Scripps cardiologist Eric Topol (not commenting on this article): "That's wrong. The CAC is anything but definitive. Many patients are told they have significant coronary artery disease by calcium score and it turns out, by CT angiography or cardiac catheterization, they have normal arteries.
No less anxiety (often chronic and severe) and unnecessary procedures that are induced by false positive CACs." https://x.com/EricTopol/status/2092682606815117763
Coronary calcium scans quantify calcified atherosclerotic plaque but cannot reliably distinguish stable plaques from rupture-prone plaques or detect noncalcified plaques, some of which may be particularly vulnerable.
Eric Topol has some opinions. Some other cardiologists disagree. There probably is value in CAC for at least a subset of patients.
In the messy real world of medicine there are hardly any definitive screening tests or imaging studies. Everything will have some false positives and false negatives, or even if the output is physiologically accurate it may not be practically useful in improving patient outcomes. For screening tests we also have to weigh the costs versus benefits in terms of the number of procedures performed or dollars spent to save a life; if the numbers are too high then those scarce resources should be expended on other healthcare services.
For broad screening coverage by most health plans the key next step is an evaluation by the U.S. Preventive Services Task Force. This process is already underway but it takes a while for them to evaluate all the evidence and make a decision. For Medicare coverage there is a separate coverage determination process.
On a similar personal note, I had a half-year health scare that ended just today.
In May, they told me on ultrasound that my dilated aortic root has grown by more than 2 mm in the last year and that if the progression does not stop, an operation will sooner or later be necessary.
I got a referral to magnetic resonance and had to wait for it until October. Was there last week, nervous. Today I got the result: compared to the MR from 2021, there is no progression at all. The same 44 mm as then. The ultrasound was just not as precisely done, or the doctor measured it slightly askew or what.
Sorry to inject whatever uncertainty this produces, but how do you know that the most recent "no growth" reading is the correct one? To me your story justifies at least 1 or 2 more regular scans.
I was told by the cardiologist who ordered both scans that MR results are very precise, while ultrasound is more of an "orientation scan" and small variations in how the doctor holds the probe and interprets the picture can add up to milimeters of difference. If there is a discrepancy, MR is the gold standard for decisions about treatment.
This was at IKEM in Prague, one of the best cardio units around, so I trust their judgment.
What I've never understood is the weird dichotomy of preventive and reactive governance in the minds of US citizens.
We're willing to spend god knows what shooting rounds that cost entire mortgages to save miltary lives and project a presence of power to deter acts of terror/war, but then are also totally fine having people way as much as 4 or 5 people, eating several days worth of sugar for breakfast, smoking tobacco, putting 3 cups of coffee in a can we drink 4 or five of in a day, do next to nothing to adress recidivism of all classes of criminal, drag our feet kicking and screaming in to a semblance of modernity in worker protections...
In some ways, US healthcare is already very aggressive for some forms of preventive medicine. Compare the colon cancer protocols across the world. Basically nobody else is recommending colonoscopies to the entire population with no cheaper tests, but that's the standard of care in the US. It's not free to receive, and it's expensive in general, but for some reason in the US it is standard, instead of starting with non-invasive tests.
And yes, regarding smoking, the US has had one of the most effective preventive actions in the world. Compare actual numbers of smokers in the US vs, say, Spain, France or Turkey. So it's not anywhere near as clear cut as what you are trying to make it sound.
Walk into a US gastro with a hang nail and you'll walk out with a colonoscopy requisition.
They make money on the procedure, not the office hours. And they write the standards of care.
That being said, my father delayed a screening, developed colon cancer, and now no longer has a colon. Would cheaper / higher compliance tests have caught it sooner? Hard to say.
That's not entirely true. For screening procedures it's mainly the USPTF that writes the standards. They take inputs from the gastroenterology community but the process is more holistic.
> The Affordable Care Act (ACA) requires both private insurers and Medicare to cover the costs of all colorectal cancer screening tests that are recommended by the United States Preventive Services Task Force (USPSTF). The law stipulates that there should be no out-of-pocket costs for patients, such as co-pays or deductibles, for these screening tests.
Smoking ironically saves in medical costs because people die before getting into real expensive age related care, and also smoking disqualifies you from a large number of medical procedures that would otherwise be given. Keeping a relatively healthy 90 year old alive for 2 more years costs significantly more than keeping an unhealthy 60 year old smoker alive 10 more years before they have a heart attack or stroke.
It is in lifetime medical care costs and there have been a few studies in Europe. The majority of medical costs is for age related care that grows exponentially with age, and smoking cuts decades off their life. Most smokers die before they get lung cancer, when they do it rarely results in surgery because they smoke, and it is easier to give a younger person chemo than and older person.
Also have you seen the kind of medication regimes that most 90 year olds take? Many of them take as many pills in a week as a 60 year old has took over the last decade or more.
You did not say lifetime medical costs initially but compared adding 2 years to a 90 year old vs 10 years to a sick 60 year old.
> Keeping a relatively healthy 90 year old alive for 2 more years costs significantly more than keeping an unhealthy 60 year old smoker alive 10 more years before they have a heart attack or stroke.
> Basically nobody else is recommending colonoscopies to the entire population with no cheaper tests
I'm not sure if I understand what you're saying. Kaiser Permanente sends me a take-at-home colonoscopy test every year, and some light googling suggests the cost is $20-$89. I've never done an in-person colonoscopy, but the home version must be cheaper, right?
Based on my personal experience with Kaiser and their home fecal test (FIT test) as a cheaper screening method, I suggest opting out of it and insisting on a colonoscopy.
The problem is that the fecal tests are totally inconclusive. Every positive test must be confirmed by a colonoscopy. And then you get into tricky waters with insurance. My Kaiser gastro doc insisted that my colonoscopy after a positive home FIT test would be billed as diagnostic and not covered at no charge as preventive screening. Which means I would pay over $2k. Despite the USPSTF publishing explicit guidance on this exact scenario still being screening. He was dead wrong, and I wasn't billed, but he and his department did everything they could to discourage me from following up with a colonoscopy.
And at one point he even turned the tables around on me and said this was all a consequence of my having opted for the FIT test instead of a colonoscopy. Which I never did, I was not given a choice. But from his statement I would assume that you can opt in to colonoscopy instead at Kaiser. Then again this could be yet another piece of misinformation on his part.
Kaiser has some very opinionated beliefs that their medical leadership pushes. From my partner's T2D issue (from no history to an ICU stay with DKA): "You cannot go into remission with T2D". "You will need to keep your A1C between 6 and 8 otherwise you will have issues with the medications you are on". They also have many medications they will not prescribe, regardless of the reason.
And don't start me on their pharmacy. She had root canals with some infection, and was in substantial pain. Dentist prescribes short term pain meds between procedures - she's in agony. I drive her from dentist to the Kaiser pharmacy at their UC/ER-lite/whatever facility, that I know from my previous work as a paramedic has pain management medications on site (day surgery, etc.)
"This is a pain management prescription. We do not fill those in person. You will need to submit it to our mail order." "How long will that take?" "5-7 business days, and then shipping time."
"Oh, look at you, coming from the dentist with verifiable surgical procedures done and in pain - just in case you might be drug seeking, you can hang on for a week or two and get your pain management then."
That last one is, I'd argue unethical and against most pharmacists "oaths".
The take home thing is a vial into which you put a stool sample and mail it back. Then it gets tested for signs of colon cancer. I've seen them advertised on TV as well.
That is not a colonoscopy. That is a stool sample and as other replies noted this gets sent out every two years to every one. In the UK from age 60 Australia seems to be from 50.
If that tests positive then you get a colonoscopy to check more things.
If you have had colon cancer then you get a full colonscopy evry two years and an MRI every year.
No it is not an alternative to a colonoscopy it is a different test.
If this test finds something then the next step is not treatment it is you need a colonoscopy.
It is a test that cuts down on the number of colonoscopies needed and is cheap enough to find problems earlier than everyone having a colonoscopy which is just unaffordable,
I've got extremely normal marketplace health insurance and my doctor is at an extremely normal overworked large regional health chain, and I would have to argue with him to get an at-home test; the whole system is set up to funnel us all into colonoscopies.
This is standard in Australia. Everyone between 50 and 74 receives a free kit in the mail every two years, and there are regular TV ads from the federal government (featuring actual TV stars) encouraging everyone to do the test and mail the results in.
Hypothesis: The American diet contains more carcinogens (dyes, additives, pesticides, supplements in poultry/beef/pork) and therefore USA is is more need of CRC screening.
USA generally has higher CRC rates than other developed nations:
I think that article is from 2009. Need something more recent. Also it mentions that as countries become high-income economies, the incidence rate increases.
My doctor in the US did everything he could to tell me that my screening colonoscopy would be charged as diagnostic and I would have to pay over $2,000 for it, despite no history or indications of a problem. So it isn't all a bed of roses.
There actually has been a really big push against this in the US. I was shocked by the amount of smoking I saw on a recent trip through Northern Europe, whereas smoking in public is pretty rare to see in the US these days.
Now we just vape our nicotine directly, or smoke weed, depending on the state.
Cigarettes have definitely gotten a trashy vibe in the US. It's kinda nuts how fast we went from smoking sections in fast food restaurants just 30 years ago to even bars banning it. In college 10 years ago, the only people I knew who regularly smoked cigarettes were from Europe, China, and India.
Cigars are still cool though, but those have always been the higher status tobacco due to the cost per stick. Also most people don't go through public spaces smoking a cigar, so it doesn't have the annoyance factor of vapes. Hookah still has a fun vibe too, probably because of the social factor.
You can't smoke in the bar but you can smoke outside the front of the bar and they don't care in open air patio areas generally. People smoke a lot casually outside too. I see a lot of people smoking golfing or skiing.
Can you say where in the US you find it rare to see smoking in public? I live in Kansas City and have been in Vegas, Seattle, and NYC recently and there is plenty of smoking everywhere. Less than the 80s, sure, but certainly not rare.
How recently were you in Vegas? I was blown away by how little smoking there was post pandemic even compared to 2018. Like, most casinos no longer reek of cigarette smoke. I'm sure that's partly explained by better air circulation installed to reopen sooner post-COVID, and probably taking the closures as an opportunity to replace some seriously steeped carpet, but the amount of smoking was way, way down. It used to be if you saddled up to craps table, at least one, if not two people would be actively smoking. Now you can look around the entire pit and not even see one. The combination of anti-smoking measures in broader society, and the uptake of vaping has wildly reduced the amount of smokers. We're talking a 60% reduction since 2000, and that was after the trend was already heading that direction.
Compare that to most places internationally, and the contrast is stark. The US has less than half the cigarette consumption per capita than the EU, with only the U.K., Norway, and Sweden having lower rates. China has a similar rate to the EU.
Just to drive that point home a little harder, the state with the highest number of smokers is West Virginia, sitting at 21% (the national average is 9.6%). That would be middle of the pack in Europe, similar to Italy.
I was in Vegas in August for Def-Con and there was a ton of smoking. Our hotel’s casino/lobby was disgusting. The smokers area outside the convention was plenty busy. Walking to the monorail there were people outside most hotel back doors smoking.
Which reminds me: Also, the smoking area of every airport I’ve been to in the last 2 years has been thick with smokers.
I know it’s better than the 80s. I was there. But I don’t think it’s rare in the US at all.
Rare as in you can absolutely spot a person smoking sometimes, but there is not the perception that everyone is smoking, the air does not always smell like cigarettes on the streets and even inside businesses, and the ground is not covered in cigarette butts everywhere.
NYC vs Hamburg, Amsterdam, or Brussels are night-and-day differences on this point.
I'm not sure Vegas is representative of much of anything, but last time I was there what I smelled was weed, not tobacco.
In my daily life, every day, I am behind cars with people smoking, see people on their smoke breaks outside the doors of offices and retail, walk behind people on the sidewalk smoking, and see it on basically every job site I pass.
I only bring this up because I keeping seeing people say it's "rare" in the US, but is something rare if you run into multiple times every single day?
I guess we can keep arguing about the definition of rare, but about half the smoking rate of many European countries is pretty significant, and immediately noticeable walking around cities in both places. It's also a significant reduction in the US since the 90s, when every restaurant and workplace, and decent number of homes, smelled like cigarettes.
Rare in the northeast US. In fact, I saw two students smoking on a college campus just last week and did a double take. I had not seen a single student smoking in at least a decade. Then I laughed remembering how when I was in college in the 90s, almost everybody smoked at least a little (often at parties), and seeing students smoking at the entrance to the dorm was pretty normal. I am an asthmatic so I've never smoked, and I remember my friends being stunned by this one night when we were out at a bar. Things have changed a lot around here.
In my college dorm in the 70s, nobody smoked. Well, there was one. He got a lot of pressure from the rest of us, because it stunk up his room and the hall. He finally gave in and moved elsewhere.
I think this is a case of rare being relative to the past.
In the 90s and earlier it was hard to be in a city and not be breathing cigarette smoke pretty much constantly. Offices had ashtrays in the elevator waiting areas for people who couldn't wait to get to their office, restaurants had half the seating reserved for smokers, there were ashtrays in the armrest of every single seat on an airplane.
Its kind of crazy how much norms have changed around smoking in public. It's not "rare" to see a smoker, its that it is much rarer than it was in the past.
Idk if it would call it rare because yeah going on a walk in a downtown area you will definitely see at least a couple people smoking. But 30 years ago it seemed like every other person you passed on the sidewalk was smoking.
There’s an economic disconnect working against preventative medicine in the USA. The commercial interests take more of a cut on the expensive reactive treatments.
