In the past month, the Food and Drug Administration yanked its formal stamp of approval on Avastin – a chemotherapy drug designed to starve tumors of their blood supply – for the advanced stages of breast cancer. Because the drug still carries approval for other indications (especially late-stage colon cancer), patients can still obtain the drug by prescription for off-label use. But because it will lack formal indications for breast cancer, insurers are highly unlikely to continue paying for it. And at an estimated $100,000 per year for sustained use, Avastin is one of the most expensive drugs ever to hit the pharmaceutical market; it is very unlikely that few if any breast cancer patients will be paying for it on their own.

The outcry was immediate and predictable. Breast cancer advocates of some stripes decried the decision as a crime against women’s health – a travesty against hope. The opposition notes that the costs come with desperately little proven benefit, and that the drain on health care resource might go to uses that better suit both breast cancer patients and others who desperately need a slice of the health care pie. (A notably contrary voice in the debate has been the always-stalwart Breast Cancer Action, which applauded the FDA for revoking approval of Avastin, and implored the FDA to “uphold stringent drug approval standards over hasty access without legitimate clinical benefit”). Either way, one can bet the FDA did not tackle this bombshell topic lightly.

On the technical side, the FDA’s role is to protect and promote health, and they may be doing just that by revoking this specific indication for Avastin: in defense of women’s health, the risks of Avastin – risks like heart failure, internal hemorrhage, and intestinal perforation – come with little to no extension of life in the face of metastatic disease.

On the political side, the enemy of Avastin access is not necessarily the FDA: the FDA did not remove access to Avastin – the functional result of the decision was simply that Avastin will likely not be paid for by insurance because it no longer has an official indication for breast cancer specifically. (Off-label prescribing is allowed for most medications on the market with some rare exceptions – as long as a medications is FDA-approved, doctors can prescribe it for just about any indication, though insurance is less likely to cover expensive medications for unapproved uses.) If the medication were reasonably priced, this would not be an issue; instead, continuous use of the medication costs more than a mortgage on a split-level two-car garage house in most midwestern cities. But there is little outcry against Roche/Genentech, the makers of the drug, for their outrageous price gouging – an implicit collusion between the activist voice and the profit-makers that suspiciously mimics the dynamic between a hostage-taker and the sufferer of an obtuse form of Stockholm syndrome. While breast cancer activism has largely aimed its wrath at the FDA, few outside of Breast Cancer Action have squared off against Roche/Genentech for their rapacious pricing scheme that truly forms the barrier between patients and last-ditch use of the drug.

Avastin is not the first or last drug to land in the middle of such controversy over end-of-life access to drugs with potentially sweeping effects on both disease and remaining normal tissue. The compassionate use movement did not start with antiretroviral drugs – the revolutionary compounds developed in the early 1990s to combat AIDS – but that’s where the move to expedite trials and allow dying adults the right to off-label use outside of regulated trials got a foothold. And perhaps rightly so: during the worst of the AIDS epidemic, the rapid mortality rate far outstripped the ability of formal trials to absorb the number of people who could benefit from them – people who had nothing at all to lose. There is likely no way now to know for sure now, but some AIDS patients probably died faster from unproven and ultimately harmful experimental drugs. Some got the miracles they sought, miracles that are now go by routine names like nevirapine and abacavir, Combivir and Kaletra. This is the legacy that Avastin was born into when it was approved in 2004, and this is the environment that Roche/Genentech banks on when it faces down the FDA with a cadre of its own medico-legal experts backed by an army of breast cancer patients and family girded to fight the battle for a drug that annual nets the pharmaceutical conglomerate some several billion dollars – a sum that will take a large hit in the wake of the FDA’s recent decision. (Bizarrely, one line of this activism invokes a strain of libertarian reasoning that is equally circular as it is paranoid: that Avastin’s revocation by the FDA as a secret victory for ObamaCare socialist cost-control measures – in the same sentence decrying that Medicare will no longer cover the drug without FDA coverage, without ever wondering why Avastin costs so damn much in the first place. Government hands off my Medicare? Indeed.)

So to answer to the real root of whether Avastin should be available to women with stage-four breast cancer – whether the FDA was acting in the best interest of women at large and women with this horrific disease in particular – one also must now ask some tough questions beyond evidence and cost-effectiveness: Is it enough to rely on the internal narrative of the breast cancer patient – the first-person ethnographic voice that drives much of activism in the internet age – when this narrative may conflict openly with medical evidence? Can we rely on patient self-advocacy, when that patient self-advocacy movement had been so intentionally and powerfully tainted by the pharmaceutical manufacturers whose profits rely on the very lucrative and politically powerful business of breast cancer activism?

Every terminally ill person dreams of this age of miracles that AIDS sufferers received in the 1990s – a last-minute Lazarus reprieve that stays the executioner’s bell of their disease. Every pharmaceutical company knows this, and none have shown any moral restraint in invoking this sentiment and this desperation to their advantage, while twisting the knife of a substantial price tag into the backs of sick and dying consumers. As profit-generating entities, this is, after all, their raison d’etre. Pharmaceutical companies are like your distant acquaintance that shows up with supper when you’re sick, only to seduce your husband behind your back: they appear with cheery illusions of comfort. But they are not your friend.

Reasonable solutions are possible, but are unlikely to be invoked. Roche/Genentech could provide the few breast cancer patients who have actually responded to Avastin with supplies of the drug at cost – a true invocation of the phrase “compassionate use” – until this generation of patients fades out; with over a billion dollars a year in profits, this isn’t an unreasonable request. Insurers could also look at these few with some exception in mind. Moreover, research needs to be done (and probably already is) to understand and ultimately predict those exceptional Avastin responders – much as we understand why some breast cancers respond to tamoxifen and Herceptin, and others do not – and tailor chemotherapy regimens specifically for use specifically for people most likely to benefit from Avastin.

Until then, however, the FDA decision stands. Will the decision ultimately save or harm the lives of women with end-stage breast cancer? That remains to be seen.

The New York Times reported Friday on a move by Pfizer – the makers of the blockbuster cholesterol drug Lipitor – to manipulate the market to limit generic supplies to a number a major drug management agencies after Lipitor goes generic in the coming months:

“Pfizer has agreed to large discounts for benefit managers that block the use of generic versions of Lipitor, according to a letter from Catalyst Rx, a benefit manager for 18 million people in the United States. The letters have not previously been made public. A pharmacy group and an independent expert say the tactic will benefit Pfizer and benefit managers at the expense of employers and taxpayers, who may end up paying more than they should for the drug.” [emphasis mine]

Lipitor is said to be one of the most profitable drugs ever produced, generating over $100 billion in sales and forming a mainstay of Pfizer’s drug portfolio. And this is not necessary bad; Lipitor saves lives. It plays a role in primary prevention of cardiovascular disease, it can be the difference between rehabilitation after a heart attack or stroke and rapid recurrence leading to greater debility or death. It is not without problems, but overall, it is an important drug in the modern arsenal against chronic disease.

But there are a couple complications to this picture.

One is that in the world of the statin drug class to which Lipitor belongs, not everyone with high cholesterol needs Lipitor – or, more importantly, a medication as expensive as Lipitor. There are half a dozen other drugs in the same class, several of which went generic so long ago that they appear on the Walmart list of $4-per-month medications. The older generic statins are notably weaker; this isn’t a secret. But for your average middle-aged person walking around with high cholesterol – those who eat a little too much butter, exercise a little too little, or just drew the genetic short straw on the lipid metabolism front – the cheap medications will effectively get the cholesterol numbers to where they need to be (so too often will diet, exercise, and some other non-medicinal approaches, but let’s set those aside for a moment for the sake of argument). The truly more potent (and notably more effective, and notably more expensive) statins – that is, Lipitor and Crestor – can generally be reserved for people with true disease in whom there has been a failure to get to goal cholesterol levels with weaker medications: people with prior heart attacks and strokes, people with familial cholesterol running sky-high numbers for no good reason, people who have undergone surgery to actually remove cholesterol plaques from their arteries.

