Wednesday, July 01, 2009

The Civics of Health Care

I am a fat smoker – and according to the arguments currently (hell, traditionally) being made to define what citizens most need to do to greatly lower the costs of health care is to combat obesity (it’s an epidemic!) and continue to tax, coerce and harass smokers into quitting – which makes me and those like me Bad Americans. I take objection to this Nanny State posture disguised as concern for the greater good, to being made to feel like a social pariah because, in today’s everything-must-be-politically-correct environment, one’s personal “bad habits” have become a legitimate public concern. This doesn’t face or solve the real health care problems and it’s neo-fascist bullshit – and here’s why.

First, according to the National Coalition on Health Care, the cost of health care in the U.S. in 2007 was $2.4 trillion, representing $7,900 per person and 17% of the GDP. Unchecked, this figure will reach $4.3 trillion and 20% of GDP by 2017. The Coalition notes that “Experts agree that our health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.” My being a fat smoker – or not – does not and will not affect the gross deficiencies of the health care industrial complex.

Second, more specifically, according to Pub Med, a service of the U.S. National Library of Medicine and the National Institutes of Health, “Recent estimates suggest that obesity accounts for 5.7% of US total direct health care costs, but these estimates have not accounted for the increased death rate among obese people. …Direct health care costs from 20 to 85 years of age were estimated to be approximately 25% lower when differential mortality was taken into account. Sensitivity analyses suggested that direct health care costs of obesity are unlikely to exceed 4.32% or to be lower than 0.89%. Conclusions: Increased mortality among obese people should be accounted for in order not to overestimate health care costs.”

Third, according to a study published in The New England Journal of Medicine, “Methods: We used three life tables to examine the effect of smoking on health care costs – one for a mixed population of smokers and nonsmokers, one for a population of smokers, and one for a population of nonsmokers. We also used a dynamic method to estimate the effects of smoking cessation on health care costs over time. Results: Health care costs for smokers at a given age are as much as 40% higher than those for nonsmokers, but in a population in which no one smoked the costs would be 7% higher among men and 4% higher among women than the costs in the current mixed population of smokers and nonsmokers. If all smokers quit, health care costs would be lower at first, but after 15 years they would become higher than at present. In the long term, complete smoking cessation would produce a net increase in health care costs, but it could still be seen as economically favorable under reasonable assumptions of discount rate and evaluation period. Conclusions: If people stopped smoking, there would be a savings in health care costs, but only in the short term. Eventually, smoking cessation would lead to increased health care costs.”

No honest, reasonable person will deny that there are frequently health problems associated with both obesity and smoking – but it bears noting that because of the physiological dynamics of obesity (such as the development of weight set-points and the fact that one may lose hundreds of pounds but one never loses a single fat cell), there are many fat people who are fat and healthy because of “good” eating and exercise habits.

Similarly, according to Health Clinic: Life Management Health Systems, “New research shows that even among long-term, heavy smokers, the risk of getting lung cancer can vary dramatically – from less than 1% to a whopping 15%. The risk of getting lung cancer was most heavily influenced by age, duration of smoking and how much a person smoked, says Dr. Peter Bach, lead author of the study and an epidemiologist and pulmonary physician at Memorial Sloan-Kettering Cancer Center in New York City. `Before this study, anyone who smoked for 25 or 30 years thought that they were at extra high risk of lung cancer when, in fact, there is lots of difference in risk,’ Bach says. …Researchers then applied the model to a sample of 300 people who had undergone cancer screening at the Mayo Clinic and came up with these sample profiles:

-- A 51-year-old woman who smoked a pack a day for 28 years and then quit has only a 0.8% chance of getting lung cancer in the next decade.
-- A 52-year-old woman who smoked a pack a day for 35 years and who continues to smoke has a 2.8% chance of getting lung cancer in the next decade.
-- A 58-year-old man who smoked 25 cigarettes a day for 40 years but quit three years ago had a 4.1% chance of getting lung cancer in the next decade.
-- A 56-year-old woman who smoked two packs a day for 44 years and continued to smoke had a 8.4% chance of getting lung cancer in the next decade.
-- A 68-year-old man who smoked two packs a day for 50 years and refused to stop smoking had a 15% chance of getting lung cancer in the next decade. His risk would drop to 10.8% if he quit.
`At the high end, you're talking about one in seven people,’ he says.”

I’m glad that our smart, skinny, cigarette-battling president is doing all he can to create a sane, workable, economically and medically sound health care system for America, which presently ranks way, way below the fiscal efficiency and medical effectiveness of every other industrial nation in the world. But please, let’s not turn this into a simplistic, finger-pointing process that demonizes fat people and smokers, yet gives short shrift to the cost/care facts associated with extremely advanced age; end-of-life care that regards death as a defeat, rather than a natural and inevitable part of life; the unwanted births of hundreds of thousands of babies who are often doomed to poor pre-natal and childhood medical care and poor nutrition stemming from poverty (not an undisciplined craving for junk food).

Indeed, let’s not ignore the enormous role of poverty (or close to it) in health and health care. It’s easy to sneer at fat people and smokers and say “You’re the reason medical care and health insurance costs are so high!” It’s much harder to take a more honest, detailed, comprehensive look at the problem as a whole and devise a system that cares for everyone, whatever their lifestyle choices may be. Some of us are fat and/or smoke. Others of us breed like farm animals, engage in dangerous sports, or just live longer than humans ever have before. And all of us are victimized by insurance and pharmaceutical companies, hospitals, doctors, and the support services they work with. Let’s keep this a medical and financial issue – and not create a false and mean-spirited social/moral divide.

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