I’m from a country where you are mailed things like a free bowel cancel screening kit every two years unsolicited from the time you turn 50 (Australia). The reason is that the kit and test cost a few cents and detecting it early saves the socialised medical system so much money this sort of thing is a no brainer. There’s a direct economic incentive for socialised medicine to integrate preventative care into day to day life.
There SHOULD be the same incintive in private health care like the US to also lower costs. but when we voted in the ACA (Obamacare) there was a well meaning clause that said insurers had to spend 85% of their premiums on care. That should also re-inforce the cost savings part, but then the largest companies started buying Pharmacies, Pharmacy Benefit Managers, Doctors offices, and even whole Hospitals.
Now they can still spend 85% of the INSURANCE premiums on care, but then those costs are going to their other divisions which can raise prices at will, and make massive profits for the whole group.
Nobody's twirling their mustaches hoping people get sick, but they don't need to be for fee-for-service incentives to bias standard practice towards responses to conditions rather than prevention. On the other hand: you can go too far the other direction (and some cardiologists would point to CAC tests as an example). Preventative care can be bad if the tests drive unnecessary procedures.
It’s very strange to include caffeine in that list of unhealthy things. Everything else in that list is proven to be bad for society/health, except for caffeine. Why did you choose to highlight caffeine consumption when there is not really any evidence it causes health issues?
The comment said “putting 3 cups of coffee in a can we drink 4 or five of in a day” that would be 1,000–1,500 mg of caffeine. The FDA guidelines is 400mg a day and drinking 1200mg quickly can induce seizures
16 oz can of white monster (stereotypical energy drink) has about 150mg of caffeine. A grande (16 oz) black coffee from Starbucks has about 310mg of caffeine. You would need to drink 2 16 oz monsters to get the same amount of caffeine as a single grande cup of coffee from Starbucks.
If you're just looking at caffeine intake you'd be better off switching from coffee to energy drinks. You could drink about 3 per day and be close to the 400mg/day guidance.
edit: white monster has no sugar in case anyone was about to bring that up
> If you're just looking at caffeine intake you'd be better off switching from coffee to energy drinks
This is less true now than it used to be. I'm somewhat sensitive to caffeine and always look on the can to see how much is in it, and 150 is on the low side of most of the options available now-. 200 to 300 seems to be a lot more common among the brands that are newer than when monster and Rockstar first came out.
When a flock of geese shit into the pile of beets, gnaw on the beets for a few days, and then the beets get boiled down and put into your Gatorade, sucrose ≠ sucrose.
You know manure and the soils produced from composting are literally feces from animals and bacteria, right?
And that manure is an excellent natural fertilizer?
And that outside that, worms exist? And they poop?
Oh, and that if you were to take bird shit beets and worm poop beets and mash them up and extract chemically pure sucrose from both you'd have no way of determining which came from which?
Assuming that you do know all of these things, you're saying that horse shit and worm poop is fine, but you'll be damned if a bird is involved?
I mean, I can see where you're coming from. A potatoe coming from a toilet is probably not as clean as a potatoe coming from a sterile lab, but that's not what you're saying. You're saying that the toilet has somehow altered the physical chemical compounds involved in the structure of the potatoes rather than has potentially added other chemicals to the mix that was the potatoe. The starch is the same in both. The starch = the starch. The starch and the toilet =/= the starch and the lab because the toilet =/= the lab, but those are different arguments.
It’s included in a list of things bad for “ society/health.” While overconsumption on that level would certainly be a health issue for an individual, it doesn’t even register compared to the other things he lists as a social issue, like chronic obesity and Tobacco use. It’s just weird and misleading to include it in that list, is all I was pointing out.
I don't think there's long term evidence for negative problems. However, high dosages of caffeine are dangerous and have killed people. Those dosages are easily achieved through the likes of energy drinks.
Chronic long-term use of high amounts of caffeine (>600 mg, or two Starbucks Grande coffees) are linked with: bone density issues, sleep issues, anxiety issues, cardiovascular strain, stomach acid issues. They aren't super bad, but definitely not harmless.
High dosage of water have also killed people. And easily achieved through energy drinks? I strongly doubt that. Most energy drinks are not any stronger than coffee
Lower dosages of caffeine kill you than the water dosages that kill you.
> And easily achieved through energy drinks?
Yeah, once you start pushing 1000mg of caffeine, you are getting into areas where if you have heart problems, you could be putting yourself in danger.
> Most energy drinks
But not all. So why strongly doubt it?
There are plenty of energy drinks which are fairly popular with huge amounts of caffeine and there's little labeling requirements to let people know that. Bang energy drink is a good example of that. 300mg per can, meaning 3 cans is putting you in dangerous territories.
Because people are unable to conceptualize the idea of government-funded voluntary preventative campaigns, despite these showing success in the past.
This may be partially due to the many all-or-nothing crusaders who would prefer to use force in their quest for full protection of the citizen. Many people overcorrect because they fear that even voluntary programs are steps in this direction. Trust is low.
We have a long and sordid history with extreme and failed prevention (prohibition, the Mann Act, war on drugs).
Much of the US doesn't think of it in terms of proactive vs reactive governance but instead in cultural/moral expectations of how you should "pull yourself up from your bootstraps" to be great. This view is often to the point many see removing the need to pull oneself up from their own bootstraps as removing the ability for them to better themselves (& wasting everyone else's money/freedom/whatever to do so). A soldier and an obese person are examples at polar opposites of that moral spectrum.
The policies just follow that. This comes up in all sorts of areas such as prison as punishment vs rehabilitation.
I think you're looking at an effect instead of a cause. The main reason for the desire for a small government is not some inherent and absolute obsession with smallness, but because of the belief that larger governments are incapable of effectively utilizing their power (for reasons beyond just incompetence), are prone to inevitable abuses, and so forth. And that belief itself is not simply ideological, but based on history through most of all time.
Even with rehab versus punishment - it's the same story. The view isn't that punishment is inherently superior, but simply that rehabilitation is more of an ideal than a reality, and that typical appeals to places like Norway - a relatively homogenous and extremely wealthy microstate - don't necessarily translate well to large diverse societies, especially ones where there are substantial chunks of society that adopt cultures that glorify criminality.
My views on this subject are far too detailed to want to get into here, but I am confused at your choice to call Norway a "microstate". It's certainly on the smaller side of countries, but there are over 5 million residents and 300,000km2 in size. It's just a normal country.
"Microstate" is a term generally reserved for tiny geographical locations that can't even support their own defense.
It has a lower population than e.g. Wisconsin, in an area about twice as large. You could fit 61 Norways (in terms of population) into the US. I think there's a lot of things that work really well at smaller scale, but just don't work at larger scale. It's not really possible to say where 'smaller scale' ends because it's going to depend on factors other than just population, but I think Norway is comfortably far into the very small side of things in part because of population and in part because of those other factors.
A microstate is not just "one smaller than another" though, and nobody lists Norway as a microstate of Europe/the EU.
But with what you had meant - it means Norway is pretty comparable to a typical US state division or, in other words, something US states could be expected to implement successfully in their state prison systems if there weren't other reasons than scale they do things differently.
And you'll find that a number of states of a comparable makeup as Norway have comparable and even lower recidivism rates than Norway. Oregon is the lowest in the US, with a recidivism rate of 12%, contrasted against Norway's ~20%. [1] And that has nothing to do with punishment vs rehabilitation.
Similarly, Asia is another interesting counter-example to Norway. For instance the Chinese penal system makes the US look like a trip to Disney Land. Beatings, physical+psychological torture, and more are regular aspects of their prison system which is not only punitive but borderline sadistic. And their recidivism rate? One of the lowest in the world, around 8%. And perhaps even more important than the recidivism rate is their crime rate, which is also one of the lowest in the world.
I don't think there is a clear cause and effect (or even separation) of those two things. The early views/situations of those who made America are largely the same force which drove the desire for small government and vice versa. I.e. what you believe is ideal in reality is going to be based on the way you weigh things morally just as much as the way you weigh things is going to be based on what ideal is held.
There is, of course, more than one reason people hold the views they do, but I do believe things like rugged individualism & the Protestant work ethic definitely played a major role in why the majority of Americans hold the desires and fears about government they do - particularly in the aspect of these examples. Without those influences, I think what America has tried vs what it has feared would be a very different list today (which is not to say whether it'd've been more successful or not).
Did you know that you can be sentenced to life imprisonment in the UK for suggesting that the monarchy should be abolished? [1] That's quite progressive, since it used to be the death penalty. Now in reality you probably won't be, but that law is an echo, still ongoing, of the sort of systems everybody used to live under. That directly leads to ideals of a smaller government. So I don't think these sort of values we're speaking of are abstract or moralistic in nature.
It's also not just in the past. We continue to live in the era of mass domestic surveillance, Patriot Act, Snowden leaks, regular oppression for political views (see: pro-Gaza protests), two tier legal systems, and much more. All the while governments with vast resources plunge sizable chunks, verging on a majority of discretionary spending, into militarism flirting with WW3 and the viable end of humanity it would entail. And I'm not even going to get into the insanity that's going on, worldwide - including the West, with the treatment of political candidates and elections. Suffice to say that's also enough to make a lot of people quite concerned.
So again all of this makes one begin to think 'perhaps governments shouldn't have this much power or wealth' at a point that I imagine you would say is, itself, already relatively low. I think that should all be fairly reasonable, even if one might disagree at some point. But I'm not entirely sure what the comparable evidence for the alternative is.
Well, again, it's not that these things take place of each other it's that they influence each other. Taking the first example, America only exists because individuals went to settle and conquer new lands and then pulled themselves up by their bootstraps to defeat the tyranny of the monarchy. There is no way in which this can happen without these cultural traits in the same way there is no way it could have happened and not driven these cultural traits further. The other examples follow the same line.
That's not arguing small government is supposed to be good or bad, it's just saying what the American mindset considers important when judging things - which is on traits which align with its mindset over its history, not on whether or not the application of policy seems evenly distributed to all.
I'm not going to debate the history beyond observing that most people were fleeing persecution or seeking a better life for themselves and their families. Scarcely few set out to conquer anything. But I think the most important point is that now a days I think if you put just about anybody in the current state of America, you'd see a trend towards desiring smaller government.
The exact phrase 'smaller government' is triggering because it's been so politicized into being a left vs right concept, but when left leaning individuals seek to decrease the strength of ICE, decrease the rights/capacity/scope of law enforcement, limiting executive powers especially as related to war, and other such things they are themselves also directly appealing for a smaller government, in at least some ways.
I think this hypothesis (that 'anybody' would trend towards seeking smaller government) is even testable with things like Asian Americans. Many/most have roots from more social type societies, and predictably trend towards voting liberal in America as a result of such, to say nothing of historical issues. But they are leaning more and more conservative over time, to the point that at current trends they will likely be a majority conservative bloc within a few decades.
It's simply that once one sees what 'big government' amounts to in the US and the current state of the US government, it quickly leads many people to start running in the opposite direction. And once you start running from such, the opposite (self responsibility/reliability/etc) inevitably grows in proportion simply because there is no other choice.
The primary purpose of prison is neither punishment nor rehabilitation, but rather to protect the general public. Whether incarceration is the best approach to accomplish that goal is a separate issue, but the reality is there are a lot of dangerous and antisocial people who can't be running around loose.
America is the wealthiest nation on Earth, but its people are mainly poor, and poor Americans are urged to hate themselves. To quote the American humorist Kin Hubbard, 'It ain’t no disgrace to be poor, but it might as well be.' It is in fact a crime for an American to be poor, even though America is a nation of poor. Every other nation has folk traditions of men who were poor but extremely wise and virtuous, and therefore more estimable than anyone with power and gold. No such tales are told by the American poor. They mock themselves and glorify their betters. The meanest eating or drinking establishment, owned by a man who is himself poor, is very likely to have a sign on its wall asking this cruel question: 'if you’re so smart, why ain’t you rich?' There will also be an American flag no larger than a child’s hand – glued to a lollipop stick and flying from the cash register.
Americans, like human beings everywhere, believe many things that are obviously untrue. Their most destructive untruth is that it is very easy for any American to make money. They will not acknowledge how in fact hard money is to come by, and, therefore, those who have no money blame and blame and blame themselves. This inward blame has been a treasure for the rich and powerful, who have had to do less for their poor, publicly and privately, than any other ruling class since, say Napoleonic times. Many novelties have come from America. The most startling of these, a thing without precedent, is a mass of undignified poor. They do not love one another because they do not love themselves.
To put it in context, the poor elsewhere were poor by class. No attempt to become rich was permissible by law so it was key that this supermajority of the population did not believe they were downtrodden, and unfairly opposed.
Claiming the poor have more virtue, but only in their class status, is one way to do it.
Consider how many caste systems claim the farmer is the highest status, the wisest, the most virtuously hard working … but well still needs a good noble king to lead them.
Things have changed a lot since Kurt Vonnegut wrote Slaughterhouse Five in 1969. Now even people in the poorest US state have higher incomes than the UK. America is the wealthiest nation on Earth, and its people are mainly rich (relative to global standards).
We should do more to help the underclass and remaining desperately poor citizens to lift themselves up. But it's amazing what we've accomplished since 1969. Let's celebrate that.
> Now even people in the poorest US state have higher incomes than the UK.
Higher income does not mean higher quality of life.
I'm an American who has spent the majority of my adult life living abroad, and much of that time has been in developing countries.
I have no illusions about poverty and am not going to pretend that the US isn't a "rich" country. But I've also noticed a very stark trend in the past decade: fewer and fewer people express interest in emigrating to the developed world.