But that’s actually kind of a small market compared to the millions and millions of essentially healthy 50ish folks who could head off problems in the future with a little help from a statin friend – ie, those who will probably do fine on a generic drug. So why is Lipitor such a blockbuster when the number of people who need it relatively small?

That, of course, comes down to marketing. Pfizer has long advertised the potency of Lipitor – and wouldn’t you want the best for your heart? – failing to note that cost-per-cost, the best just isn’t necessary for many people. Samples given through doctor’s offices (which are invariably branded drugs, never generics) instill brand loyalty from the side of both the doctor and patient. Moreover, pharmaceutical companies skew or hide the true cost of these upper-echelon drugs by marketing schemes like copayment vouchers that reduce the cost to the insured consumer for branded drugs from higher cost (where they should be) to zero – encouraging patients to request more expensive drugs than are necessary because the up-front cost to themselves is so low.

But true market manipulation on the scale described – that is, using the clout of a major manufacturer to block the early sales of generics – is a dangerous and costly precedent. This process is enabled by the streamlining of drugs through “pharmacy benefit managers” such as Medco, which you might have encountered as one of the “mail-in” pharmacies that more and more insurance carriers are requiring patients to utilize. However, the unspoken secret of these “mail-in” pharmacies is that many of the discount brick-and-mortar pharmacy chains carry generic medications at a fraction of the price of the mail-in servicers – sometimes at prices less than a standard generic copay for an insured patient. Insured patients are made to feel that they are compelled to use these monopolizing benefits managers, when in fact consumers are only required to do so if they want their insurance carriers to pay; if a brick-and-mortar pharmacy charges less than their standard copay for a generic drug, there is actually no reason to go through insurance at all, but rather just pay cash and bypass these middlemen altogether – something the insurers and “pharmacy benefit managers” would prefer that consumers not know about as they pay higher prices for the mail-in services.

The net effect of this is that nations like the United States that allow unfettered market manipulation pay – you guessed – more for health care while achieving less health than countries that frown on this kind of shady tactics, for example by setting formularies that account for cost-effectiveness and allowing for planned deviations when medical necessity demands.

Am I blaming Pfizer for the all the ills of the American health care system? No. But when one hand of the health care reform effort is struggling with the untamed beast of cost control – and the other hand is paying overkill prices for drugs that outstrip medical necessity – one has to wonder where the balance will be struck between innovation and affordability.

In any case, open generic competition for Lipitor will take over in the next year, ending any debate about paying full price. But the success in consumers’ and regulators’ ability to block this kind of behavior will set a long-reaching precedent in pharmaceutical patent-holders willingness to try these kind of rank shenanigans again, the next time a blockbuster drug goes off-patent. And that is something we all have a stake in.

I stand with the 99%.

I have a choice, you see. I don’t have to stand with the 99%. I have an advanced degree, make a low six-figure income in an extremely high-demand field, and if I wanted, could double or triple my income without much thought beyond having to move somewhere I wouldn’t too much like. I have a rock-solid job with even greater future opportunity, as well as health coverage and a stellar disability insurance policy that costs as much as some families spend on food in a month. That doesn’t make me a millionaire (indeed, because of immense school debt and a rapid pay-down plan, there’s about three-digits worth of cash in my combined accounts at the end of any given month), but I identify with the 1% elite because I have the rarest of commodities these days: security.

But I choose to stand with the 99%.

I stand with the 99% because the biggest threat to my security is – no surprise – the $300,000 in student loan debt it took me to get to where I am today. My very generous middle-class parents took me through my undergraduate years, but I paid in cash and the blood for the graduate education – at a notorious poorly funded state school – that brought me to where I am today. I have no doubt that the nay-sayers are correct in predicting that the next great crash will be the student loan debt bubble (standing in great part on the shoulders of the rapacious for-profit vo-tech schooling institutions, but increasingly standing on the slumped shoulders of public school grads like myself).

I stand with the 99% because I know that if you reach back more than a generation or two, my people are not the people of the 1%. In the four corners of European mutt heritage from which I was hybridized, two lineages came to America escaping the twin beasts of poverty and famine back home, one’s history has been lost to the sands of time, and one came from a line of wealth but smartly realized that their people were not welcome in pre-War Europe. My people are not Daughters of the American Revolution people; my people are by wide majority immigrants and paupers but for a blip that started around 1950 and has no guarantee of continuing beyond my generation. There is no blue in blood in my veins; my people were always the 99%. I have no illusions about what I deserve today, and no illusions about its permanency into the next generation.

Even if I can rise above the 99%, I know that I am not so wealthy that I can take my friends and family with me into the magical 1%: my sister, for example, and her wonderful blended family that now welcomes seven children under its umbrella, the eldest two of whom are facing down college tuition costs with five more bringing up the rear on a couple of blue-collar salaries. Or my brother – an Iraq vet, paramedic, and firefighter – whose older daughter is marked by the chronic stigmata of surviving a year in intensive care then rehab with a rare childhood leukemia, and who will never be insurable on the private market. I can carry myself into the 1%, but if my family falters back in the mire of unpayable college tuition and bank-breaking health care costs and chronic debt, what have I won? For this reason too, I stand with the 99%.

I stand with the 99% because when I envision the world I want to live in, I do not envision a rarefied gated community to which I have a coveted key, surrounded by the ghetto of the world I used to be a part of. When I envision the world I want to live in, I do not see a world of poverty and desperation to which I am somehow granted immunity; I see a world in which we share livable cities and breathable air. I stand with the 99% because nothing about the world that I want to live in jives with the world we will create if we allow America to become a third-world nation of haves and have-nots.

Humanity has progressed through the millennia toward milestones meant to make life incrementally easier: increased agricultural production bent on easing food insecurity; diplomacy so that war was not the first answer; arts and music to make life beautiful; medicine to heal. Humanity did not bother to invent fire, the wheel, the internal combustion engine, and one-touch online ordering in order that we may work double the work hours of our parents at a fraction the pay and die younger for our troubles. Our ancestors did not do go through the trouble of millennia of invention and progress so that we could suffer like medieval peasants; our people did this so we could flower. Our people did this so that we could spend less time toiling in fields and slaving at stoves, more time playing with our kids and writing novels and shooting at beer cans and having backyard cook-outs and climbing mountains and tinkering in the garage with that invention that may be the next greatest thing or next week’s trash: more time being human and more time stretching the limits of what it means to be human.

Should we be proud of these moments of adversity overcome, these days when we struggled to make ends meet and survived and provided for our families, when we challenged the Greatest Generation on their home turf of hardship and hard work? Damn well we should be proud. I am proud that while the majority of my graduate school compatriots were on vacation breaks funded by parents or working partners, I worked 80-hour weeks at contract jobs on marine construction sites and came back so exhausted I spent the first half of the quarter catching up on sleep while pulling night shifts on academic rotations. People who are working three jobs at 60-70 hours per week through these crisis times should be able to look back with pride and tears and talk about 2011 the way our grandparents talk about the Depression. We should be proud of these things we survive.

But we should never strive to embrace them.

