008.

The Injustice of High College Tuition

I met a college student last weekend and promised her I’d put a post online about the outrageously high cost of college tuition.  I’m working on some figures now and hope to post a chart by tomorrow.

Meanwhile the bottom line remains the same.  It doesn’t matter much which inflation indices or economic indicators one looks at.  The brute fact is that when I went to college in the 70’s, students in California didn’t have to take out loans, but today they to have to.  Big loans, too.

1.  This indicates that we are moving backwards, not forward in terms of higher education in our society.

2. It is unjust, absurd, and socially counterproductive in the extreme to subject youth to this burden.

3. They are being taken advantage of, because they lack the historical perspective to understand that this was not the case 25 or 30 years ago.

4.  Nobody is speaking up for them or representing their interests.

5.  If anything, the costs of a college education should be declining (relative to the cost of living) because computer and internet technology can be used to facilitate distance learning, video lectures, etc.

More on this topic later…

My websites under construction

My websites (listed on the panel to the right) are currently under construction.

My old service provider (Compuserve Ourworld) has closed, and I’m gradually moving pages to a new provider. This may take a week or two.

Please be patient with any broken links, etc.

John Uebersax

Public Policy and Rapid Flu Diagnosis

This post follows up on an earlier one concerning the value of mathematical models, computer simulation, and operations research in dealing with pandemic and inter-pandemic (seasonal) influenza.

There’s a lot that can be done to control flu, once its known to be spreading. We can shut down a school, for example. But the key is to suit an intervention precisely to the need, and not to overreact. We can shut down *a school*, and not all schools in an entire city or country.

To accomplish such tailored intervention, information is crucial: we need to know who actually has the flu, and what strain of flu they have.

A current problem is that the majority of flu cases are not formally diagnosed. People get flu-like symptoms; they suffer for a week; they get better — and that’s that. Then they tell people “I had the flu”. Yet many of these people might not have had the flu at all. They may have had a cold, or food poisoning, or some other infectious disease.

Fortunately, fast, simple, and potentially inexpensive tests exist to diagnose flu and to identify viral strain class (e.g., A or B strain)  exist. However, currently, these tests usually require a visit to the doctor.

As a result, only a minority of people with the flu receive a test. First, why visit a doctor in the first place? You’re sick in bed, suffering from symptoms. The last thing you want is to get into a car (much less a bus) and visit a doctor. Besides the inconvenience, that stress is harmful (remember, the classic treatment of flu involves staying in bed getting lots of rest). Further, by traveling and sitting in a doctor’s office reception area one risks contaminating other people.

Many doctors will not request a flu test anyway. Why should they? It’s added cost and inconvenience.  And from a clinical management standpoint, a confirmed diagnosis of flu is of little value. In most cases the treatment is the same: stay home, rest, and drink  fluids.

Note this is different than for bacterial respiratory tract infections; there one wishes to identify the bacteria in order to select an optimal antibiotic.

Potentially a flu test could be of value in deciding to prescribe Tamiflu. However, Tamiflu has a short window of efficacy. If a doctor suspects flu, then the logical thing would be to prescribe Tamiflu immediately, rather than wait for the results of a lab test.

Recall what happens with a flu test. A cotton swab is inserted into the nasal passages, collecting a mucous sample. The sample is then sent to a lab for processing. It could take a day or longer for the sample to reach the lab. Then it might wait several hours before processing. And then it might take another several hours for someone to phone or fax the results to the doctor. By that time the window of opportunity for Tamiflu would have potentially passed.

A Paradigm Shift

What we need to recognize is that the real value of flu testing is not to benefit an individual patient, but society. That is, the main value is epidemiological, not clinical.

A flu test should be routinely performed so that we can track the spread of flu virus during an outbreak and to make judicious interventions on that basis.

Because of this, we should consider paying for flu tests out of the public coffer, instead of billing patients individually. Further, we should consider streamlining the flu assay process. Here are some suggests towards that end:

1. Develop even faster, cheaper tests. The tests are already simple. A flu antigen test can be performed in 15 minutes, using paper tabs, analogous to a home-based pregnancy test. However, currently these are performed in a lab, by a trained technician. The costs are not currently stated online, but a reasonable guess would be at least $50. What would be ideal is a home-based test, purchasable at a local drugstore. With many more test units being sold, one could easily imagine the price dropping to $10 or even $5 without loss of total revenue to manufacturers.

2. Mobile flu test units. It might take a while to overcome institutional resistance to a home-based test. In the meantime, we could in the US develop something that is already common in Europe: lab courier. Lab couriers are people who can come to your home and pick up a something like a urine sample and take it to the lab for processing.

Option 1 a no-brainer. Eventually this will likely happen. The only question is when. Again, there is probably institutional resistance to overcome. In a sense, this takes work away from doctors and labs.

Option 2 requires a little analysis however. All the parameters involved are straightforward. We can estimate how many people would use such a service (hopefully, if the cost is low enough, nearly everyone with suspected flu). We can also estimate the potential value to society. By tracking the spread of a flu outbreak with almost complete accuracy, we could issue local alerts, close schools, etc. We could optimally distribute antiviral drugs, and launch rapid-response immunization programs. We could also prevent hysteria and unnecessary closures. By tracking an outbreak with complete precision, we could potentially prevent a pandemic.

How much would that be worth? To judge from government investments in bird flu contingency plans, billions of dollars.