I currently live in one of the fastest-growing countries in the world. Its per capita GDP PPP is about a fifth of the America's and...the number of people I meet who say they'd want to live in the US is tiny.
People around the world are increasingly hip to the reality: the US is still the land of opportunity. But opportunity is more and more difficult to come by. The country is expensive, has massive social problems and lacks attributes (such as safety nets provided by family) that make life in poorer countries feel better to many people.
Even your idea that the "underclass and remaining desperately poor citizens" need to "lift themselves up" is a distinctly American idea. There are tons of working poor in the US. They are trying to "lift themselves up" but can't afford a $1,500/month apartment, $30,000 starter car, $5+/gallon gas, $5,000 health insurance deductibles, etc.
Hear, hear. It would be good for more people to travel abroad and experience firsthand how much better we have it in the US than most other places. The concern is that we actually have it better than most yet too many actually want to replace our current system with something else that has a horrible track record.
If many of our welfare programs actually helped their intended recipients we would be able to help those in need get to being self sufficient instead of the fraudsters stealing all that money.
America does a better job at assimilating immigrants than most of the rest of the world. It’s just a very hard problem, and the US does more of it than anyone.
People facing racial discrimination can and have overcome it, throughout our history.
People hold out willing non-white immigrants succeeding as proof there is no significant racial discrimination. But this ignores a large selection bias. People who voluntarily immigrate almost always have a great deal of drive and often some resources. Most of them would have been more successful then average if they had stayed in their home country.
I definitely wouldn't say my lineage had any call in "immigrating" into the US.
And yes, don't underestimate how such maneuvers are very indirect means of white flight. African Americans could only (legally) own a home in much of the US for 50 years. At the very best, that is 2 generations of wealth to accrue, which puts that demographic a good century behind what potentially could have been economically.
50 years would be 1976. Perhaps you're confusing it with the myth about women being legally prohibited from opening bank accounts. (1972 was when sex discrimination by businesses was outlawed at the Federal level, though there was never a law that prohibited a women from having a bank account, not directly, and not indirectly since the 1800s. Some banks discriminated against married women, but unless they lived in a one-bank town there were others that were happy to have their business.)
So 58/59 years if we want an exact date. But a law passed de jure doesn't mean everyone throws their hands up and willingly complies, so the sand will still be shakey for a good decade.
Of course, YMMV per state, so it's not like the Midwest or west coast had the same level of discrimination as the deep south. But that's the line that this policy became federal.
Okay, but like with the banking myth there was no law or official government policy that specifically prohibited black ownership. And the only legally enforceable impediment after the 14th Amendment were racial covenants on private property (drawn up by property owners themselves by private agreement), which became void in 1948 after SCOTUS said it was unconstitutional for courts to enforce racial covenants.
Notwithstanding that they were examples of extra-legal discrimination (in the sense of not being direct legal prohibitions), racial covenants and red lining also didn't just effect black Americans, though nationwide they were disproportionately impacted. I only point that out because most people would say it was incongruous to claim Jews or Polish or Asians were legally prohibited from owning land in many areas.
I think it's an important distinction because there are vestiges of redlining that persist today. First time homeowner mortgage subsidies, the first major stepping stone for building wealth for most people, effectively exclude many kinds of multiunit housing, such as condos and, IIRC until recently, attached housing like duplexes. This disproportionately impacts prospective urban black homeowners, and quite deliberately. Likewise, IIUC prefabbed homes or similar are excluded, which disproportionately impacts poor rural whites and blacks alike. There are legitimate concerns behind those restrictions, such as developer and rental fraud, just as nominally there were legitimate concerns behind redlining, namely sustainability of property valuations. Though in all these cases it's obvious the reason they persist(ed) as-is is for largely discriminatory reasons, as the legitimate substance of the concerns could be addressed. At the same time, we wouldn't say they legally prohibit ownership; if you're wealthy enough they're no impediment at all, just like redlining and covenants were no impediment if you were wealthy enough (racial covenants could be overcome by just buying up all the adjacent property so there was no other property owner to enforce the covenant; the government couldn't by itself enforce such covenants, only adjoining property owner "beneficiaries").
Perhaps counterintuitively, black letter property law was one of the legal areas most resilient to both racial and sex discrimination. The 1800s saw some regression, but that didn't last long, often because courts themselves couldn't tolerate the illogic. People criticize it, but property is indeed sacrosanct to American legal and political culture, and it was very difficult to carve out exceptions that permitted blacks and women to be excluded without threatening the underlying principles of the system that secured owners' rights. That's why prejudiced treatment tended to come in the form of private, regulatory, or extra-legal discrimination, which arguably persists today in the form of restrictive zoning and related development policies which not coincidentally are impediments to free & clear property ownership, just enough to be tolerable to the well-off while disproportionately impacting the real targets.
I don't know why you got downvoted. If you don't believe this, read "Dying of Whiteness" by Jonathan Metzl. Something like 30% of this country will reject quality of life improvements for themselves if they see that it will also benefit people of other races who "don't deserve it".
The entire social structure of the south was (and mostly still is) based on wealthy whites convincing poor whites to accept the situation because blacks are even worse off.
You shouldn't have to believe, because the various poor white guys who died for the south wrote plenty about how their driving motivation was that a black guy having the same social status as them was worse than death.
They literally wanted to kill northerners for daring to make them equal to black people.
Then really shouldn't it be "everything is about money"? After all, it's clear that the actual lie is convincing a big group of people that they don't share a common cause. Racism has many causes, but using it as a divide and conquer tactic has to be one of the most disgusting ones.
Judging by the color of one's skins is one of the easiest and oldest ways to discriminate. Only behind by the contents of one's genetalia. But the latter at least has a biological need to care for one another.
It's a bit of a chicken and egg situation. At least when someone looks at someone who "looks like them" but is poorer, they see "potential" (there's a name for this effect, but I forget). But the end goal is getting theirs first and foremost.
True, but this effect tends to diminish at the highest levels of wealth.
At lower levels you have the “labor aristocracy” effect, which gives the more well-off workers a material stake in racism. And this division is useful to prevent organization.
> the end goal is getting theirs first and foremost
Its also about language and colloquialisms. If you grow up poor, but go to a school with many wealthy children, you will learn to speak the "language" of the wealthy, which is, in my opinion, what mostly explains the "having potential" that the ruling class will see in your as you enter adulthood.
In the US there's an extreme attitude of "I'm not paying for someone else...", and any sort of preventative care, like a heart score test, would fall into that category. This attitude is grounded on the personal responsibility mindset, that every person is responsible for taking care of themselves. So, for the 800K people that had heart attacks, the attitude in the US is largely, "They should've been proactive on their own, gotten the $100 test. Their heart attack is their own fault."
I don’t entirely agree, but it’s not inconsistent. The idea is that government is supposed to protect you from bad guys (criminals or enemy countries) but it’s not their job to protect you from yourself. If somebody wants to shoot you, the government is supposed to stop them. If you want to eat an entire cake for lunch every day, that’s your own business.
> What I've never understood is the weird dichotomy of preventive and reactive governance in the minds of US citizens.
When the underlying economic model of CONSUMPTION = GOOD is viewed as a religion or universal law of nature, it's actually not surprising that people are irrational about this.
Big assumption that the average citizen’s opinion has any effect on what the government spends money on. It’s pretty easy to campaign on not doing X and then proceed to do X once you’ve won the election.
If you keep in mind that the median voter in a primary is 65, then the government we have seems to do a pretty good job of reflecting the opinions of the politically engaged subset of the population.
I’d argue government investments are extremely exposed!
Consider that the majority of Americans do in-fact vote. In doing so, they literally delegate the power of the purse to the representative was most supported in their local community.
Look at the work put into ‘communication’ about those budgets also. In addition to having comptrollers to monitor the auditors or whatever.
The UK Expenses Scandal was funny, but Thatcherism is still doing too much residual harm to laugh about.
Promising x and doing y is a winner-takes-all democracy problem. Coalition governments solve this by sexing-up y as the natural outcome of the public vote. This also makes technocracy easier / more normalized.
Follow the money; lots of wiggle room for fraud and quid pro quo in an emergency
So we have to perpetually live in emergency mode to create liquidity
If we could all just live our lives there would be no reason to shift large sums of capital around for the usual hands to get their cut
Historically post office and social security ran surpluses; boring and predictable. All that was phased out to create the current shit show of a virtual economy for the youth
Sam Altman isn't concerned with efficiency except his own line go up
This is just a longer version of "If we can spend so much on defense, why can't we do X?". The OP is compelling enough in understanding the tradeoffs of medical prevention vs. treatment. No need to rope in your pet peeve du jour.
I won't speak for other countries, but in the US, the answer to "Why do we spend so much on X" is typically because X is in large part a jobs program for special interests who are really good at lobbying, whether it is healthcare or defense or any other industry.
Representatives like high employment in their districts and employees of X like high salaries. It's an incentive-compatible equilibrium.
It's easy to understand. US optimizes for whatever helps with more overall spending. They can print money and export inflation to others. All this new money then goes to the companies that hold power through lobbying.
While I agree the US meddling in the Middle East has caused wars/terrorism, the general US military presence globally is a massive benefit for the entire world. Once the US starts pulling back more (as they seem to want to do) we'll see more and more regional chaos that grows into trade disruptions and wars. Regional tomfoolery like the South China Sea stuff will occur all over the world and will escalate into wars.
> we'll see more and more regional chaos that grows into trade disruptions and wars
Every accusation is a confession, as they say. How can you say this with a straight face given the current situation in Iran lol? They keep pulling the same shit and NPCs keep licking the boots, it's insane...
> "As an example, consider a hypothetical 2-year wellness program that costs $400 per month per person (say, $13 per day for healthy food) and reduces the risk of heart failure by 1 percentage point, from 5% to 4%. For the first 90 days alone, heart failure treatment is much more expensive at $22 000 than the wellness program, but that doesn’t mean that the wellness program saves money. In this case, 100 people must participate in the 2-year program to reduce the incidence of heart failure by 1, from 5 people to 4 people. In other words, the number of people who must be treated with the prevention program to avoid 1 heart failure is 100 (NNT = 100)"
1. Why is the person's food cost attributed to the wellness program, instead of the person's food budget?
2. Most people are overweight or obese. I would expect $400/person/month of healthy food to lead to weight loss as part of the intervention. This skim-read study of 5000 people[1] concludes that "Modest weight losses of 5 to <10% were associated with significant improvements in CVD risk factors at 1 year". The hypothetical uses 1 percentage point, which sounds insignificant.
3. This Novo-Nordisk page[2] says: "According to a post-hoc analysis from the Look AHEAD trial, individuals with type 2 diabetes who lost ≥10% body weight had a 21% decrease in 4-point MACE incidence (defined as CV death, non-fatal acute myocardial infarction, non-fatal stroke, or hospitalisation for angina). A weight loss of 5% has significant health benefits". Again relatively small weight loss shows significant improvements.
(Comparison: someone 300lbs losing weight at 1 lb per week takes eight months to lose ten percent of their bodyweight. Healthy weight loss is often discussed at twice that rate or 2 lbs per week. In the TV show My 600lb Life Dr Nowzaradan gives morbidly obese people targets of 5-10lbs/week initially. The hypothetical wellness program is two years?).
The improvements from healthy diet which leads to weight loss ought to be more than just reduced risk of heart attack. Reducing hypertension (high blood pressure) leads to reduced risk of stroke and chronic kidney disease. Reduced body fat and healthier diet leads to reduced risk of Type 2 Diabetes and its complications (vision loss, neuropathy, slowed wound healing, worse immune function). Reduced weight leads to reduced risk of back pain, knee pain, sleep apnoeia, non-alcoholic fatty liver disease. Reduced body fat leads to reduced risk of some cancers, better diet reduces risk of other cancers. The hypothetical only considers treatment for heart attack in the savings but there should be a lot more savings.
The hypothetical only considers the treatment cost of a heart attack for 90 days but is that all the treatment they need? Are they not on regular drugs and checkups long term? And someone who survives a heart attack is at increased risk of another heart attack from all the same reasons they had the first one. American Heart Association says "about one in five people who have had a heart attack will be readmitted to the hospital for a second one within five years"[3].
And avoiding the prodcutivity loss from all the time off work from heart attack, back pain, sickness, medical appointments and treatments over years and decades. Intervention may not save money, but it may lead to increased ability for the economy to generate more money than it cost.
There's probably a point in that article, but why use such an easily criticised hypothetical to try and make a point? Not even going into $13/day vs 'beans and rice' or saving a person money on takeaway, cigarettes, alcohol, gasoline, or the costs to a person of moving to a walkable area or joining a gym, or all that kind of lifestyle intervention.
In the limit, one would expect that to be the case: at some point the marginal cost curves will intersect. I’m quite surprised that we are already at that point. I suppose more things are at the efficiency frontier than I had imagined.
If something disproportionately affects black people negatively, it has a significant amount of support from certain voters. The whole origin of the anti-abortion movement in the 19th century was double-pronged to displace midwives (who were often minorities) and that too many white women were getting abortions, which was labelled "race suicide" [1].
Need more? Infant mortality skews heavily by a state being red or blue and by the racial makeup [2]. Iowa is a red dot in a sea of blue because it's particularly white. Compare the US to other developed nations [3].
So this particular issue is with heart disease. And guess what? Black people are disproportionately affected and have worse outcomes [4]. Shocking.
Many people have a shallow view that racism is using slurs. It is not. Racism is systemic. And it's not as direct and nefarious as people in a smoke-filled room getting together to try and create worse heart disease outcomes for black people. It's a series of steps taken such that this problem isn't solved. It's just not prioritized.