We should never, ever strive to make the 70-hour work week the norm, to make two jobs the minimal and three jobs the expectation. We should never allow the good old Protestant work ethic to be co-opted by neo-feudalism to the point where we begin to enforce the high-expectations/low-pay ethic on ourselves. Those who want to work 60- or 70-hour weeks should be doubly rewarded – not used to foment a new common denominator. Because if 60-70 hours a week becomes the norm, the new just-getting-by, there then becomes no way to get ahead. No way to work that mortgage down in advance and retire a little better than you might have otherwise. No way to cushion for the stochastic blow of a slow year in your industry or a bum shoulder you need surgery for. No way to set a little aside so you can take that brave step out onto the plank, quit your job, open that small business and become one of the “job creators.” No way to dream that your children might one day have it better than you. No way to save for the six months to might want to take off one day to follow your dream, or stay home with your first baby, or take care of your father in the last months of his life. No way to become anything more than a cog in the grinding wheel of someone else’s profits.

I stand with the 99% because I stand for the American way. This is not a way of laziness or sloth, this is a way that works hard but believes firmly in the limits of hard work. This is a way that believes in a good solid eight-hour day followed by a good solid eight hours of doing the other business of life: raising kids, reading a book, cooking a meal at home, watching trashy TV, keeping up on the events of your world, running in the rain, caring for your ill or your young, doing whatever it is that you do. And then, getting a good solid eight hours of sleep. Some call this “European socialism;” the rest of us call this “the American dream.”

I have a choice, and I choose to stand with the 99%. I stand with the 99%, and I am not alone.

In 2007, medical marijuana became legal under a physician’s directive in New Mexico, one of sixteen states allowing some variation of medical use of ­­Cannabis sativa. Since then, regulation of medical marijuana in the state has swung with the political tides: founded and liberalized under former Democratic governor Bill Richardson, then tightening under current Republican governor Susan Martinez, who made a campaign vow to reverse the move toward medical legalization of marijuana altogether.

Caught in the middle of these political tides are the physicians who are asked to make the judgment call as to whether a patient is an appropriate candidate for medical marijuana. Predictably, medical providers fall into largely political camps in the decision whether to engage with the medical marijuana question at all – many refuse to sign the paperwork on an ideological basis, a few will sign any patient’s paperwork out of reverse ideological concerns, and a good number want nothing to do with it simply because they do not want the word to get out that every weed toker in town then come knocking on their door. The guidelines about who can prescribe for which conditions are only marginally helpful: a tangle of specialists needed for one condition, primary providers sufficient for another, and dual requirement from both for yet other conditions. The unifying theme behind these guidelines is that there is virtually no evidence behind a single one of them – to guide what conditions are covered, under what circumstances, and under the guidance of which specialists. In the era of evidence-based medicine, this is problematic.

But this problem is not accidental. Evidence is not a god-given entity; it is a good that must be gathered through clinical trials and observational data and then run through the grist mill of statistical analysis. The dearth of evidence for the safety and efficacy (or lack thereof) of one of the most frequently used mind-altering substances in the United States is due in no small part to a quirk of the way that the Drug Enforcement Agency classifies illicit substances: the schedule of controlled substances under the 1970 Controlled Substances Act. This law attempted to sort out serious drugs (and serious drug offenses) from drugs of more minor import, as well as drugs that have some dual role in both medicine and abuse. Schedule I drugs are the most serious offenders, with high potential for abuse and no role in medicine (they cannot be prescribed under any circumstance and theoretically cannot be permitted for research, though this rule is sometimes not strictly adhered to); Schedule V drugs are minor offenders with widely overlapping medical applications, and Schedule II-IV runs the spectrum between. You may be surprised to know that marijuana occupies a premium spot in the Schedule I category, right beside heroin, GHB, LSD, and ecstasy. You may be even more surprised to find that cocaine and methamphetamines are considered squarely less dangerous than marijuana, in the still-venerable Schedule II category (cocaine is used in some ear/nose/throat procedures; amphetamines are too close to a cluster of ADHD medications to make a useful distinction – thus the placement in Schedule II). Essentially, the DEA is far more vested in eradicating the scourge of marijuana than ridding the streets of methamphetamines and cocaine. (Interestingly, tobacco and alcohol were never rated by the DEA, probably because they are legal substances.)

It is because of this Schedule I placement that the feds take marijuana so seriously, and why state laws legalizing medical marijuana so flagrantly flout federal statute – and will likely eventually force a constitutional read of the issue at the SCOTUS level. (Several years ago, an acquaintance investigated the quandary of what to do with a notoriously brown-thumbed tenant who was producing a substantial quantity of the moldy pot plants in the drafty attic of his old San Francisco Victorian with a questionable grower’s license; in the course of his investigations, the landlord discovered that the city police didn’t care, the state law enforcement office reacted with studied indifference, the local housing authorities told him not to bother to get involved, but that every branch of the feds he contacted simply wanted to know the address so that they could initiate a bust immediately.)

It is because of this Schedule I status at the federal level that there is notably scarce data in the formal literature on the effect of marijuana on chronic pain, PTSD, depression, inflammatory conditions, asthma, palliative care, weight loss associated with cancer and AIDS, and the other conditions for which patients routinely request it of myself and hundreds of other physicians in the states where it is legal. American researchers are critically restricted from effective study of the medical effects of marijuana (except in the purified form of THC marketed as Marinol, marketed as an appetite stimulant and universally panned for its ineffectuality beside the supposed panacea of real marijuana) because forty years ago the federal government declared – in a nearly heroic accomplishment of circular reasoning – that there is no medical indication for marijuana.

And thus we set the stage for the farce that is medical marijuana. In New Mexico, physicians actually have a list of approved indications, which includes chronic pain, inflammatory arthritis, PTSD, glaucoma, painful peripheral neuropathy, and (in an ironic nod to the state’s epic battle with injection drug use) the discomfort associated with hepatitis C. We have no evidence that this substance is effective for any these conditions (nor any evidence that it is ineffective, or that it is harmful, nor that it is ineffective for a long list of excluded conditions), but someone came up with a list of inclusionary and exclusionary criteria, and there we are.

Because it is not produced uniformly and studied legally, I cannot come up with a reasonable dosing regimen at which I can expect results or move on to a different medicinal approach. I know roughly what twenty milligrams a day of Lipitor should do to your cholesterol, and how many milligrams of ibuprofen can reasonably be expected to turn off your headache pain before you risk an ulcer, but I can’t even hazard a guess at how many ounces of Mary Jane should evaporate your back pain, or alleviate your anxiety, or lighten up your mood. Because it is so poorly studied, I cannot give a patient a list of contraindications, side effects, or even long-term dangers (some claim, for example, that inhaled cannabis works well as a bronchodilator for asthma; not only do I find this disingenuous if there is no evidence to back it, there is reasonable cause to suspect that chronic marijuana smoking may be a culprit in emphysema just as well as cigarettes).

Without any kind of dosing standardization or quality control, handing out medical marijuana cards is essentially the equivalent of telling patients to open up a bottle of Jack Daniels, insert a straw, and start drinking until you feel better. Except that instead of properly bottled whiskey, make it the stuff that some guy stilled in an old bathtub out back of his cabin: it may be authentic, but the public health department isn’t exactly looking in to ensure he washed his hands first. (The state of New Mexico does license growers, but they are not inspected and regulated the way the FDA watches over pharmaceutical factories. Indeed, one of the little-spoken health concerns about marijuana is that large-scale illicit growers are not exactly environmentalists: you might be smoking some of the most potent pesticides and fertilizers on the market when you inhale a crop produced under the duress of a growing seasons shortened by the threat of federal surveillance.)

So what then to do with the patients who claim benefit from marijuana in all is chemical glory? Well, I say let ‘em smoke it. Or eat it, or vaporize it, or spread it on their toast in the morning in the form of weed butter. But get me out of the middle of it.

