09 January 2008

Pesticides for breakfast, HSAs on the side

In its wisdom, The Denver Post chose free-market crank Jackie Avner to be one of their Colorado Voices this go round. Inconceivable. Did the editors look back on their poor work in balancing the massive shift from the center to the right that took place in their pages in the 1990s and continues today, and decide that this time around they'd do things differently?

Back in the '90s, when the right was in full cry against the supposed liberal bias of the media, editors and producers obligingly began giving right-wing views far more print than progressives were allotted.

Now it's liberal voices noting a real imbalance — but the press has learned their lesson, and aren't to be moved. And thus the current crop of Colorado Voices?

In her most famous column, Avner wrote, "I don't like to buy organic food products, and avoid them at all cost. It is a principled decision reached through careful consideration of effects of organic production practices on animal welfare and the environment. I buy regular food, rather than organic, for the benefit of my family."

I doubt even John Caldera takes such a principled stand.

Today Avner takes on the health care crisis with equal astuteness. In her considered opinion, it's regular folks' own fault that medical expenses are too high.

This is a shopworn talking point from the right; one that has elements of truth but is far from the real reason that costs are out of control. That's especially true since Avner doesn't include the fact that people do share some personal responsibility for falling for the fear-mongering myths about single-payer spun out by the health insurance industry. It doesn't take much effort to discover a virtual mountain of data showing that guaranteed, universal health care, with either a single payer or very nearly single-payer financing, gives quality health care at a far lower cost.

In any case, here are some of the problems with Avner's article.

"Some Americans choose to buy things other than health insurance. Nearly 40 percent of the uninsured reside in households with earnings greater than $50,000. Their health care costs are spread among everyone else."

The U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation found in 2005 that 27% of the uninsured have incomes above 300% of poverty, with one-in-ten (11%) uninsured above 500% FPL. Federal poverty level for 2007 is $10,210 for an individual; $13,690 for a two-person household; and $20,650 for a four-person household. Here in Colorado, the Colorado Health Institute reported that for 2003-2005, about 42 percent of Coloradans with family incomes under 100 percent of the poverty level (then $19,350 for a family of four) were uninsured, compared with 6 percent of those with incomes above 400 percent of the poverty level ($77,400).

It looks as though Jackie may have been misled about that 40 percent figure. Her source material might be biased. And before we get too exercised about how those folks making four times the poverty level should have health insurance, consider that the average health insurance policy for a family is about $12,000. For a family with special needs — Nathan Wilkes' family, for instance — $12,000 a year is in your dreams. At what point is insurance unaffordable? When it's $1,000 a month for an individual? When it's a quarter of your income? When the choice is between insurance and housing? Not to mention the ugly choice between insurance and the American dream of starting your own small business.

As for the cost shifting, it's hard to say how much of it is justified and how much comes from the uninsured. Medicare and Medicaid also are a cause here, as are a myriad of other elements. What is Avner's solution? It's hard to believe she'd be in favor of forced mandates to buy health insurance, so what does she propose? Denying care? (Which is, of course, already done to some extent. Ask my brother's widow.)

Most Americans choose to overeat. According to the World Health Organization, 74 percent of U.S. adults are overweight or obese. Obesity contributes to expensive, chronic conditions such as diabetes, hypertension and heart disease.

Take a look at the bugs. What is the correlation? Since every country on that chart except the U.S. has guaranteed health care, one might almost conclude that knowing that your health care was secure caused people to eat less.

Americans over-consume pharmaceutical drugs, tests and procedures from the buffet of health care options, including those our doctors think will be marginally effective. Our reasoning is, "If it doesn't cost me anything extra, why not try it?"

That excess consumption of marginally effective pharmaceuticals couldn't have anything to do with the barrage of advertising with which we're deluged, could it?

Actually, this is a problem that all health care systems grapple with. Europeans do indeed consume more health care than do Americans. They see their doctors more often, have more procedures, etc. And yet per capita, the cost is about half as much. Dang.

Avner goes on to beat this dead horse for several more paragraphs. It's odd — the right usually likes to tell people that it's everyone else's fault but their own, but not here. Then again, most people don't consume too much health care. About 70 percent of health care dollars go to just 10 percent of the population. They are the sick and injured ones, after all. A certain number of people though will want to believe that the answer is as simple as keeping (other) people from overconsuming. They've all heard of the lonely old lady who goes to her doctor for hangnails.

This argument sits uneasily with the one that says that universal health care isn't a good idea because it might limit our consumption of health care — rationing, you know.

Ironically, the British are now experimenting with a program that would encourage people to do more self-care — keeping track of their own blood pressure, etc. — and the right has decried it as proof that "Britain's 60-year-old National Health Service can no longer support the weight of its clamoring clientele."

Eh. Who knows whether it's a good idea to have people monitor their heart activity, blood pressure and lung capacity using equipment that has been placed in the home — with them telephoning or emailing in the results. Obviously there's room there for bad judgment. Not all patients will be capable of doing it. But all in all I think I'd rather take my own blood pressure at home than have to trek into a clinic twice a week to do it. In fact, that sounds like just the kind of thing computers and education are supposed to empower us to do.

Avner thinks the solution lies in that great innovation health savings accounts. Because she now has an HSA, she now shops for the best deal she can find for dental and eye glasses (odd examples, since an awful lot of insurance policies don't cover those items anyway) and she uses generic drugs. "My behavior is entirely different, and entirely more responsible as a result of a simple incentive from the government," she writes, seeming to agree that in fact government can be a force for good. Through tax policy.

Uwe Reinhardt has an essay in Health Affairs blog on HSAs. Reinhardt notes that HSAs do work as advertised by the right when the purchasers are in a high tax bracket and have a low deductible. "...[T]he tax-preference accorded to HSAs effectively makes health care more expensive for low-income persons than for high-income persons," he writes.

That's already the case, of course, but Reinhardt's analysis shows that HSAs are a solution only for higher income families like Avner's — whose husband is a physician.

Now about that aversion to organic food. Blood samples of children, ages 2 to 4, show concentrations of pesticide residues to be six times as high for kids who eat conventionally farmed fruits and veggies — the kind Jackie likes — compared to kids eating organic.

But maybe organophosphorus pesticides are only a cancer risk for the reality-based community. And sunspots are responsible for the itty bitty weather changes we may or may not be seeing. And there were caches of WMDs in Baghdad.

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