You see the same thing with medical misogyny and medical racism. Symptoms are downplayed and ignored. This has been thoroughly tested where doctors have been given a file genders changed and there are statistically different outcomes.
I'm too young for medicare, but when I asked my dr. to prescribe the heart scan, he kept stalling. When I followed up, he said my insurance wouldn't pay for it. Then I checked into pricing and it was $130 lol. If I have a family history, why would he assume I didn't want to pay the $130? I later found out that the his medical practice gets penalized by the insurance company for recommending "too many tests." So that plays into it.
If you want a CAC scan you can just go directly to an imaging center that offers it and order it yourself. It doesn't require a prescription. In most cases it won't be covered by insurance for screening purposes.
It varies. At the largest medical provider in my region they stipulate "To self-refer for a Heart Scan, you must be male between the ages of 40-65 or female between the ages of 45-70 and have a qualifying risk factor."
Wow, I would have expected something like this to be $thousand$ but a quick check with AI claims that in the U.S. the self-pay rate is anywhere from $100-$400. Still not cheap, but much more affordable than I expected.
I once tried to get some pills at CVS. I was charged something like $500, and asked for my insurance information. When I told them I had no insurance, they told me to go talk to a person a few meters away so that he can help me... I got the pills for $30.
I am not asserting that it applies in the above instance, but...
In broader medicine, one basis that can lead to the above sort of dynamic is compassionate protocol ("we are losing a little money on this deal, but you are in-need and we're here to help everyone"), as opposed to greed protocol ("we medicos are here for the big insurance money, and only charge the True Low Cost when forced").
And on balance, the nature of the people who choose the occupation of medicine tends towards the former.
A lot of doctors are willing to cut their rates if you're willing to pay cash for the full amount. It's the paperwork that inflates insurance costs. I'm sure AI will cut through that and make it less a problem though. /s
Beware that some providers are in contracts prohibiting them from taking cash payments if they know a patient is covered by the contracting insurance carrier. I don't know the specifics of the business justification for these terms but they do exist.
I've had providers tell me they'd have been happy to charge me less, making less than their insurance reimbursement, but not have to mess w/ billing my insurance, but they were unable because their contract with my insurer did not allow it.
"Paying cash" doesn't mean literally that in this context. Cash, credit card, check... "Paying cash" just means paying directly without involving insurance.
Imaging is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.
- If you made a dietary change (e.g., more fiber and less saturated fat), the tests tell you whether it actually worked.
- Statins are dosed based on the LDL or ApoB reduction you need. The most powerful statins cut cholesterol by 50%, but at higher doses the risk of side effects does go up.
- Other medications like PCSK9 inhibitors and ezetimibe exist, and whether to use them depends on the other numbers. For example, PCSK9 inhibitors have a secondary benefit of lowering Lipoprotein(a), and statins and GLP-1s have a secondary benefit of lowering inflammation.
- If blood pressure, HbA1c, etc is high, then there's a slightly different set of diet advice and a very different set of medications. For example, lowering blood pressure through diet is mostly about reducing sodium and increasing potassium.
Behavioral changes can only do so much to lower ApoB. It is a meaningful marker and may trigger additional workup. It may also signal that you should at least consider a statin.
ApoA is completely out of your control and will not change with behavioral modification.
So, no, you're incorrect that these tests are superfluous and all you need to say is "diet and exercise". Besides, even if that was always the answer to these results, you should still have a baseline to see if behavioral modification is doing anything.
"Why not just skip the HbA1c tests? After all, you know they'll give you insulin. Just start taking it."
Do you think everyone with poor blood test indicators is aware of how unhealthy they are? How quickly they need to reverse course? Or do think there might be some possible validity to discussing your results with an actual doctor and understanding how acute your symptoms actually are? Do you think there are no side effects to statins and everyone should just be on one at all times, forever? Do you think there might be some value, for those patients, in discussing GLP-1s? Or nah, everyone can just like, go run 10 miles tomorrow because some 20 year old in SV said so?
I'm always deeply confused by people who think all medicine is "just repeat whatever ChatGPT said as if it's profound, like, duh - I'm smart and invincible and can't quite figure out that other people aren't me", in spite of them not knowing anything about medicine in the first place.
Because for the same behavior, risks are going to be very different on the other side. In my family, for instance, we need significant interventions to get a reasonable risk due to all the bad genetic factors. In my wife's family, not so much. So knowing how serious the risk seems much better than just handing statins to absolutely everyone.
Its the fundamental problem of our age: everyone is building pieces of a system, and almost no one is actually looking at how those pieces fit together into a system.
This is not about (just) the healthcare system ... it's the core problem with:
- our legal system (millions of laws and rulings and zero effort spent reconciling them into a good system that treats everyone equally)
- our economic system (we reward people who create true wealth in many different ways ... but those rewards are wildly disproportionate to how much true wealth they add)
- our tax system (again, millions of laws, and yet the people who should be paying the most pay the least because of how they fit together)
- our electrical system (although, due to its centralization, this one is actually catching up much faster than the rest)
Individual people claiming to have a superior Big Picture for humanity is basically what big politicians are. We assign them, then give them 3-4 years to remake the world in their vision.
And once we have a few dozen of them in a room together, it's the recipe for endless passionate arguments about exactly what Truth is, and what Value is, and what Goodness is, about anything and everything.
One of the biggest challenges is that rules are set by experience, but every new rule is also the start of a new story we've never read (called 'The Future'). And humanity changes pretty fast!
The argument made in the article seems inarguable, but I don't see how a coronary artery calcium score is going to prevent a heart attack. You gotta do statins, exercise, and eat right basically no matter what. FWIW I had a coronary artery calcium score ordered by my doctor at my last checkup. It was $120.
I assume they mean.. have the test and then act upon it with diet/exercise/medicine to prevent the heart attack
If you never had the test, maybe you don't know you are at risk and don't make any changes and then you get the heart attack
It’s also not just a “treat or not” decision. I have a family history and high test results so was already treating on the assumption I’m high-risk, but the scan revealed that we needed to be more aggressive. (And hopefully in a few years a scan will show we’re reversing the progression.) Personal data is always better than population data for treatment decisions.
I have been disabled on medicare for 23 years. I have often told my doctors that if they spent the time and money to look at my biology more closely it would have saved the tax payers so much money from medicare and likability payments.
Health care is actually sick care.
I obviously have a genetic condition because it runs through my mothers side of my family, but they refuse to look at my genetics. So, did. I found things. I begged a researcher to test me for a special sort of immune deficiency (ADA Deficiency) . The tests shows I have a partial immune deficiency. I showed it to my doctor and nothing.
When my condition flares up (Too mush ATP and GTP) it effects my brain and nervous sytem and I have to be institutionalized. Five times now. I keep telling them my mood problem is caused by an immune deficiency but now one cares.
Insurance, and I presume Medicare in particuar, will generally only pay for the standard of care. They don't care about you as a unique patient, you are instead an average one.
'Preventing a heart attack' means taking life long medication to reduce the absolute risk of heart attack by about 1%, which is worth doing, but complicates the maths a little bit. The scan doesn't magically eliminate heart attack risk
Sources? That 1% number is in my understanding wildly incorrect for statins, if that's what you're referring to. Are you comparing use of statins for people who already are low risk for heart attack over the next 10 years?
Insurance was invented to pay for emergencies. Your home insurance doesn't pay to perform routine maintenance on your roof, but neither will it pay to repair "normal" wear and tear. Your home insurance pays when a tree falls on your roof.
Our healthcare system has co-evolved with insurance in a sort of partial free-market, partial heavily regulated environment. Arguably we get the worse parts of both: Kafka-esque beaurocratic mazes and shareholder value optimization for private firms.
There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
Can the invisible hand do this when providers are offering mainly treatments with token preventative care visits thrown in?
>There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
You're criticizing health insurance but payers are far more incentive-aligned with patients on lowering total cost of care than the providers. They carry the risk and have to pay out claims. Providers, on the other hand, have an incentive to provide lots of expensive reactive care that's bound to expensive labor.
I agree with the sentiment of your "only for emergencies" point and wish direct care was more affordable. The problem is providers charge insanely high rates for services because a) they can get payers to cover it, and b) they're covering the cost of labor that's getting increasingly expensive with no commensurate increase in productivity [0].
For prices to come down substantially in the US, we'd need a much greater supply of doctors or more automated care. The former is against the financial interests of current doctors and the latter is an uphill battle against FDA regs, state medical boards, and billing codes from CMS to make it reimbursable.
Payers are bound by law to spend at least 80% of premiums on healthcare. So if they can drive up healthcare costs across the board, they can profit more (by taking the same 20% of a bigger pie).
Yeah MLRs removed an incentive for payers to fight long run rate increases as long as they can model the risk effectively and pass on the cost to members via premiums, but they still tend to fight rapid increases because they break their models and retroactively misprice existing plans. Otherwise we wouldn't see contentious contracted rate negotiations between commercial insurers and providers, but we do.
Absolutely not here to praise US health insurance companies, but they're not the ones using regional leverage to negotiate higher rates - that's the providers.
> There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
Value-based care, e.g. Medicare Advantage.
The idea is that the government gives you $X for the care of a patient, with multipliers on risk factors. The government's goal is for that to be basically exactly what care costs. The provider is incentivized to treat you for less. Which sounds perverse, but if they, for instance, deny all care, a patient will end up in the hospital and cost exponentially more than they would have through proper preventive care. It is not perfect, and it should be broader, but it is a strong optimizer for providing the right care to keep a patient healthy, without providing hundreds of unnecessary tests (and especially imaging) that are medically unnecessary.
It is absolutely a system that should be rolling out to more and more patients.
Value-based care is a good idea in general in terms of better aligning provider incentives with patient best interests and controlling costs. But it doesn't necessarily equate with Medicare Advantage. Many MA health plans still operate largely on a fee-for-service basis with perhaps some minor VBC aspects.
I agree with the concept and idea expressed; paying for prevention is good and wise and we do far to little of it.
I don't like the title. I can't believe it is really $100. Even if the scan is $100 that doesn't fix things itself. There is the cost of whatever the treatment is etc. There are likely added expense from false positives (or similar idea), where it flags someone as needing more testing, new interventions when in fact they didn't...
I wish the article was more detailed on those costs (or at least not claim the cost is $100 when it is much more in reality, unless I am wrong about that and the fixes are free somehow). It feels like a biased promotion of this thing we like and/or have a financial interest in so lets make exaggerated claims that hopefully people won't notice.
It is $100 if nothing is wrong. If something is found correcting it is cheaper than a heart attack. Statins are not expensive and knowing how bad things are leads to how aggressive you perscribe them.
Certainly it seems likely treating it for those instances where a heart attack would result is cheaper.
But there is no evidence presented that say for every 1,000 of these test we correctly find 1 that wouldn't have been found (and we have zero false positives) or whatever. So then 1,000 * 100 = $100,000 and saves $50,000. Even in this case there are benefits beyond the expenditures (if you save someone from the $50,000 you probably give higher quality of life...).
Basically my issue is not with the idea that more testing and preventative action would improve our current system. I believe that.
But in order to make that argument in a specific case you need more complete data. Things get complicated so I understand why people don't want to do that for a simple story. But the problem is when you leave off all sorts of costs, issues (false positives, treatment options), etc. the statements you make are not very compelling to those that know a test that tells you something bad is more likely for this person is not nearly sufficient to claim why this test is good.
((aka Present Responsibility Vs. Future Response))
"An ounce of Prevention is worth a pound of Cure" (as the old expression goes...)
Observation: Most health insurance policies today, whether they are government or private corporation, national or regional, are based on the idea of paying for medical/health problems AFTER the onset of the health problem...
Prevention, preventative health, preventative medicine, and preventative programs -- would not only do a lot to preempt future health problems, but it would also save a ton of money (a ton of taxpayer money if the health insurance is a government sponsored one), as the above article so eloquently makes clear!
Observation: Some insurance policies do include some preventative health aspects -- but as medicine is complex and there are always new discoveries, there is always another step up, another higher level in what could be delivered...
In other words, these could always be improved...
"An ounce of Prevention is worth a pound of Cure" (as the article implicitly suggests...)
>Observation: Most health insurance policies today, whether they are government or private corporation, national or regional, are based on the idea of paying for medical/health problems AFTER the onset of the health problem...
There's a lot wrong with health insurance in the US but this problem is largely on providers, not payers.
Insurance claims submitted by providers are effectively itemized using standardized Current Procedural Terminology (CPT) codes. Those codes are written by the American Medical Association (AMA), the lobbying group for physicians. Doctors make more money when services are expensive and require a doctor to be involved. As a result, reimbursable services tend to be reactive (i.e. more lucrative), rates have a tendency to go up, and CPT codes tend to favor reimbursing for physician time rather than patient outcomes.
In fact, there's a whole category of preventive health companies (e.g. Virta) that sell to insurers because the insurance companies bear the financial risk and benefit from a healthier member base. Insurers will pay for these programs on their members' behalf and try to get them to enroll so they don't have more expensive problems later. Providers make a lot less money when prevention works.
I don't think it's some grand conspiracy by evil doctors, just incentives gradually reinforcing bad patterns at scale.
You need to decouple care from labor as much as possible or you'll just end up trading off between cost and quality without meaningfully moving the frontier.
Healthcare in the US is mostly gated on physician labor. Physician labor is scarce. Scarce labor is expensive.