The medicalization of marijuana has been a shrewd and well-calculated move by the pro-legalization crowd to crow-bar the power of compassion for the terminally ill and fatefully traumatized into political capital toward the normalization – and eventually legalization – of marijuana. And fundamentally, I agree with that goal. Many decades ago, this country decided that the social cost of restricting your right to a mildly mind-altering substance was not worth the crime wave that came with trying to enforce temperance; prohibition only serves the task-master of organized crime, and in my lifetime I would like to see the United States of America come to the realization that if drinking a fifth of vodka does not warrant ruining one’s life with a jail sentence and one’s community with organized crime, neither then does smoking a joint.

But I don’t appreciated being used as a tool toward that end. The medicalization of marijuana means that I am forced into the farce of pretending that marijuana is modern medicine. Marijuana is medicine only in the way that opium poppies are medicine: there’s something in there that’s awfully potent, but I wouldn’t feed it to patients straight up if wanted a predictable effect from a set dose – which is the essence of what separates modern medicine from the stuff your great grandma boiled up in her kitchen to treat the neighborhood nose bleeds and fevers. Marijuana is medicine only in the way that that proverbial bottle of Jack is medicine: it sure does something, but as a doctor, I’m pretty sure that is a something I don’t want to be responsible for prescribing.

The medicalization of marijuana means that I spend appointment time with complex patients discussing – ad nauseum – the intricacies of who needs to sign the annual paperwork for their cards for their particular condition, instead of focusing on actual medical conditions. The medicalization of marijuana means that I field a fair number of patients who establish care only to ask for this service (only some proportion of whom are actually ill), who are severely put out to discover that I cannot provide it to them under the current guidelines and who are unafraid to tell me so in angry and explicit terms. The medicalization of marijuana means that I spend public dimes at the community clinic where I work explaining and re-explaining the guidelines and limitations of this program, verifying and re-verifying the changing landscape of requirements which – I think it is only mildly paranoid to suspect – the current right-wing regime in the state may one day use to punish physicians who veer at all from the exacting nature of the program. The medicalization of marijuana fundamentally means a large bureaucratic headache for an issue that I fundamentally feel is none of my business (and as a primary care physician, bureaucratic headaches are something I do not require any more of than I already have). Unless they are troubled by it or using it to an extent that is causing medical or mental health issues, I do not feel that marijuana use by my patients is my business, pro or con – much as a glass of wine with dinner does not concern me.

My only entry in this dog and pony show is as a half-hearted civil libertarian (of the kind that appreciates being left alone if I’m not hurting anyone else, but recoils at the rather horrifying spectacle of Tea Party libertarianism), and a fulltime harm reduction-ist, of the sort that heartily supports needle exchange programs and drug treatment over punishment for those in the throes of addiction. The full legalization of marijuana fits both those bills: get the government out of the business of busting people for a drug that is fundamentally about as harmful as alcohol and tobacco, and take the breeze out of the sails of the organized crime that has been the sole beneficiary (alongside, perhaps, the terrifyingly profitable privatized prison industry) of this late-date Prohibition. But the medicalization of marijuana defeats all these purposes: creating new headaches and bureaucracies without tackling any of the social ills of prohibition. Moreover, medical marijuana disingenuously asks doctors to play the mediator in the age-old cat-and-mouse game between stoners and law enforcement – trying to suss out whose pain is real, who is not just looking for a get-high-no-jail card – a role that I have no aptitude for and even less desire to engage in.

It is high time that the pro-marijuana crowd step up to the plate and aim their efforts at their true goal: legalization. (Or, in the interim, moving cannabis off the Schedule I list to somewhere more reasonable.) And please, spare me being shoe-horned into the middle of your efforts – I appreciate the core sentiment, but I do not appreciate the paperwork, the headache, or being used for purposes that defy the calling of my profession.

Let the ill have their relief and the hedonists have their day. And please: let the physicians practice their craft without pretending that unrefined herbiage is part and parcel of modern medicine.

On any given day, you can hear talking heads on a dozen sides of the health care reform debate arguing about which version of health care delivery is the most efficient. Many lay claim to this holy grail of financing, they cannot all be right, so who is doing the truth-telling and who is doing the lying?

“Efficiency”, like many jargon-able phrases, has different meanings to different people who use the word. In classical 101-level economics, efficiency is a market phenomenon that happens when you allow an unfettered entry of buyers and sellers to a common exchange. Demand and supply sort themselves out to some sort of equilibrium, and a movement of goods occurs at a point where the maximum possible number of buyers and sellers are happy with the outcome – a mechanism essentially mediated by price. This is a dynamic process, with price rising as a good becomes more popular and sellers can demand more compensation (concert tickets on the day of a sold-out show, plywood and flashlights on the day a hurricane rolls through town), and price dropping as surpluses flood the market or goods lose the cache to drive high price (disco shoes circa 1980, manual labor in the era of mechanization). Though this kind of efficiency by no means makes everyone happy, it is one way to reach maximal contentment with minimal interference and to drive supply in accordance with demand. (This model harbors a wealth of flaws when applied to health care, but set those aside for a moment.)

“Efficiency” in the health care world has taken on a life of its own, and in looking at the cross-purpose uses of this word, we can start to understand why so many sides of the debate lay claim to this distinction – and while none of them are exactly lying, how we can use a better understanding to pick which of these sorts of “efficiencies” actually align with reasonable health care systems.

On one hand, one could reasonably use the term “efficiency” to describe how much of a system’s health care dollars go into actually health care, versus how much goes into overhead, upkeep, and general bureaucratic usage. To give you a sense of the norms, Britain’s National Health Service runs a usual overhead rate of about 5%. Medicare – America’s near-universal program for insuring retirees, run by the much-maligned US government – comes in at a spectacularly low 3% overhead rate. In both of these notably “socialist” programs, 95% or more of the cash flow runs straight to actual health care.

Private for-profit insurers in the United States routine run an 80-20 split: 80% to actual health costs, 20% to overhead and other costs. By any measure, for-profit US insurers are an entire digit less “efficient” than the universal insurers in any other developed country. Shocking, no?

Well, maybe not. Because it depends on your actual goal when you define the term “efficiency.” In the very succinct words of TR Reid in his eminently entertaining jaunt through comparative health care economics, The Healing of America:

“It’s revealing that, in the lingo of the US health insurance industry, the money paid to doctors, hospitals, and pharmacies for treatment of insured patients is referred to as “medical loss.” That is, when health insurance actually pays for somebody’s health care, the industry considers it a loss. (Health insurance executives explain that “loss ratio” is a technical term borrowed from the fire and casualty insurance business.) Insurance executives, securities analysts, and the business media carefully watch each company’s medical loss ratio to make sure that the actual medical payments don’t eat too deeply into administrative costs and profits. If a health insurance company consistently spent much more than 80 percent of its money on actual health care, its stock would plummet and its CEO would be axed.”

If your goal is health care, 3% overhead is a remarkable feat of efficiency. If you goal is profit – as it is for the bulk of American coverage providers – efficiency is measured not in low overhead, but in low outlay toward “losses” – losses that, for Medicare or the NHS, add up to a whomping 95-97% of their budget. This view of efficiency (maximizing profit, minimizing unnecessary losses) would ring true for a car manufacturer, a legal services office, a retail clothing outlet – why would it be any different for a commercial insurer? Read from this angle, the American private health insurer is a star of efficiency, wringing a spectacular profit out of an industry in a manner achieved in no other developed-world nation. And incidentally, along the way, creating the most expensive health care system with some of the most notably mediocre outcomes in the developed world.

By looking through these opposing lenses, we can start to see how both the universal-coverage proponents and the free-marketeers both claim the mantle of efficiency. The question then simply becomes which kind of efficiency we want: the kind in which the cash flow through the health coverage system is maximized for health, or the kind in which the monetary investment in the health insurance industry is maximized for profit? This is a question of both desired outcomes and moral fiber of a nation. It is a question that is currently being answered for us in a variety of ways, but which behooves us to step up to the plate and take a brave stab at answer for ourselves.