The question is whether a publicly financed mobile flu-test units, or some other innovative program, would be cost-effective, in terms of saving money and reducing morbidity and mortality. These are, in principle, simple calculations to make, and perhaps someone at a public health school or the CDC will run them!

Swine Flu, Vaccines, and Mathematical Models

The recent swine flu outbreak in Mexico reminds me that, although lately I’ve been working on other things, I should also continue my work in health policy research and related areas.

Here we consider the problem:  in a flu pandemic, what strategies can we use to conserve scarce vaccine?

Let’s assume, for example, that during the first 3 months of a flu pandemic, a country has 1 million doses of flu vaccine.  How can this quantity, which is not sufficient to immunize the entire at-risk population, be used as effectively as possible?

First we need to decide what “as effectively as possible” means.  Is the objective to minimize total mortality, to minimize mortality and morbidity, to maximize what are called QALY’s (quality-adjusted years of life), or to reduce negative economic impact?  All of these are defensible criteria.  This requires some careful analytical modeling and work.

As just one example related to this, should scarce vaccines be direct more towards children, young adults, or older adults?  Older adults are a likely target, as they have the highest mortality rates in a flu pandemic.  However they are, unfortunately, least likely to exhibit a positive immune response to flu vaccines.

Conversely, children respond well to the vaccines; and by potentially saving a child’s life, one theoretically gains  many years of productive life. Further, while this may require further epidemiological study, children, who attend school along with dozens or hundreds of other children, are probably disproportionately both at risk for flu and involved in transmission once they catch it.   However school-age children also tend to have fewer complications and lower mortality rates with flu.

In the end, an optimal allocation of flu vaccine may require a fairly complex analysis and/or computer simulation.  Various parameters that feed these analyses would need to be quantified beforehand.  For this we would have two choices:  (1) either estimate the parameters based on a combination of guesswork and literature review, or (2) to conduct small experimental studies aimed to supply more realistic values.

The choice between (1) and (2) could itself be made by performing mathematical sensitivity analyses within the simulation models; highly sensitive parameters — those for which small differences have a large effect on results — would be worth investing more money to quanity precisely.

In general, it should be noted that everything discussed here — simulations, literature reviews, mathematical analyses, etc. — are extremely inexpensive compared to the costs of large-scale population immunizations.  Half a million dollars, say, buys an immense amount of mathematical research.  And it could easily save tens or even hundreds of millions of dollars by preventing disease or streamlining immunization efforts.

Predicting Individual Response to Vaccine

Another productive area of mathematical modeling here would be to try to predict individual  response to vaccines.  For a given flu vaccine, only a certain proportion of people develop the intended antibodies.  For a particular population and vaccine, for example, this rate may be only 70%.  It would be worthwhile to know in advance whether a given person is among the 70% that respond to a vaccine or the 30% that do not.  If someone won’t probably won’t respond, spare the vaccine dose and give it to someone who will.

Such analyses can be performed using routine predictive statistical methods, like logistic regression, or perhaps more modern techniques.  Possible predictor variables might include:  subject age, sex, immunization history, flu history, ethnicity, overall health, weight.

Other predictive variables might be measured via blood tests or even DNA testing.  The choice concerning how heroically to collect predictive variables would depend on factors unique to the pandemic, such as the virulence of the strain, and the amount of existing vaccine.  In theory, if a flu strain is dangerous enough, and if vaccine is scarce enough, literally every available dose must be directed to someone it can potentially benefit.  In that case even as expensive (currently) a procedure as micro-array DNA screening could be utilized.

Other benefits from mathematical modeling and prediction in a pandemic might come by analyzing cross-reactivity of previously-developed vaccines for the current flu strain.  In the past vaccines have been developed for perhaps dozens of flu strains.  In theory, each of these vaccines is unique.  The usual assumption is that a vaccine for one flu strain offers little or no protection for a new strain.
However, that is not always the case.

The only way to be sure would be to test old vaccines against the new flu strain.  In theory, this could be done using human subjects in only a few days, at the outset of a pandemic.  All that is required is to administer an old flu vaccine to a subject, wait a few days, and then see if their blood contains antibodies effective against the new strain.

Perhaps this is a long-shot, but we might get lucky, and would lose nothing by trying.

An even more elaborate strategy would involve trying to predict cross-reactivity of previous flu vaccines to the new strain in a particular patient.  That is, by considering demographic, biological, or genetic variables of a given subject, we might identify those will exhibit favorable crossreactivity.

In addition, we could probably make some good guesses about crossreactivity simply by comparing the genetic composition of the new strain to previous ones, and applying mathematical or artificial intelligence models.

More broadly, there’s a lot more we can do at the behavioral level to prevent or limit a flu pandemic.  Public information aimed at teaching people how to prevent spread of flu is effective and cost-effective.  The pharmaceutical company GSK, for example,  has produced some excellent web-based presentations that teach people about flu prevention.  People need to learn, for example how to wash their hands correctly (30 seconds; warm water; wash both sides and between fingers).

Personally, I would like to see studies done on the potential preventive effects of wearing surgical masks on airplanes or subways.  Or perhaps, in the case of airlines, does anybody know what’s going on with the air recirculation system?  Is it filtered, and, if so, can the filters trap virus-bearing dust particles?  Airlines might be reluctant to address this issue.  Pictures of mask-wearing passengers isn’t exactly good advertising.  But on the other hand, people now are already avoiding air travel because of flu fears.  If the airlines could show that masks significantly reduce risk of contagion it might actually be good for them.