Physician labor shows negligible productivity growth over time. Wages have to increase to compete for labor against high productivity growth sectors (e.g. software). On top of that, institutionally managed bottlenecks on labor supply prop up high wages (e.g. limited residency slots artificially constrain the number of doctors entering the market). Training more doctors would supposedly compromise patient safety because it would mean lowering the bar for admissions and straining existing staff that need to train them. Even if you could admit and train them all, supplying enough doctors to meet market demand would cause a wage collapse breaking the ROI of med school expenses. So the labor is not going to get cheaper.
So care requires labor that's expensive and only getting more expensive. If you want to reduce the cost of care without reducing the cost of labor, you need to deliver more care per labor-hour (i.e. get more efficient). Provider orgs that employ doctors try to boost efficiency by squeezing every last ounce of time and energy out of their doctors and booking impossibly full schedules. They have a strong incentive to make this work, yet the doctors get only marginally more efficient (and way more burnt out).
To meaningfully move the cost/quality frontier, the majority of care cannot be handled by a human.
8VC laid out a vision [0] that I strongly recommend reading and mostly endorse. It's a long series of hard technical problems but I think the harder problem is actually winning over the institutional gatekeepers (FDA, state medical boards, CMS, AMA). I can't tell exactly what doctors are supposed to do in this envisioned future but the answer will have to be something that sways the gatekeepers even if it's not what's best for patients.
Hopefully future healthcare policy makers (both in the public and private sector) will read them, and get some good advice from them...
>"Training more doctors would supposedly compromise patient safety because it would mean lowering the bar for admissions and straining existing staff that need to train them. Even if you could admit and train them all, supplying enough doctors to meet market demand would cause a wage collapse breaking the ROI of med school expenses."
There seems to be a vicious circle in place between too much medical regulation requiring a corresponding amount of long and expensive education, and the high cost of medical education in general...
Which one is cause and which one is effect I do not know...
It would seem to the casual observer, that both aspects might feed into one another...
One thing I do know is that doctors from foreign countries, especially if they are third-world countries, typically have had to pay less, sometimes a whole lot less, for their medical education, compared to their U.S. counterparts...
Is that medical education as good as a U.S. medical education? Well, I don't know! Maybe it is in some cases, maybe it isn't in others...
What is known though is that foreign medical educations frequently cost less, sometimes a whole lot less -- than their U.S. counterparts...
Is hiring foreign doctors the solution or part of the solution?
I don't know that either, but I do know that there are a lot of foreign doctors (and previously foreign doctors before becoming U.S. Citizens) in the U.S., and certainly many more abroad...
Is AI the solution, or part of the solution?
It's definitely a wildcard with promise at this point; it'll be interesting to see where it goes in the future...
Anyway, you make some excellent points!
Hopefully future policy makers will read them and act on them...
Tangentially related: I'm about to turn 65 and would be punished if I continued to pay for my own healthcare. My Obamacare/ACA insurance here in the state of Washington costs me $70K/year with premiums, deductibles, meds, etc. That's just for me and my wife.
And you know what? It's totally worth it to me. This year I had 4 operations+10 ER visits and my wife had 3 brain surgeries+radiation and 2 ER visits. About $2 million worth of treatments, quite good care overall. So I'm willing to continue paying for private insurance. I am fortunate I can pay for it and would like not to make you good folks pay for it.
But Medicare won't let me without penalizing me permanently more an additional 10% for every year I don't go on Medicare. Luckily Washington has phenomenal Medicare. But it would be nice if I weren't punished for trying not to be a burden to the dwindling population of taxpayers.
Same insurance company denied authorization for CAC twice; once bc I wasn't sick enough and once bc I was too sick (ie, just start taking a statin). All this happened in the last year.
I paid for it after the second denial. CAC = 175
All after the same Dr. told me my heart had "extra protection" every year since 2009.
I have a hypothesis, from my own interactions with sports medicine/healthcare, that medical tests which are in-line with more expensive and specialized procedures performed within the same medical group/hospital are easier to get and cost less.
Medicare could be paying younger people to do the things necessary to prevent them from encountering the healthcare system later on in life. Really, if you're only going to cover part of the population based on age, you should want to cover the part of the population that 1) still produces economic output and 2) has fewer and less-expensive medical needs.
I got one covered by Cigna a few months ago. I said I had a mild chest pain and they did it plus some bloodwork. Nothing turned up but I didn’t have to pay anything extra.
I really can't believe there's anyone left who thinks deregulation solves anything. Everywhere it's tried it is a demonstrable failure. It's just an excuse for an uptick in profits at the expense of safety, the environment, etc.
Safety regulations are written in blood. They exist because people died because the industries could not and cannot be trusted to regulate themselves.
The most generous interpretation is that people conflate regulation with rent-seeking. These are two entirely different things.
>Safety regulations are written in blood. They exist because people died because the industries could not and cannot be trusted to regulate themselves.
This sort of absolutist rhetoric is why people waste so much time arguing against maximal regulation and zero regulation in the abstract, neither of which is actually popular or sane.
Many regulations are good, necessary, and effective. Many of them are short sighted, over-specified, or written by lobbyists against citizens' interests (shouting that rent-seeking and safety regs are mutually exclusive doesn't make it so).
And of course the people writing things in blood are always intelligent, well informed people making strictly rational, unbiased decisions which perfectly balance the needs of all in perpetuity.
You're really missing the point. There are no regulations preventing anyone from ordering a CAC screening study if they want it. You can pay out of pocket and get it at any imaging center.
Obviously the regulations regarding ionizing radiation exposure still have to be followed as with any x-ray procedure. No one has seriously proposed deregulation on that.
The sort of food people are going for doesn’t even exist in the natural environment. Good luck finding so much refined sugar in one place or processed fat. Never mind the various preservatives that play the cognitive dissonance game of being a hostile environment for foreign microbiota but hopefully don’t do anything untoward to your own gut microbiota.
It isn’t just playing our systems, but hacking them and giving them inputs they would never usually see for far stronger effects than would be possible.
I guarantee the Unhealthy Snack Industry has their top scientists hard at work trying to find some kind of formula to make people on GLP-1 drugs go back to craving the soda and doritos.
They already do that. Zero calorie sodas on grocery shelves now that specifically advertise they have supplemented them with protein, which glp-1 users seek much like a vampire to blood.
The most tenuous of the health concious vc efforts are the nonaloholic beers though. They are eating their own industry. Bars and beer industry does not exist off people getting 2 drinks and going home. They depend on the whales who drink 10+ beers in a sitting who subsidize all the 2 drink and goers. Alcoholics make bars and the beer industry work. It is an open secret. No one is going to buy a 12 rack of Athletic NA Beer and drink the entire thing in front of the bears on tv. No one is ripping a 6 pack of athletic in the parking lot before they go into work. Bars aren’t going to be able to stay open with everyone buying just 1-2 $12 Athletic pints.
If you thought that was bad you have all sorts of drugs that affect libido negatively. In evolutionary terms that’s as good as a poison pill, reproductive fitness of zero.
They'll use flawed research to claim diet and exercise don't work for obesity, then the general public uses that research and claims, "Diet doesn't work for fat people."
Soon, everyone is convinced every guy with a trivial amount of weight to lose needs to be on GLP-1s.
This is always the most boring part of any health thread. Both sides of this have airtight arguments. The diet/exercise people will talk about thermodynamics, and the "it's more complicated" people will talk about epidemiology and the fact that "diet/exercise" hasn't worked as a population-level intervention at any point in modern memory. It's a classic axioms vs. empirics battle and it will never go anywhere useful.
Ok but if they acknowledge it's an addiction, that's still a medical issue requiring treatment. Maybe that means going to food addiction anonymous meetings but if GLP-1 is like methadone for food, why not do it?
GLP-1 will prevent you from eating so much, but it won't make you eat healthy. You can and likely will still fill yourself up on junk, and will deal with the risks associated with that. Albeit it won't be enough to make you fat, but that's only one slice of health.
Learning to control your diet solves both problems.
I'd also argue there's a lot of value in learning to not be dependent on medication to control your behavior, because it's not available in most situations.
You can't take an exercise pill.
You can't take a career success pill.
You can't take a "hard, but necessary conversation with my partner" pill.
Those all require you to consistently do things you at times don't want to do, just like avoiding junk food.
If you are in a place where you truly can't control your habits then of course GLP-1s are an amazing tool. However, if you don't adjust your life-style you will relapse when you get off, so the real solution is to adjust your life style. Also, there are benefits to exercise that aren't connected to losing weight. In my experience, 100% of the people I know on GLP-1 drugs are not exercising. I'm sure I'll get 1000 responses of people who do, but in my experience they don't. So you put yourself in a position where you're not addressing the actual problem, you are on a drug for life, and you aren't being healthy in other capacities. Are there times where these drugs make sense? Yes. Of course. Spare me the lecture. Everyone I know on these drugs are middle class people who absolutely could be healthy but don't want to put in any work.
Thats like saying running the car does little for gas burning because you can fill up in 5 mins.
You have to actually kick your ass when you exercise. Most people don’t push that hard. Michael phelps ate what 6k calories a day or something crazy to maintain his prime form with the amount of caloric burn he was doing in training. If he continued to eat like he did in those crazy olypmpian training years, he’d be morbidly obese. If he ate like he does now in those years, he’d starve.
I think the "you can fill up in 5 mins" analogy is apt and reasonable, actually.
For the average person it's much harder to exercise out of a bad diet than just change the diet. I think it's an easier "sell" for most people to start off trying to eat less than to keep eating the same way and jump right into "kick your ass"-level exercise.
The killer with exercise is that it makes you hungry, proportionally to how hard you worked out.
It's a real killer for "calorie blind" people to go on a 750 calorie hike, and then stop by for a "treat" on the way home. That treat being a 500 calorie blueberry muffin with 200 calories of butter on it. Then they go home and have dinner.
Diet and exercise tells people what to do, but not how to do it.
Knowing that you should do something, doesn't necessarily mean can do it. There's still the question of exactly how.
E.g., diet is heavily influenced by hormones/hormonal cycles and access to quality food choices, which vary significantly between people. The glp1s available now are a big help with the hormonal part of this, but they are not within reach of a large proportion of people.
> To me this is just subconscious denial/defending of their food addiction.
If you have to make up unobservable phenomena to explain plainly visible facts, it's usually a sign to look for a different overall model.
I can't think of another thing that is called addiction yet requires this very specific wording. Can you give me another example of something that is required for life, but too much is called an addiction?
It's something I've read a few times. Most of the studies I've seen say it's effect is modest at best. At least if it was a drug there wouldn't be enough evidence for it to get FDA approval (especially with all the "side effects" such as injury)
Arguably this is a limitation on how the studies were done, as nobody is going to pay for extensive studies since you can't patent exercise.
The studies can’t really prescribe very intensive excerise either. I mean they have to take people where they are. They might have them on a treadmill for a 30 min walk and call that the excerise component of the study. No one is making them squat heavy to failure or clean and press anything. No one is running them on the track until they puke.
Bodies are all different. Diet and exercise can work for one person and not another. But the type of person who wants to believe all fat people are slothful, all unemployed people are lazy, and so on, will invent in bad faith the straw man argument that we think diet and exercise do not work at all. They're not worth engaging with.
According to the nasty, nasty fights I've had with people about this topic there are, apparently, some people whose bodies are actually perpetual motion machines and I'm various kinds of insensitive for even bringing-up physics as it relates to weight. >sigh<
A $100 test for an existing condition is NOT what prevention is. The issue is already there.
I expected an article on actual prevention, but I suppose it'd unthinkable to consider not eating trash and moving oneself in any other way than by motor vehicle.
It’s only $100 without insurance. Hospitals charge about $2500-$4000 when it’s “covered”. I know from personal experience just getting one and the hospital erroneously filed it as covered originally.
> The CAC scan, which detects calcified plaque in the arteries, is recommended for adults with borderline or intermediate risk of coronary disease for whom the decision to start preventive therapy such as statin drugs remains uncertain.
That is such incredibly bad advice. DO NOT WAIT until a CAC tells you to start a statin. You know you need to start if your LDL is high right away.
My doctor referred me to get a self pay ($100 at the time) CAC 9 years ago. It was completely clear.
However last year I had a cardiac ultrasound and it showed calcification.
In reality the CAC caused a false sense of security. My LDL had been high the whole time and not managed with any intervention despite having been tested multiple times and showing high over that time. This was a failure by my doctors IMO. (No it’s not diet or weight related before people give advice).
I didn’t need a CAC to tell me everything was fine. I needed to be on a low dose of statin that whole time.
A clear CAC doesn’t mean you are safe. And a positive CAC is already too late and is not really telling you anything useful.
What people need to do is just watch your LDL regularly starting from any age (yes even some 20 year olds need to check this). Don’t wait to middle age. And no matter your age use whatever methods you prefer to get that down as low as possible. Think of it as cumulative exposure over time that matters.
(There are new oral PCKS9 inhibitors out now which is cool, but the reality is all the misinformation about statins has been bullshit, don’t be afraid of them.)
And a CAC somehow magically prevents a heart attack?
In borderline cases it can tip the scale to prescribe statin rather than not. But telling you what has happened to your heart doesn't prevent heart attacks.
This is the ultimate case for AI. Intelligence is partly scored based on predictions/planning, so if AI is really intelligent it should be able to tell what remediations are worth it and then lower your insurance cost based on following its recommendations. and back it up by backing those premiums itself.
Home insurance can benefit from this too. I just got a quote on a property i looked at with a $20k/yr premium, partly because of being in CA with a slope and age of the property.
At $20k/yr, there should be some economic way of an insurance company essentially saying "instead of $20k a year in premiums, here is a $300,000 30 year loan to do preventive measures on the property, and if you do them, your policy will drop to a more normal $3k/yr" or something along those lines.