Now let me put a third spin on the definition of “efficiency” – or in this case, inefficiency. Outside of the hallowed halls of academic economics and the somewhat shadier halls of the for-profit health insurance business, there are the busy and chaotic halls of your local hospital and clinic. On ground zero of the coverage debate – where physician meets patient – a different version of inefficiency arises, one that has little interest in actuarial tables and national policy and theoretic curves of supply versus demand. This is a nebulous, harder-to-define inefficiency, along the lines of how a famous person once described pornography: “I know it when I see it.” It goes like this:

On an average day, I see a certain number of patients, treat their complaints, send them on their way. And then I take a deep breath and dive into the hours of paperwork generated every day by the intentional hoops, denials, and obfuscations created by a system fractured into competing for-profit insurers. These hours are spent completing prior authorizations, appealing denials, cooking up secondary codes when insurers don’t want to cover diabetic blood tests under the code for “diabetes.” Hunting down lists of approved drugs only to receive a fax back declaring the medication chosen was actually not on the approved list, then filing a prior authorization, and then receiving a fax back declaring that oops, it actually was on the list to begin with. Memorizing arcane grids of which labs work with which insurance agencies, and remembering to choose the purple tube or the green tube before performing basic tests (and calling patients back for repeat testing if by chance I pick the wrong one, or they change insurance carriers in the interim). Fielding calls from panicked patients that a test that should have been covered was not. Fielding calls from angry patients that three weeks into a request, we still have no answer on a prior authorization. Fielding mystified looks from patients who legitimately ask, “Will this be covered by my insurance?” when the answer from me is that I have no way of answering – not only because I cannot memorize some thousands of constantly-changing benefits packages, but because if I hazard a guess, I know I will be held to it. This sort of inefficiency may not be well-theorized by the economists and financiers, but it perhaps the one that most affects your satisfaction with your health care. It is driven – both intentionally and not – by the multiplicity of insurers and the drive to deny services and maintain that 80% maximum outlay toward “medical loss,” as the insurers call it (or “health care” as the rest of us call it).

This is the soul-grinding inefficiency that makes so many primary care doctors want to flee the business altogether. It is also a rankly understated part of the reason why health care is so expensive in the US: not only are private insurers routinely skimming 20% of the health care dollars that pass through their hands, almost no model I have ever seen accounts for direct patient care time lost to the demands that insurers place on doctors. I could see several more patients per day at the same salary were it not for the trail of paperwork each leaves behind - sometimes several-fold the actual face time spent with a patient. This is time that increases insurance company profits at the expense of decreases physician income per hour - essentially, unreimbursed time providers spend working on behalf of the profit interests of insurance companies. And with delays, uncovered costs, and a thousand other annoyances small and large, this contributes mightily to the soul-grinding inefficiency that makes so many patients so dissatisfied with their primary care experience.

Single-payer (or at least more tightly regulated) systems remove a large part of this latter inefficiency by offering more uniform benefits packages that physicians might reasonably be expected to master, by forcing ancillary services like labs and imaging centers to utilize less fractured logistic practices, and ultimately by making the goal of health care to take care of people rather than to deny services. And therein allowing physicians to do what they do best – practicing medicine – instead of do what we usually do worst: push paper.

Note: Much of the background information for this discussion is derived from TR Reid’s most impressive The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care – which tackles the usual dry topic of comparative health economics in a most enjoyable format. This should be required reading for any non-expert interested in the problem of health care reform, and I highly recommend it for anyone interested in understanding the different formats of single payer/universal coverage around the world and at home.Efficiency in the health care market: A short treatise on a perplexing paradox

Struggling to regain her position as heir-apparent to the dubious legacy of Tea Party darling Sarah Palin, Michelle Bachmann took the opportunity at the recent Republican debate to let the crazy out of the GOP closet on topic of Gardasil vaccine. Bachmann railed at Perry for making the vaccine mandatory for sixth grade girls in Texas; Perry waffled on the issue, guessing that maybe he should have taken it to the Texas legislature before issuing the rapidly-rescinded edict. Hilarity ensued.

There are many good reasons to make a vaccine mandatory. It pushes insurance to cover the drug, it normalizes the process of opting out rather than opting in (which drives higher acceptance rates among those who don’t really care one way or the other, but wouldn’t go out of their way to get the injection), it gives uptake rates a hard shove toward the threshold needed for herd immunity. There is only one bad reason to make a vaccine mandatory, and Rick Perry managed to nail it: because the manufacturers donated $5000 (oops, or was that $30,000?) to your campaign coffer.

Meanwhile, in the opposite corner, Bachmann went on record as stating that she opposes the vaccine in no small part because a woman came up to her after the debate and claimed that her child’s mental retardation was caused by the HPV vaccine. The most obvious guess on this gaff is that Bachmann was probably thinking of the MMR vaccine (also long exonerated as a causal factor in autism) when the letters “H-P-V” conveniently popped into her head, but no matter: this brings a new low to the quality of rhetoric in this country. The HPV vaccine is first given at age nine or later; it would be an extraordinary case if a nine year-old suddenly experienced new-onset mental retardation except by means such as surviving encephalitis. [I was able to pull up 203 adverse events for the HPV vaccines on the CDC’s somewhat clunky Vaccine Adverse Events Reporting System (VAERS); this included a number of events like “broke out in a rash a month later” and the dryly amusing “adverse events: none.” Aside from these dubious contributions, I found two references to encephalitis – one of which was probably due to HIV and one of which may have been the real deal – and one reference to a severe central nervous system event that occurred several months after the vaccine was administered and could not be conclusively linked to the vaccine. I could find no references to mental retardation.] So unlikely is the veracity of Bachmann’s off-the-cuff claim that renowned bioethicist Arthur Caplan offered a rather substantial sum of cash to anyone who can produce the child (with medical records) that Bachmann was referring to with this statement. So far the cash has not been claimed.

Still, mental retardation is a difficult thing. So let’s examine the role of the HPV vaccine in mental retardation because – really – there actually is a connection. It goes like this.

Pre-term labor is the bane of obstetrics. There are many things that obstetrics has become quite good at, and many of those things border on heroic on any day of the week (if you’ve ever seen a baby with no measurable heartbeat on a monitor survive a crash c-section, you know this with a gut terror you’ll never forget). Many of these things are boring as heck but very quietly result in decreased morbidity or mortality for moms and babies that would have died in other eras; controlling diabetes in pregnancy is one of these areas.

Pre-term labor is not one of these areas. Despite decades of efforts to the contrary, obstetrics as a practice is piss-poor at predicting pre-term labor and – once it gets started – finding any way to stop the steam-roller progress of a baby coming into the world too soon, with lungs and eyes and a gut not ready for the outside world. Mortality in this group is high; so are complications like blindness, gastrointestinal disease, and cognitive impairment – that is, mental retardation.

There is one factor though that we know causes pre-term labor – a predictable risk, a known quantity in the preterm labor game: having your cervix frozen, cut, or cauterized because of HPV disease, also known as cervical dysplasia. The damage to the cervix from these procedures – which are done to stop the progress of high-grade lesions a couple steps short of actual cervical cancer – raises the risk of preterm birth and causes a somewhat undefined number of NICU visits in the US every year. In fact, this problem is a large part of why the latest revision to the Pap smear guidelines in the US dictate that no woman under 21 should even get Pap smears (except under special circumstances like known immuno-suppression): cervical cancer is vanishingly rare in this group – most women pick up one HPV strain or another in their teens (yup, guess what, sex happens), but young women clear even high-grade lesions extraordinarily well. The net impact of doing Pap smears in this group is the treatment of lesions that would have disappeared on their own, with the consequence of putting those women at life-long risk of preterm labor just as they are starting their reproductive years. Pap smears are best reserved for women in the age groups that do develop cancer: women in their 20s-60s, where the benefits of looking for abnormalities and treating precancerous lesions outweigh the risks of messing around with the cervix.