I think author of the article doesnt understand how America works. Its not about helping the public its about money, just look at the numbers in the title.
I'm interested in this intersection of technical problems where we already have the tech to solve it, but the bottlenecks are social/legal/financial incentive.
Recently there was an old lady in the family that had an appendicitis, an ambulance rejected her, and the next day it got worse, and at that point she was accepted, but it was a bit too late.
One hypothesis is that triaging is hard and there's a lot of demand so things only go in when it's bad enough (considering there was medical insurance, they aren't charging per patient, so there's no incentive to take on more patients). But if that were the case, then preventive measures would actually reduce the total burden on their system.
The more cynical hypothesis that I'm holidng is that that health system is maximizing for work, if there's 10 appendicitis per month, and they are all handled in time, that's maybe like 5 hours of billable hours per patient? But if the appendicitis becomes bad enough and there's a puncture, then you have infections, complications, the patients have to stay for weeks and often come back for checkups, we are looking at maybe 100 billable hours? So the financial incentive is there.
In that sense what I want to add is that the title would be completely wrong, the solution is not for the hospital to pay 100$ for prevention, but for prevention to be more accurately priced, we should be paying 50k, and maybe even 100k for prevention, because we value it more than emergency action.
In a broader economic sense, there's a lot of cases where there's a huge difference between the cost and the value, Shkreli got a lot of heat for surging up medicine prices, but I don't think it's immediately obvious that something should be valued in proportion to what it costs. Maybe if we price heart prevention at 100K, there would be more incentive for everyone involved to just get a fucking pill to those in need, imagine how many people would jump at that opportunity to make it happen, call centers, bureocrats, NOC support, legal teams, all dedicated to making sure a pill gets to the patient before a heart attack does.
Nobody likes to say this out loud, but because the US healthcare system is largely based on “fee for service” billing, it is true by definition that the sicker the patients are, the more profit the providers make. So incentives for actually making people healthier have to be imposed in indirect ways.
There are some pockets of “per capita” payment, where the provider gets a fixed amount per person and is thus encouraged to reduce treatment costs, which indirectly should encourage preventative care, but also encourages just refusing to treat people.
We could remove these weird constraints by making health care a government service rather than a highly contorted pseudo-market, but that would not be the American way. It has to at least look like a market, even if it’s an ineffective, inefficient, opaque, corrupt one.
> We could remove these weird constraints by making health care a government service rather than a highly contorted pseudo-market, but that would not be the American way. It has to at least look like a market, even if it’s an ineffective, inefficient, opaque, corrupt one.
It is still a market (and a single-payer one, ultimately) in these places, but it is not a government service. It is the best solution: the government funds the appropriate cost of care, the provider group is financially responsible for meeting it, and they are incentivized directly to get it right.
The left needs to stop shrieking about Medicare-for-all and the right needs to stop pretending like it can even spell healthcare. There are good solutions.
> but also encourages just refusing to treat people.
It categorically does not. It would be foolish to do so.
>It categorically does not. It would be foolish to do so.
Foolish hardly implies categorically false. It's a well-documented incentive for other risk-bearing entities (see insurance claim denials). Why are providers under capitated contracts categorically immune to refusing treatment to protect margins?
The Medicare “star system” attempts to compensate for this, but somewhat perversely by giving higher reimbursement rates to providers with higher quality. Logically, they should be getting lower rates because they’re more efficient at providing the service. But because the only real incentive is their profit margin, it has to be that way. And of course the star system definitions end up being a constant target of lobbying and stat-gaming.
IIRC this gets gamed by patterns like refusing to readmit patients following complications to hack low readmission rates and preserve higher reimbursement rates? Feels like so much in healthcare where you have a well-intentioned patch trying to solve deep incentive alignment issues and creating more problems.
Completely agree with your characterization of the current system but why does making healthcare a government service necessarily lead to better outcomes vs current state or a more sensibly constrained market?
Seems obviously right in terms of total cost to the median patient (less obvious for individuals in higher tax brackets), so I'm not disputing that. More curious about incentives to improve care delivery for better long-term outcomes.
Healthcare as a government service is one approach to the actual goal, which is healthcare that maximizes the quality of life and productivity of the citizens, rather than maximizing the profits of the providers.
When goods are discretionary and there are no externalities, it’s fine to have a purely autonomous market solution. Healthcare fits neither of those criteria. There’s a reason we don’t (or at least shouldn’t) have private subscription markets for baseline levels of law enforcement, fire prevention, public transit, food and drug quality enforcement, etc. etc. That same reasoning applies to healthcare.
Capitated reimbursement is a hybrid approach that helps a bit, but you can see from Medicare Advantage how the private sector relentlessly games the system because that’s how the incentive is inherently set up by the for-profit nature of the providers.
Yeah capitated reimbursement moves the risk but doesn't seem to effectively encourage innovation on care delivery when it's relatively easy to just cut costs at patients' expense because they have no agency and meaningful recourse.
Your criteria for when a market is (not) a good solution seem reasonable. My biggest concern is there's a fundamental problem with scaling labor-driven services that's exacerbated by entrenched interests constraining the labor supply to support wage growth. Care delivery needs to change if you want to fix both cost and quality, and I have a hard time imagining monumental changes to care delivery from a government service. Care will be expensive as long as it's constrained by scarce labor. That means either costs will balloon at the taxpayers' expense, service quality will decline to cut costs, or more likely both.
The way you fix that is either a) dramatically increasing the supply of qualified clinicians, or b) automation. Clinicians don't want more clinicians because it lowers their wages, so it will be fought at every level in the name of patient safety. But they also don't want automation to decouple care from their labor, so automation, too, will be fought at every level in the name of patient safety.
Most of this is opaque to voters who are largely under the impression that it's all health insurance executive greed, so there's not much of a political incentive to impose meaningful changes.
I don't quite get the difference, patients pay a fixed amount for insurance, hospitals charge "fee for service" to the insurance. Both systems coexist, it's not one or the other.
To be clear, I'm not suggesting changing the whole system, I think that's infantile sorry to be blunt, I'm proposing a more down to earth (and commercially appealing approach) of increasing the price (and thus financial incentives) of medical goods that have low cost but high health values.
My economic theory clearly isn't as strong, because how much should a CT scan and a pill be priced at relative to a heart attack response with a 1 week hospitalization and a bunch of work. Because the cost of a CT scan and a pill is low (100$), the value of it is high (50K$ lower bound), and the cost of treating a heart attack is clearly around 50K$, but the value of it is clearly lower than the preventive treatment (perhaps stochastically adjusted).
So should we be pricing by cost or pricing by value? The naïve approach is pricing by cost, so that everything is cheap, the first issue with this approach is that it disincentivizes research, which is why legal systems widely recognize patents, copyright and intellectual property.
I looked into Shkreli's case a bit deeper, and he was a stupid kid of course, but it's what comes to mind when thinking of 'raising prices' of medicine, there's not many faces to that idea.
That said, I'm not saying that prices SHOULD be hiked, just that I'm not convinced that medicine pricing should be cost based, or that it should be value based, or that some supply-and-demand principle would magically find a value in the middle. I'm just saying that it can be either way, and I just don't know which way it ought to be.
And ultimately, it's a decision that every actor in the industry can make, what they price their products and time at. And to reiterate my thesis, pricing your product as cheaply as possible might counterintuitively reduce it's impact, since there is no incentive for intermediaries (or even yourself) to work on it. So I'm not saying that prices should be maximalized either, just that the relationship between price and value contributed to society is not linear, if you price your medicine at 0, you go bankrupt, that's not helpful obviously, and evidently pricing a CT scan and a heart attack pill at 100$ is not cutting it either, hike that up.
>I don't quite get the difference, patients pay a fixed amount for insurance, hospitals charge "fee for service" to the insurance. Both systems coexist, it's not one or the other.
I think their reference to "per capita" here is referring to a capitated payment structure where a provider organization is given a fixed amount per patient up front instead of billing for every service they provide. The software analog would be something like a flat subscription fee vs usage-based billing. While it's not the default in the US, it theoretically encourages providers to provide cost-effective care rather than just racking up bills on unhealthy patients.
The mechanism here is who bears the financial risk. The model you're familiar with is one where the payer (commercial insurance or medicare/medicaid) is the risk-bearing entity. They want more cost-effective care so they can protect their margins while the provider is incentivized to push a high volume of expensive care so they can boost their margins. Don't have it handy but the data on this shows providers are winning this battle with healthier, growing margins vs insurance companies whose margins generally aren't great.
Insurance companies generally have regulated profit margins. Healthcare providers don’t. However, note that this is all percentages — if the total cost of healthcare goes up, providers and insurance companies both win in absolute dollar terms.
Yeah absolutely re regulated profit margins (indirectly through MLRs - their actual margins are way below the cap due to expenses) but that only reinforces my point that providers are having more success growing their margins (on a relative basis, anyway).
Great point on bigger pie increasing both shares. I didn't mean to imply it's zero sum.
Oh the irony of MLRs encouraging insurers to provide terrible service (opex recovery boosts profits) and let providers push fees ever upward (bigger pie, bigger premiums, bigger net profit on constrained margin).
There are a lot of misaligned incentives in the US healthcare system, but Medicare and Medicaid health plans generally offer similar preventive care benefits as commercial plans.
Rugged Individualism. The Hero's Journey. Jesus Christ. The ethos of the one weird man and the one weird trick. None of these have anything to do with prevention. The myths of the western world are all about story arcs: conflict + resolution. And this is very much embedded in any venture, whether private-sector or public-sector. We much prefer to read the harrowing article of a poor brave man saving someone from a ridiculous dangerous situation than preventing it to begin with.
This truism, "an ounce of prevention is worth a pound of cure", is so true...that like so many truism, it has become a minor, persistent annoyance of thought. It can be safely filed away with the Austrian school of economics.
Scripps cardiologist Eric Topol (not commenting on this article): "That's wrong. The CAC is anything but definitive. Many patients are told they have significant coronary artery disease by calcium score and it turns out, by CT angiography or cardiac catheterization, they have normal arteries. No less anxiety (often chronic and severe) and unnecessary procedures that are induced by false positive CACs." https://x.com/EricTopol/status/2092682606815117763
Coronary calcium scans quantify calcified atherosclerotic plaque but cannot reliably distinguish stable plaques from rupture-prone plaques or detect noncalcified plaques, some of which may be particularly vulnerable.
https://www.ahajournals.org/doi/pdf/10.1161/JAHA.118.008564
https://www.jacc.org/doi/10.1016/j.jcmg.2017.03.005
https://www.atherosclerosis-journal.com/article/S0021-9150(1...
Eric Topol has some opinions. Some other cardiologists disagree. There probably is value in CAC for at least a subset of patients.
In the messy real world of medicine there are hardly any definitive screening tests or imaging studies. Everything will have some false positives and false negatives, or even if the output is physiologically accurate it may not be practically useful in improving patient outcomes. For screening tests we also have to weigh the costs versus benefits in terms of the number of procedures performed or dollars spent to save a life; if the numbers are too high then those scarce resources should be expended on other healthcare services.
For broad screening coverage by most health plans the key next step is an evaluation by the U.S. Preventive Services Task Force. This process is already underway but it takes a while for them to evaluate all the evidence and make a decision. For Medicare coverage there is a separate coverage determination process.
https://www.uspreventiveservicestaskforce.org/uspstf/
https://www.cms.gov/medicare/coverage/determination-process
On a similar personal note, I had a half-year health scare that ended just today.
In May, they told me on ultrasound that my dilated aortic root has grown by more than 2 mm in the last year and that if the progression does not stop, an operation will sooner or later be necessary.
I got a referral to magnetic resonance and had to wait for it until October. Was there last week, nervous. Today I got the result: compared to the MR from 2021, there is no progression at all. The same 44 mm as then. The ultrasound was just not as precisely done, or the doctor measured it slightly askew or what.
Ooof.
Sorry to inject whatever uncertainty this produces, but how do you know that the most recent "no growth" reading is the correct one? To me your story justifies at least 1 or 2 more regular scans.
I was told by the cardiologist who ordered both scans that MR results are very precise, while ultrasound is more of an "orientation scan" and small variations in how the doctor holds the probe and interprets the picture can add up to milimeters of difference. If there is a discrepancy, MR is the gold standard for decisions about treatment.
This was at IKEM in Prague, one of the best cardio units around, so I trust their judgment.
https://www.ikem.cz/en/
What I've never understood is the weird dichotomy of preventive and reactive governance in the minds of US citizens.
We're willing to spend god knows what shooting rounds that cost entire mortgages to save miltary lives and project a presence of power to deter acts of terror/war, but then are also totally fine having people way as much as 4 or 5 people, eating several days worth of sugar for breakfast, smoking tobacco, putting 3 cups of coffee in a can we drink 4 or five of in a day, do next to nothing to adress recidivism of all classes of criminal, drag our feet kicking and screaming in to a semblance of modernity in worker protections...
In some ways, US healthcare is already very aggressive for some forms of preventive medicine. Compare the colon cancer protocols across the world. Basically nobody else is recommending colonoscopies to the entire population with no cheaper tests, but that's the standard of care in the US. It's not free to receive, and it's expensive in general, but for some reason in the US it is standard, instead of starting with non-invasive tests.
And yes, regarding smoking, the US has had one of the most effective preventive actions in the world. Compare actual numbers of smokers in the US vs, say, Spain, France or Turkey. So it's not anywhere near as clear cut as what you are trying to make it sound.
Walk into a US gastro with a hang nail and you'll walk out with a colonoscopy requisition.
They make money on the procedure, not the office hours. And they write the standards of care.
That being said, my father delayed a screening, developed colon cancer, and now no longer has a colon. Would cheaper / higher compliance tests have caught it sooner? Hard to say.
That's not entirely true. For screening procedures it's mainly the USPTF that writes the standards. They take inputs from the gastroenterology community but the process is more holistic.
https://www.uspreventiveservicestaskforce.org/uspstf/
Insurance is mandated to pay for preventive colonoscopies with no patient responsibility. No coinsurance, no copay, no deductible.
https://www.cancer.org/cancer/types/colon-rectal-cancer/dete...
> The Affordable Care Act (ACA) requires both private insurers and Medicare to cover the costs of all colorectal cancer screening tests that are recommended by the United States Preventive Services Task Force (USPSTF). The law stipulates that there should be no out-of-pocket costs for patients, such as co-pays or deductibles, for these screening tests.
Smoking ironically saves in medical costs because people die before getting into real expensive age related care, and also smoking disqualifies you from a large number of medical procedures that would otherwise be given. Keeping a relatively healthy 90 year old alive for 2 more years costs significantly more than keeping an unhealthy 60 year old smoker alive 10 more years before they have a heart attack or stroke.
How do you figure? I know several smokers who are now over 60 who had gotten lung cancer, becoming unhealthy and costing 200k each chemo session.
It is in lifetime medical care costs and there have been a few studies in Europe. The majority of medical costs is for age related care that grows exponentially with age, and smoking cuts decades off their life. Most smokers die before they get lung cancer, when they do it rarely results in surgery because they smoke, and it is easier to give a younger person chemo than and older person.
Also have you seen the kind of medication regimes that most 90 year olds take? Many of them take as many pills in a week as a 60 year old has took over the last decade or more.
You did not say lifetime medical costs initially but compared adding 2 years to a 90 year old vs 10 years to a sick 60 year old.
> Keeping a relatively healthy 90 year old alive for 2 more years costs significantly more than keeping an unhealthy 60 year old smoker alive 10 more years before they have a heart attack or stroke.
Population statistics
Population statistics showing it is cheaper to prolong the life of an unhealthy 60 year old for 10 years than a relatively healthy 90 year old for 2?
> Basically nobody else is recommending colonoscopies to the entire population with no cheaper tests
I'm not sure if I understand what you're saying. Kaiser Permanente sends me a take-at-home colonoscopy test every year, and some light googling suggests the cost is $20-$89. I've never done an in-person colonoscopy, but the home version must be cheaper, right?
Unless you're putting a camera into your colon, it's not a colonoscopy
they're referring to a screening kit like this: https://www.cologuard.com/
That's not a colonoscopy. It's a colon cancer test, but not a colonoscopy, which, by definition, involves a scope.
Camera-pill?
Based on my personal experience with Kaiser and their home fecal test (FIT test) as a cheaper screening method, I suggest opting out of it and insisting on a colonoscopy.
The problem is that the fecal tests are totally inconclusive. Every positive test must be confirmed by a colonoscopy. And then you get into tricky waters with insurance. My Kaiser gastro doc insisted that my colonoscopy after a positive home FIT test would be billed as diagnostic and not covered at no charge as preventive screening. Which means I would pay over $2k. Despite the USPSTF publishing explicit guidance on this exact scenario still being screening. He was dead wrong, and I wasn't billed, but he and his department did everything they could to discourage me from following up with a colonoscopy.
And at one point he even turned the tables around on me and said this was all a consequence of my having opted for the FIT test instead of a colonoscopy. Which I never did, I was not given a choice. But from his statement I would assume that you can opt in to colonoscopy instead at Kaiser. Then again this could be yet another piece of misinformation on his part.
Kaiser has some very opinionated beliefs that their medical leadership pushes. From my partner's T2D issue (from no history to an ICU stay with DKA): "You cannot go into remission with T2D". "You will need to keep your A1C between 6 and 8 otherwise you will have issues with the medications you are on". They also have many medications they will not prescribe, regardless of the reason.
And don't start me on their pharmacy. She had root canals with some infection, and was in substantial pain. Dentist prescribes short term pain meds between procedures - she's in agony. I drive her from dentist to the Kaiser pharmacy at their UC/ER-lite/whatever facility, that I know from my previous work as a paramedic has pain management medications on site (day surgery, etc.)
"This is a pain management prescription. We do not fill those in person. You will need to submit it to our mail order." "How long will that take?" "5-7 business days, and then shipping time."
"Oh, look at you, coming from the dentist with verifiable surgical procedures done and in pain - just in case you might be drug seeking, you can hang on for a week or two and get your pain management then."
That last one is, I'd argue unethical and against most pharmacists "oaths".
I haven't heard of a take-home colonoscopy. How does that work?
The take home thing is a vial into which you put a stool sample and mail it back. Then it gets tested for signs of colon cancer. I've seen them advertised on TV as well.
That is not a colonoscopy. That is a stool sample and as other replies noted this gets sent out every two years to every one. In the UK from age 60 Australia seems to be from 50.
If that tests positive then you get a colonoscopy to check more things. If you have had colon cancer then you get a full colonscopy evry two years and an MRI every year.
Right, it's an alternative to a colonoscopy. As standard-of-care it's relatively new in the US.
No it is not an alternative to a colonoscopy it is a different test.
If this test finds something then the next step is not treatment it is you need a colonoscopy.
It is a test that cuts down on the number of colonoscopies needed and is cheap enough to find problems earlier than everyone having a colonoscopy which is just unaffordable,
I've got extremely normal marketplace health insurance and my doctor is at an extremely normal overworked large regional health chain, and I would have to argue with him to get an at-home test; the whole system is set up to funnel us all into colonoscopies.
Replace colonoscopies in that sentence by anything that can be made money from and pays doctors.
Sigh, we’re so far behind in anything that’s actually good for the common person. We’re way ahead in capitalistic societal development, though.
This is standard in Australia. Everyone between 50 and 74 receives a free kit in the mail every two years, and there are regular TV ads from the federal government (featuring actual TV stars) encouraging everyone to do the test and mail the results in.
The home version is cheaper, and inferior
Hypothesis: The American diet contains more carcinogens (dyes, additives, pesticides, supplements in poultry/beef/pork) and therefore USA is is more need of CRC screening.
USA generally has higher CRC rates than other developed nations:
https://pmc.ncbi.nlm.nih.gov/articles/PMC2796096/
the screenings may make sense, here
I think that article is from 2009. Need something more recent. Also it mentions that as countries become high-income economies, the incidence rate increases.
[flagged]
Based on 2022 data, rates are lower is US compared Japan, Russia, Italy, France and UK.
https://www.wcrf.org/preventing-cancer/cancer-statistics/col...
Maybe that implies more dyes, additives, pesticides, supplements in poultry/beef/pork in those other countries?
My doctor in the US did everything he could to tell me that my screening colonoscopy would be charged as diagnostic and I would have to pay over $2,000 for it, despite no history or indications of a problem. So it isn't all a bed of roses.
Most insurance covers preventive care, so that’s why it’s popular
> smoking tobacco
There actually has been a really big push against this in the US. I was shocked by the amount of smoking I saw on a recent trip through Northern Europe, whereas smoking in public is pretty rare to see in the US these days.
Now we just vape our nicotine directly, or smoke weed, depending on the state.
Cigarettes have definitely gotten a trashy vibe in the US. It's kinda nuts how fast we went from smoking sections in fast food restaurants just 30 years ago to even bars banning it. In college 10 years ago, the only people I knew who regularly smoked cigarettes were from Europe, China, and India.
Cigars are still cool though, but those have always been the higher status tobacco due to the cost per stick. Also most people don't go through public spaces smoking a cigar, so it doesn't have the annoyance factor of vapes. Hookah still has a fun vibe too, probably because of the social factor.
Pipes are making a comeback amongst young adults.
Cigs are still huge in the boozing scene.
I haven't seen anyone smoke in a bar in over a decade (it's been illegal where I am for quite a while).
You can't smoke in the bar but you can smoke outside the front of the bar and they don't care in open air patio areas generally. People smoke a lot casually outside too. I see a lot of people smoking golfing or skiing.
Can you say where in the US you find it rare to see smoking in public? I live in Kansas City and have been in Vegas, Seattle, and NYC recently and there is plenty of smoking everywhere. Less than the 80s, sure, but certainly not rare.
How recently were you in Vegas? I was blown away by how little smoking there was post pandemic even compared to 2018. Like, most casinos no longer reek of cigarette smoke. I'm sure that's partly explained by better air circulation installed to reopen sooner post-COVID, and probably taking the closures as an opportunity to replace some seriously steeped carpet, but the amount of smoking was way, way down. It used to be if you saddled up to craps table, at least one, if not two people would be actively smoking. Now you can look around the entire pit and not even see one. The combination of anti-smoking measures in broader society, and the uptake of vaping has wildly reduced the amount of smokers. We're talking a 60% reduction since 2000, and that was after the trend was already heading that direction.
Compare that to most places internationally, and the contrast is stark. The US has less than half the cigarette consumption per capita than the EU, with only the U.K., Norway, and Sweden having lower rates. China has a similar rate to the EU.
Just to drive that point home a little harder, the state with the highest number of smokers is West Virginia, sitting at 21% (the national average is 9.6%). That would be middle of the pack in Europe, similar to Italy.
I was in Vegas in August for Def-Con and there was a ton of smoking. Our hotel’s casino/lobby was disgusting. The smokers area outside the convention was plenty busy. Walking to the monorail there were people outside most hotel back doors smoking.
Which reminds me: Also, the smoking area of every airport I’ve been to in the last 2 years has been thick with smokers.
I know it’s better than the 80s. I was there. But I don’t think it’s rare in the US at all.
rare compared to Europe where seemingly everyone smokes
Rare as in you can absolutely spot a person smoking sometimes, but there is not the perception that everyone is smoking, the air does not always smell like cigarettes on the streets and even inside businesses, and the ground is not covered in cigarette butts everywhere.
NYC vs Hamburg, Amsterdam, or Brussels are night-and-day differences on this point.
I'm not sure Vegas is representative of much of anything, but last time I was there what I smelled was weed, not tobacco.
In my daily life, every day, I am behind cars with people smoking, see people on their smoke breaks outside the doors of offices and retail, walk behind people on the sidewalk smoking, and see it on basically every job site I pass.
I only bring this up because I keeping seeing people say it's "rare" in the US, but is something rare if you run into multiple times every single day?
https://worldpopulationreview.com/country-rankings/smoking-r...
I guess we can keep arguing about the definition of rare, but about half the smoking rate of many European countries is pretty significant, and immediately noticeable walking around cities in both places. It's also a significant reduction in the US since the 90s, when every restaurant and workplace, and decent number of homes, smelled like cigarettes.
The price of cigarettes varies widely around the US, which may affect demand. Though I thought VA is a tobacco state.
I loved Amsterdam but the amount of litter, composed mostly of cigarette butts was eye-opening.
Rare in the northeast US. In fact, I saw two students smoking on a college campus just last week and did a double take. I had not seen a single student smoking in at least a decade. Then I laughed remembering how when I was in college in the 90s, almost everybody smoked at least a little (often at parties), and seeing students smoking at the entrance to the dorm was pretty normal. I am an asthmatic so I've never smoked, and I remember my friends being stunned by this one night when we were out at a bar. Things have changed a lot around here.
In my college dorm in the 70s, nobody smoked. Well, there was one. He got a lot of pressure from the rest of us, because it stunk up his room and the hall. He finally gave in and moved elsewhere.
Maybe smoking trends come in waves.
I think this is a case of rare being relative to the past.
In the 90s and earlier it was hard to be in a city and not be breathing cigarette smoke pretty much constantly. Offices had ashtrays in the elevator waiting areas for people who couldn't wait to get to their office, restaurants had half the seating reserved for smokers, there were ashtrays in the armrest of every single seat on an airplane.
Its kind of crazy how much norms have changed around smoking in public. It's not "rare" to see a smoker, its that it is much rarer than it was in the past.
Idk if it would call it rare because yeah going on a walk in a downtown area you will definitely see at least a couple people smoking. But 30 years ago it seemed like every other person you passed on the sidewalk was smoking.
I remember walking into buildings in the 1960s and they all stank of stale cigarettes. Not at all today.
The massive shift away from cigarettes is incredible. I didn't believed it possible.
DC suburbs here, I can’t remember the last time I saw someone smoking.
There’s an economic disconnect working against preventative medicine in the USA. The commercial interests take more of a cut on the expensive reactive treatments.
I’m from a country where you are mailed things like a free bowel cancel screening kit every two years unsolicited from the time you turn 50 (Australia). The reason is that the kit and test cost a few cents and detecting it early saves the socialised medical system so much money this sort of thing is a no brainer. There’s a direct economic incentive for socialised medicine to integrate preventative care into day to day life.
There SHOULD be the same incintive in private health care like the US to also lower costs. but when we voted in the ACA (Obamacare) there was a well meaning clause that said insurers had to spend 85% of their premiums on care. That should also re-inforce the cost savings part, but then the largest companies started buying Pharmacies, Pharmacy Benefit Managers, Doctors offices, and even whole Hospitals.
Now they can still spend 85% of the INSURANCE premiums on care, but then those costs are going to their other divisions which can raise prices at will, and make massive profits for the whole group.
Nobody's twirling their mustaches hoping people get sick, but they don't need to be for fee-for-service incentives to bias standard practice towards responses to conditions rather than prevention. On the other hand: you can go too far the other direction (and some cardiologists would point to CAC tests as an example). Preventative care can be bad if the tests drive unnecessary procedures.