And that’s where the HPV vaccine comes in. Yes, Gardasil and its cousin Cervarix are “cancer vaccines,” but this a cancer we already know how to treat in its early stages. So this “cancer vaccine” prevents more than cancer – it prevents the sort of medical treatment for cervical dysplasia that can lead to very high morbidity in future pregnancies. In one of the stunning ironies of the great GOP race of 2011, mental retardation can actually be prevented with the HPV vaccines. (If you’re looking for other ironies in the vaccine debate, you’ll note that an autism-like cognitive disorder is one of the harms of congenital rubella that the MMR vaccine was designed to prevent. That’s always a fun one to bring up with the Jenny McCarthy-ite crowd.) Because a portion of pre-term babies die, there’s a certain pro-life tang in here too: remove all the sex-panic hypocrisy – as well as the known phenomenon of anti-abortion-ites caring about babies right up until the moment they are born – and what you have here is the world’s first pro-life vaccine.

But the best conclusion to this fiasco came from an unlikely source: Rush Limbaugh – not known for temporizing or thoughtful rhetoric – commented that it looked like Bachmann’s campaign might have finally “jumped the shark” with this debacle.

We can only hope.

In 1965, a decades-long legislative and social battle culminated in the passage of one of America’s most enduring and populist social programs: government-sponsored health coverage for the elderly and disabled that you know by the name Medicare. So devastatingly popular is this subsidized coverage that it has spawned one of the iconic moments of irony in the decades-long battle over the soul of American health care reform: all the variations – self-deprecating and entirely serious – of the “Government hands off my Medicare!” genre of political protest.

Medicare is a foundationally popular social program for good reason. Along with Social Security, it has transformed the retirement years. Once the province of poverty and privation, the elder demographic has evolved from an unrepresented minority to a powerful force with its own lobby in Washington. Federal subsidies for health care and retirement funding in no small part facilitated the development of the nuclear family – transferring the financial care of elders from the family unit to the government dole and freeing the nuclear unit from in-home care of elders that has shaped the family structure for most of human history; the net benefits and losses of this radical restructuring are arguable, but the effect on the American social landscape is nevertheless marked. The combined forces of Medicare and Social Security have – somewhat unintentionally – helped make the retirement years a golden age, a second life, a well-deserved respite from long years of work before the senescent years of true old age.

Set all of these successes aside for a moment (as well as the fact that Medicare is precisely as socialist as Canada’s wildly successfully experiment with government-sponsored health care), as there is a sinister underbelly to Medicare that is seldom if ever acknowledged in the health care reform debate.

Medicare is designed to pick up two general populations that the bulk of insurers are not fond of: those over the age of 65, and the disabled. (Medicaid, contrarily, is designed to cover the poor.) Medicare cherry-picks its patients in the reverse manner of the majority of insurers: whereas private insurers cull these two expensive, resource-intensive populations from the rolls, Medicare preferentially takes on these same difficult groups by legal mandate. This is a welcome relief for these patients, who would indeed find it very difficult to obtain coverage on the open market; almost by definition, these are the patients who have spent a lifetime acquiring a variety of pre-existing conditions and other red flags that would certainly land their applications for private insurance in the rejection pile.

Medicare serves as a relief valve for private insurance. Private insurers maintain profitability under the guarantee that the most cost-ineffective patients will eventually shift elsewhere. Insurers are safe in the knowledge that their entire client roles are only temporary burdens – the onset of age or permanent infirmity means an automatic shift off the private insurance rolls and onto the public dole. This is a phenomenon known as “cost-shifting.” It has some profound influences on the way that private insurers treat their patients and the way that patients behave in the years leading up to Medicare coverage.

First and foremost, the promise of Medicare means that private insurers have very little incentive to emphasize or pay for preventive care and early effective care for chronic conditions. Appropriately applied preventive care has been shown to reduce cost again and again, but this financial principle only works if the long-term cost of care falls onto the same agency. If cost shifts off an agency as soon as a person becomes elderly or truly debilitated, the return on investment for preventive care becomes very minimal, and private insurers thus have a minimal impetus to pay for preventive care or early care for diabetes, heart disease, obesity, and the like.

Systems where a single agency cares for patients from birth to death have no means of cost-shifting; they absorb the consequences – positive or negative – of all health policy. When I lived in Britain for a year, I established myself at a local National Health Service clinic for routine care. I honestly answered a health history questionnaire by noting that I had suffered some bouts with asthma; it just so happens that I have the variety of asthma that causes a prolonged and persistent cough with every passing virus – the kind of cough that makes people on the subway glare at you and move several seats away – but I have never required emergency care for this mild condition. Nevertheless, every time I stopped into my local clinic for any incidental issue, time was taken to inquire about the frequency of inhaler use, peak flow measurements, and even my knowledge of the quickest route between my home and the nearest Accident & Emergency facility; adjustments were made to improve control of the condition and prevent admissions to the hospital. These inquiries were boiler-plate for asthmatics, and I watched my GP tick boxes on a pre-set template as I answered; this was just one small part of the NHS goal to reduce costs at all points of care possible. In the United States, I have never been asked about my asthma unless I brought it up. Because the NHS takes care of all British citizens from birth to death under a single budgetary umbrella, they have taken preventive measures to new heights – and have been rewarded for these efforts with an average life span a year longer than the average in the United States, achieved while spending half the GDP by percentage on health care as does the United States.

Beyond the lack of incentive for insurers to institute top-notch systems for prevention, many middle-aged people – especially in the recession era circumstance of reduced employment leading up to the retirement years – simply minimize their insurance coverage and cross their fingers that nothing devastating blow out of the winds of fate before Medicare kicks in on the magical date of their 65^th birthday. Under-insurance (especially high-deductible indemnity plans) in this demographic often results in delayed care for burgeoning issues of routine age-related conditions like high blood pressure, an issue compounded by missed targets for preventive care like colonoscopies and mammogram. Because private insurers are not invested in the health of individuals beyond the age of 65 – and because the agency that is responsible for health after the age of 65 has no access to patients before that age – many Americans roll into the retirement years far behind the eightball, battling back years of marginally neglected health with only the voodoo insurance of crossed fingers. The promise of Medicare at 65 results in complacency in the years when age-related conditions are rearing their heads and preventive care should be ramping up.

Worse yet, the understated promise of disability-based Medicare means that private insurers have far less incentive than they should to provide services to help with strict control of chronic diseases like diabetes. This problem is particularly pointed in the case of renal dialysis (for which uncontrolled diabetes is the leading indication); by a strange quirk of history, the phenomenally expensive condition of being dialysis-dependent automatically qualifies an individual for Medicare coverage, and as soon as this condition arises, the entire cost shifts off the private insurer. One can bet that if private insurers were looking down the barrel of paying the total cost for every current diabetic who may potentially need renal dialysis in the future, their incentive to get every diabetic under control would rise in grand proportion to those costs that they presently shift to the government. The existence of Medicare – by allowing cost-shifting at most critical moments of age and infirmity – allows for a health care pseudo-system that banks and profits on the avoidance of preventive and early care for all manner of disease, dumping the resultant cost on the public dime.

Medicare, by all measure, is a false god – a shell game built on good intent but a 19^th-century understanding of health care and aging, a system drawn from a time when rescuing seniors from poverty was a reasonable goal but building a functioning health care system was not yet on the radar. Medicare is a safety net, and America loves safety nets. We love soup kitchens, homeless shelters, free clinics, and used clothes bins for poor kids in the basement of local churches. We like to base our systems of wealth redistribution on charity instead of the justice of equal access, blindingly forgetting to notice that every other wealthy industrial nation has long-since ceased to rely on charity, instead building a common and formal system for social good – and that our charity-based model is the hallmark of third-world nations. Safety nets are stopgaps only; they do not replace modern, streamlined systems for the delivery of common social goods.

But in the end, I will contradict myself: Medicare is not truly a social evil. Its wild popularity from the far-flung right to the liberal left bespeaks an effectiveness and a commonality that could be used to build a universal health care system – a much-vaunted public option, a Medicare-for-all – via a quiet expansion of the system to a point where all could buy in for a premium that matches proportionally to one’s income. Medicare’s sole fatal flaw is its limited scope, its inadvertent function as the whipping child of a privatized system that allows cost-shifting onto the public dole in the name of profit-making in the private sector. As well as being the crutch that enables America to keep hobbling along while being beaten down by the rapacious system of for-profit health insurers, Medicare is also the genius child of a different era, a time when the vision of common-cause caretaking was not only acceptable but actually embraced, and politicking was slightly less contentious than today. Medicare may be a place where we can regain that common ground, and bring the far right, the far left, and the majority center together to carve out a zone of peace and quiet where the hammering out of a unified national health coverage policy can finally begin.

You never want to point fingers and say I told you so when someone up and dies all young and tragic-like on you.  But then, every once in a while, ya know, you do.

The spectacle of Ron Paul’s performance at last week’s GOP debate was chilling, to say the least.  To Wolf Blitzer’s questioning, Paul implied that an uninsured 30 year-old man without insurance should be let to die rather than rely on any kind of public funding for his care (nevermind that all insurance relies on collective funding, whether by government or for-profit institutions).  Blitzer cornered Paul on this answer, who hedged, bobbled, yammered about friends, neighbors, churches taking over.  Meanwhile, the audience roared their approval of when Blitzer asked, “Are you saying that society should just let him die?”  (The little-spoken but eminently more ridiculous part of the question was that Blitzer’s scenario included the hypothetical 30 year old’s option to get health insurance for $200-300 per month – a truly false offering that blunted the force of Paul’s response by implying that cheap, easy-to-obtain health insurance is somehow a norm.)

A week goes by, and someone did a little homework and trotted out a formerly under-publicized fact: in 2008, one of Paul’s staffers was hospitalized with pneumonia.  The staffer – Kent Snyder was his name – was uninsured, and apparently uninsurable; an undisclosed pre-existing condition precluded his ability to obtain covered.  He died.  His mother inherited the bill – a whomping $400,000.  l She couldn’t pay it, and the word went out to friends and family to help out, just the way Paul says it happened in the good old days: apparently, you’re now on the hook not only for your own bills, but you should also kick down every time a friend gets sick.  Needless to say, generosity only goes so far (especially if the benefactor is deceased and funds are going to pay post-mortem debts); best guess says less than 10% of the bill was eventually paid through these fundraising efforts.  

Trotting out this ironic moment was, I believe, supposed to be a play on the sympathies of Americans: the insurance crisis is so large that even the libertarians are not immune.  Unfortunately, this Kent Snyder guy is probably the only person in the history of the American health insurance clusterfuck that I do not have great sympathy for.  Because he was the instrument of Ron Paul’s rise, and if his overblown obit is to be believed, one of the prime movers behind one of the libertarian ilk’s most enduring caricatures.  He reaped what he sowed in spades, and in fact, he reaped what he was trying to heap on the rest of us.  He was a firm believer in the libertarian way – including the belief that heath coverage is due only those who can obtain it on the open market – and was credited with Ron Paul’s meteoric return from obscurity in 2008.    

Tea party rhetoric to the contrary, folks in my profession answer to a different set of standards than to cheer at the thought of the uninsured man dying from a treatable disease and leaving his family and friends to go bankrupt with the bill.  We answer, for one, to our own consciences and morals; and while doctors are a popular whipping boy in the health care reform debate, most of us did not go into the profession to sanctimoniously withhold care based on the color of your insurance card – we went into the profession to ply our trade, and that’s what we do.  But we also are bound by a legal mandate, a law called EMTALA. 

EMTALA is the anti-dumping law that was passed in the 1980s in response to practice of emergency rooms turning out critically ill but uninsured patients onto the street.  Under EMTALA, unless a patient is lucid enough to say they refuse any further care, hospitals are obligated to continue to treat an acutely or critically ill patient (or find a facility that will) regardless of who will pay or who will not pay the final bill. (Honestly, I have seen many direly ill people try to walk out of the ER out of terror of the bill they know they will receive, but I have yet to see a single one gallantly refuse care out of high-horse anti-government welfare mores.)  EMTALA is the secret socialist of the American health care system: everyone is guaranteed access through this back-door channel, and once you go bankrupt someone will foot the bill for you.  It’s our very American way of making sure that universal access exists, but in the most inefficient, ineffectual, and painful way possible.  EMTALA is what let Kent Snyder in the front door of the hospital when he fell ill and let him run up a $400,000 bill he would never pay.  EMTALA is essentially unpaid socialized medicine – the public dole without the cash behind the mandate, paid generously by hospitals biting the non-payer bullet, providers providing unvolunteered charity hours, tax collection structures eating the loss at income that was never garnered on patients who never pay half-million dollar bills they ran up.  Welcome to universal coverage, American-style.

The real irony of Kent Snyder’s death, of course, is not that sometimes people fall on the sword of their own idiotic making.  The irony is that public funds will likely pick up the slack for the $400,000 in services that were generously afforded to him on his way out the door.  Because nurses, janitors, lab techs, orderlies, scrub techs, and doctors don’t work for free even for the self-appointed bloody fool nobility known as the American white libertarian male, someone gets to pay that nearly half-million dollar bill, and it will likely look like this: his momma; his friends and family solicited over the website set up for this purpose; the hospital in the form of yet another loss to a non-payer patient; the local, state, and federal tax structures that will take a hit from the income loss they couldn’t tax on yet another non-paying patient. 

That’s right, Mr. Snyder: you might have lived your ideals, but you died on the dole.  And I’d really like to see Ron Paul and his ilk (and every GOP candidate who stood silently by without a word of objection to this exchange) taken to the table for that inevitable fact. 

Last week another court decision by 11^th circuit Court of Appeals came down against a key provision of the health care reform bill: the individual mandate. The individual mandate states the obvious and the somewhat subtle: that all people must buy health insurance of one kind or another. It is a key portion of the health care bill, and it is an unstated fact that if this portion is struck down, the rest of the bill is very close to moot also. And here’s why:

Insurance – as I harp on from time to time – is derived from a common risk pool. If enough people throw in premiums, the pool stays stable with reasonably low premium rates. If the pool shrinks or becomes too fluid, premiums rise – especially if the pool is in less-than-optimal health. There are two kinds of cherry-picking that the insurance industry is subject to, both of which are equally toxic to a healthy population and a sustainable health care system. The first type of cherry-picking is the one we know and love to hate: the subjective picking of patients by insurance companies for who deserves one of their policies. Picking ostensibly healthy patients to sell policies to is not the only means that insurance companies cherry-pick their insurance pool; they also limit coverage of pre-existing conditions, place boundaries on the scope and caps of coverage, and engage in a merciless practice known as “rescission,” cancelling a policy once a person gets sick (a practice made easier by the tight connection between employment and health insurance in the US).

But buyers of insurance have also been known to cherry-pick their own needs; I’ve done it myself. Though it was not my intention or my desire, I opted out of insurance coverage for three years when I was young and healthy and had no particular reason to spend an inordinate amount of time trying to obtain and pay for coverage once I was booted off my parents’ insurance. This phenomenon is a large part of the astronomical rise in premiums today: the exodus of the healthy young class – which pays in but do not typically draw out until much later – is no small part of the destabilized premium pool (there are many other reasons too, notably including record profits on the part of insurance companies). This is hardly the fault of that group of people, most of whom would probably rather have insurance but are more prone to being part of the marginally employed class, but the effect is hard to miss.

The health care reform law sets up a new dynamic: one set of rules nixes out the ability of insurance companies to cherry-pick their customers – pre-existing conditions are out, and they must take anyone who applies. At the same time, the individual mandate states that every person must contribute their share, every month along the way. This is the founding principle of all universal care systems: everyone contributes, everyone has coverage, the pool stabilizes.

But if one leg of this stable table is removed, the whole thing collapses. The only aspect of the law deemed unconstitutional in this latest round was the individual mandate; the rest stands. If this stands, people will literally be able to wait until the day they are diagnosed with cancer, and then obtain insurance immediately without ever having paid into the pool. This may be very handy for patients, but it turns the very idea of insurance on its head.

This is not sustainable. By flipping the traditional cherry-picking to favor the patients’ side without a firm cap on premiums, there is only one result that will occur, and it is extremely predictable: premiums will rise at a rate faster than you have ever seen before. So while it may seem like a fine idea to allow people the option of buying after-the-fact disaster coverage, in fact we will all pay for it in unequal measure: those responsible enough to carry insurance will bear the long-term brunt, those who choose to buy it at the last minute will suddenly realize what premiums of several thousand dollars per month feel like.

The individual mandate is one half of the social contract built into the health care reform act; the mandate to take all comers and end the practices of limiting pre-existing conditions and the like is the other half of the social contract. Without both, the whole thing falls apart. We know this because we live in a system right now where half of this social contract has simply never existed, with the predictable consequence of tens of thousands of deaths per year attributed solely to the lack of insurance coverage.

But this points to what I have always thought was a fatal flaw in the health care reform act to begin with: forcing Americans to buy private (and often for-profit) health insurance never seemed like a good idea. I fundamentally object to the government enacting a law forcing me to buy from Aetna, BlueCross, or United Health – and not because I’m a libertarian (at all), but because I object to being forced to contribute to the private cash generation machinations inherent to modern insurance companies (even the non-profit ones do not exactly act in the public interest). I get to vote on public policy, which is why I’m alright with Medicare, the VA, Medicaid and the like: in the end, these entities are beholden to the American voter. Being forced to buy from a private (especially for-profit) company feels a lot like a violation of basic conflict of interest rules to me, and I can’t really blame the rest of America – for liberal or libertarian reasons – for feeling a similar unease. We’ve all become accustomed to the public pooling of funds that supports roads, schools, and the like, and it takes very little imagination to guess how we might transform that into a public health care system.

But the social contract – everyone contribute, everyone be covered – remains an imperative part of universal health care, as it is in every country where it has been achieved. The likely result of this week’s decision is that the law will be forced to go before the Supreme Court, should the Supreme Court choose to hear it. And with only rudimentary understanding of constitutional law under my belt, I can imagine this could legally go either way. If the individual mandate is struck down, we all go back to square one, maybe with a different or better vision in mind: perhaps one based on our all-American versions of care-taking – Medicare, Medicaid, the VA, the Indian Health Service, and the like – or something new altogether. But always with that same objective in mind: this will only work if we are all in it together.

Not long ago, during a yawn-inducing day of medical review lectures, a particular speaker threw a PowerPoint slide onto the screen with a three-part photo montage of a bottle of European-label wine, a suspiciously malodorous-appearing cheese, and a copper IUD. Underneath was a caption: “Three things that cost under $10 in France.” In the United States, a copper-based Paragard IUD will run you about $300 for the device…and another couple hundred – depending on the whims of your doctor – to have it gently placed in an orifice that will make it useful for preventing pregnancy.

Thirty-fold price difference for a device that essentially contains a few dimes’ worth of plastic and copper: there’s a lot to unpack here.

IUDs are not as popular in the US as they are in some other nations (in some parts of Europe, fully a quarter of the contracepting population uses IUDs; they are even more popular in Latin America and China). This is in no small part because of the experience of the Dalkon Shield, a largely innocent contraceptive device that was unfortunately strung up with a braided filament that tracked bacterial infections upward and resulted in enough deaths of otherwise young, healthy women that the whole branch of intrauterine contraception has never quite recovered an unbesmirched reputation. But the Dalkon Shield was largely an American product; other nations had little experience with such a toxic product, and have continued to use IUDs uninterrupted for decades.

So with a history of disaster like the Dalkon Shield, why should American women be at all interested in the IUD at all? The World Health Organization puts out a neat little chart of birth control methods in a hierarchy of effectiveness. You will note that effectiveness is largely a proxy for how often you have to think about the thing: if you have to consider your contraception every day (even worse, every time you start up a little foreplay), it falls down the chart. If you have to think about it once every few years, it rises up the chart. IUDs are up at the top of the effectiveness hierarchy because of the very human tendency to forget pills and condoms (and because IUDs happen to be rather effective products all on their own). In fact, IUDs and implantable devices like the Implanon (a reformulation of the failed Norplant of yesteryear) are the only reversible methods that make the WHO’s top tier. Pills are a notch beneath; condoms are even below that.

And why is this important? Because in one of the world’s wealthiest nations, half of all pregnancies in the United States today are unplanned. Nearly half of these will end in abortion, and though I am staunchly pro-choice, this is not a procedure I suggest anyone be subject to if pregnancy prevention is possible.

The barriers to finding the right form of birth control for the right individual can be immense, and many women default to the pill simply because it is what they know, hear about, ask about, or are given without any other discussion. Price is one issue: even out of pocket, IUDs are often cheaper than pills if used for the full five or ten years, but require a steep upfront investment that many women cannot afford (federal programs cover the copper – but not the hormonal – IUD for uninsured low-income women at this time). Many practitioners who feel comfortable handing out pills don’t know how to counsel on the risks and benefits of IUDs or implantable devices, much less place them. We can all cite a few providers out there who won’t give contraception to unmarried women, or women at all, or whatever variation of limitation one might set on women’s right to limit their fertility. There are providers who won’t insert IUDs in women who don’t have children yet, or who are still in their teen years (I argue the reverse: IUDs are perfect for teens, who have the highest failure rate for daily pills, who are most vulnerable to the later osteoporosis associated with the Depo Provera shot, and who benefit immensely from a span of years to finish high school and possibly college without interference from an unplanned pregnancy).

These are all culture-bound barriers, not medically-prescribed barriers. Even the edict against putting IUDs into women who have never born a child comes from a strange age: this language was inserted into the package literature of the copper IUD back in the days when the Dalkon Shield was causing infertility in its victims – the idea being that if you don’t have kids already, you should really have some first before you use a product that might cause you to become accidentally barren. There are so many things wrong with this line of thinking, I don’t think I need to enumerate them; and the relatively contraindication of putting IUDs in women without children has been removed from more recent versions of the package insert in deference to the fact that the Dalkon Shield has now been off the market for over 35 years.

But mostly, a failure to aggressively offer the most effective forms of birth control among all the options – and let a woman decide from the variety of methods available which is most right for herself - is in fact a failure to engage in the full protection of women’s health. Obama’s recent copay-free contraception edict is a promising one, but until the full breadth of choice exist, we are unlikely to see a significant change toward better fertility management and effective women’s health care across the board.