It’s very strange to include caffeine in that list of unhealthy things. Everything else in that list is proven to be bad for society/health, except for caffeine. Why did you choose to highlight caffeine consumption when there is not really any evidence it causes health issues?
The comment said “putting 3 cups of coffee in a can we drink 4 or five of in a day” that would be 1,000–1,500 mg of caffeine. The FDA guidelines is 400mg a day and drinking 1200mg quickly can induce seizures
16 oz can of white monster (stereotypical energy drink) has about 150mg of caffeine. A grande (16 oz) black coffee from Starbucks has about 310mg of caffeine. You would need to drink 2 16 oz monsters to get the same amount of caffeine as a single grande cup of coffee from Starbucks.
If you're just looking at caffeine intake you'd be better off switching from coffee to energy drinks. You could drink about 3 per day and be close to the 400mg/day guidance.
edit: white monster has no sugar in case anyone was about to bring that up
Coffee varies. I've long understood that a normal (8 ounce, ish) cup of drip coffee averages around 100mg of caffeine[0].
Java Monster Triple Shot Mocha comes in a can, and has 300mg of caffeine per can[1][2].
This seems to suggest that getting the equivalent of 3 cups of coffee in one can is, in fact, a thing that people can accomplish.
[0]: https://www.aboutcoffee.org/beans/decaf-coffee/ https://ific.org/resources/toolkits/caffeine/ https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-h...
[1]: https://www.monsterenergy.com/en-ca/energy-drinks/java-monst...
[2]: And they're delicious
> If you're just looking at caffeine intake you'd be better off switching from coffee to energy drinks
This is less true now than it used to be. I'm somewhat sensitive to caffeine and always look on the can to see how much is in it, and 150 is on the low side of most of the options available now-. 200 to 300 seems to be a lot more common among the brands that are newer than when monster and Rockstar first came out.
Caffeine ≠ caffeine.
Forget the numbers you’re being given - what does caffeine crop that goes into a Coke or Pepsi product look like, compared to green tea caffeine?
What does the sugar look like, as a supply chain, vs sugars ingested from fruit?
Hint: it’s disgusting.
Caffeine is caffeine. Sucrose is sucrose. Homeopathy isn't real.
No.
When a flock of geese shit into the pile of beets, gnaw on the beets for a few days, and then the beets get boiled down and put into your Gatorade, sucrose ≠ sucrose.
No idea what you mean with the homeopathy quip.
You know manure and the soils produced from composting are literally feces from animals and bacteria, right?
And that manure is an excellent natural fertilizer?
And that outside that, worms exist? And they poop?
Oh, and that if you were to take bird shit beets and worm poop beets and mash them up and extract chemically pure sucrose from both you'd have no way of determining which came from which?
Assuming that you do know all of these things, you're saying that horse shit and worm poop is fine, but you'll be damned if a bird is involved?
I mean, I can see where you're coming from. A potatoe coming from a toilet is probably not as clean as a potatoe coming from a sterile lab, but that's not what you're saying. You're saying that the toilet has somehow altered the physical chemical compounds involved in the structure of the potatoes rather than has potentially added other chemicals to the mix that was the potatoe. The starch is the same in both. The starch = the starch. The starch and the toilet =/= the starch and the lab because the toilet =/= the lab, but those are different arguments.
I think growing food on soil containing shit is a whole different world than boiling my food with shit,
and if you don’t, well, let’s just leave it here.
> You're saying that the toilet has somehow altered the physical chemical compounds involved in the structure
Nah - I’m pointing out the shit that comes along with your very simplified label should be known.
Same as the folic acid American rice is washed in - but never labeled with.
> if you were to … extract chemically pure sucrose
My point is: they’re not.
and in retrospect, it was weird that I ever assumed they did.
It’s included in a list of things bad for “ society/health.” While overconsumption on that level would certainly be a health issue for an individual, it doesn’t even register compared to the other things he lists as a social issue, like chronic obesity and Tobacco use. It’s just weird and misleading to include it in that list, is all I was pointing out.
I don't think there's long term evidence for negative problems. However, high dosages of caffeine are dangerous and have killed people. Those dosages are easily achieved through the likes of energy drinks.
Chronic long-term use of high amounts of caffeine (>600 mg, or two Starbucks Grande coffees) are linked with: bone density issues, sleep issues, anxiety issues, cardiovascular strain, stomach acid issues. They aren't super bad, but definitely not harmless.
High dosage of water have also killed people. And easily achieved through energy drinks? I strongly doubt that. Most energy drinks are not any stronger than coffee
Lower dosages of caffeine kill you than the water dosages that kill you.
> And easily achieved through energy drinks?
Yeah, once you start pushing 1000mg of caffeine, you are getting into areas where if you have heart problems, you could be putting yourself in danger.
> Most energy drinks
But not all. So why strongly doubt it?
There are plenty of energy drinks which are fairly popular with huge amounts of caffeine and there's little labeling requirements to let people know that. Bang energy drink is a good example of that. 300mg per can, meaning 3 cans is putting you in dangerous territories.
You can buy a bottle of caffeine pills at Walmart for a few bucks. What are we even talking about?
How dangerous caffeine is. You can also buy a bottle of Tylenol from Walmart, that doesn't mean it's particularly safe to OD on.
less the caffine itself and more the amount. It sounds like they are talking more about energy drinks or some highly concentrated espresso shot.
I don't think that much caffeine is good for you, especially 4-5 times a day. But with everything else we gulp down it probably isn't priority #1.
Tangential, but I suppose this is a good time to highlight how caffeine undisclosed can in fact kill some people:
https://www.bbc.com/news/articles/c5y95yylxv7o
The US is founded on the idea of individual freedom, and that one of the few areas of "collective" spending should be defense.
This is 101. If you don't like it that's fine, but not understanding it can be resolved with a simple google search.
What does individual freedom have to do with whether or not medicare will cover a preventive test?
Maybe read the comment i responded to.
Because people are unable to conceptualize the idea of government-funded voluntary preventative campaigns, despite these showing success in the past.
This may be partially due to the many all-or-nothing crusaders who would prefer to use force in their quest for full protection of the citizen. Many people overcorrect because they fear that even voluntary programs are steps in this direction. Trust is low.
We have a long and sordid history with extreme and failed prevention (prohibition, the Mann Act, war on drugs).
Much of the US doesn't think of it in terms of proactive vs reactive governance but instead in cultural/moral expectations of how you should "pull yourself up from your bootstraps" to be great. This view is often to the point many see removing the need to pull oneself up from their own bootstraps as removing the ability for them to better themselves (& wasting everyone else's money/freedom/whatever to do so). A soldier and an obese person are examples at polar opposites of that moral spectrum.
The policies just follow that. This comes up in all sorts of areas such as prison as punishment vs rehabilitation.
I think you're looking at an effect instead of a cause. The main reason for the desire for a small government is not some inherent and absolute obsession with smallness, but because of the belief that larger governments are incapable of effectively utilizing their power (for reasons beyond just incompetence), are prone to inevitable abuses, and so forth. And that belief itself is not simply ideological, but based on history through most of all time.
Even with rehab versus punishment - it's the same story. The view isn't that punishment is inherently superior, but simply that rehabilitation is more of an ideal than a reality, and that typical appeals to places like Norway - a relatively homogenous and extremely wealthy microstate - don't necessarily translate well to large diverse societies, especially ones where there are substantial chunks of society that adopt cultures that glorify criminality.
My views on this subject are far too detailed to want to get into here, but I am confused at your choice to call Norway a "microstate". It's certainly on the smaller side of countries, but there are over 5 million residents and 300,000km2 in size. It's just a normal country.
"Microstate" is a term generally reserved for tiny geographical locations that can't even support their own defense.
It has a lower population than e.g. Wisconsin, in an area about twice as large. You could fit 61 Norways (in terms of population) into the US. I think there's a lot of things that work really well at smaller scale, but just don't work at larger scale. It's not really possible to say where 'smaller scale' ends because it's going to depend on factors other than just population, but I think Norway is comfortably far into the very small side of things in part because of population and in part because of those other factors.
A microstate is not just "one smaller than another" though, and nobody lists Norway as a microstate of Europe/the EU.
But with what you had meant - it means Norway is pretty comparable to a typical US state division or, in other words, something US states could be expected to implement successfully in their state prison systems if there weren't other reasons than scale they do things differently.
And you'll find that a number of states of a comparable makeup as Norway have comparable and even lower recidivism rates than Norway. Oregon is the lowest in the US, with a recidivism rate of 12%, contrasted against Norway's ~20%. [1] And that has nothing to do with punishment vs rehabilitation.
Similarly, Asia is another interesting counter-example to Norway. For instance the Chinese penal system makes the US look like a trip to Disney Land. Beatings, physical+psychological torture, and more are regular aspects of their prison system which is not only punitive but borderline sadistic. And their recidivism rate? One of the lowest in the world, around 8%. And perhaps even more important than the recidivism rate is their crime rate, which is also one of the lowest in the world.
[1] - https://usasymbol.com/rankings/crime/recidivism-rates-by-sta...
I don't think there is a clear cause and effect (or even separation) of those two things. The early views/situations of those who made America are largely the same force which drove the desire for small government and vice versa. I.e. what you believe is ideal in reality is going to be based on the way you weigh things morally just as much as the way you weigh things is going to be based on what ideal is held.
There is, of course, more than one reason people hold the views they do, but I do believe things like rugged individualism & the Protestant work ethic definitely played a major role in why the majority of Americans hold the desires and fears about government they do - particularly in the aspect of these examples. Without those influences, I think what America has tried vs what it has feared would be a very different list today (which is not to say whether it'd've been more successful or not).
Did you know that you can be sentenced to life imprisonment in the UK for suggesting that the monarchy should be abolished? [1] That's quite progressive, since it used to be the death penalty. Now in reality you probably won't be, but that law is an echo, still ongoing, of the sort of systems everybody used to live under. That directly leads to ideals of a smaller government. So I don't think these sort of values we're speaking of are abstract or moralistic in nature.
It's also not just in the past. We continue to live in the era of mass domestic surveillance, Patriot Act, Snowden leaks, regular oppression for political views (see: pro-Gaza protests), two tier legal systems, and much more. All the while governments with vast resources plunge sizable chunks, verging on a majority of discretionary spending, into militarism flirting with WW3 and the viable end of humanity it would entail. And I'm not even going to get into the insanity that's going on, worldwide - including the West, with the treatment of political candidates and elections. Suffice to say that's also enough to make a lot of people quite concerned.
So again all of this makes one begin to think 'perhaps governments shouldn't have this much power or wealth' at a point that I imagine you would say is, itself, already relatively low. I think that should all be fairly reasonable, even if one might disagree at some point. But I'm not entirely sure what the comparable evidence for the alternative is.
[1] - https://www.theguardian.com/uk-news/2013/dec/13/calling-abol...
Well, again, it's not that these things take place of each other it's that they influence each other. Taking the first example, America only exists because individuals went to settle and conquer new lands and then pulled themselves up by their bootstraps to defeat the tyranny of the monarchy. There is no way in which this can happen without these cultural traits in the same way there is no way it could have happened and not driven these cultural traits further. The other examples follow the same line.
That's not arguing small government is supposed to be good or bad, it's just saying what the American mindset considers important when judging things - which is on traits which align with its mindset over its history, not on whether or not the application of policy seems evenly distributed to all.
I'm not going to debate the history beyond observing that most people were fleeing persecution or seeking a better life for themselves and their families. Scarcely few set out to conquer anything. But I think the most important point is that now a days I think if you put just about anybody in the current state of America, you'd see a trend towards desiring smaller government.
The exact phrase 'smaller government' is triggering because it's been so politicized into being a left vs right concept, but when left leaning individuals seek to decrease the strength of ICE, decrease the rights/capacity/scope of law enforcement, limiting executive powers especially as related to war, and other such things they are themselves also directly appealing for a smaller government, in at least some ways.
I think this hypothesis (that 'anybody' would trend towards seeking smaller government) is even testable with things like Asian Americans. Many/most have roots from more social type societies, and predictably trend towards voting liberal in America as a result of such, to say nothing of historical issues. But they are leaning more and more conservative over time, to the point that at current trends they will likely be a majority conservative bloc within a few decades.
It's simply that once one sees what 'big government' amounts to in the US and the current state of the US government, it quickly leads many people to start running in the opposite direction. And once you start running from such, the opposite (self responsibility/reliability/etc) inevitably grows in proportion simply because there is no other choice.
> in cultural/moral expectations of how you should "pull yourself up from your bootstraps" to be great
Another word for that is freedom. With freedom comes personal agency and personal responsibility.
The primary purpose of prison is neither punishment nor rehabilitation, but rather to protect the general public. Whether incarceration is the best approach to accomplish that goal is a separate issue, but the reality is there are a lot of dangerous and antisocial people who can't be running around loose.
From Kurt Vonnegut in Slaughterhouse-Five:
To put it in context, the poor elsewhere were poor by class. No attempt to become rich was permissible by law so it was key that this supermajority of the population did not believe they were downtrodden, and unfairly opposed.
Claiming the poor have more virtue, but only in their class status, is one way to do it.
Consider how many caste systems claim the farmer is the highest status, the wisest, the most virtuously hard working … but well still needs a good noble king to lead them.
Things have changed a lot since Kurt Vonnegut wrote Slaughterhouse Five in 1969. Now even people in the poorest US state have higher incomes than the UK. America is the wealthiest nation on Earth, and its people are mainly rich (relative to global standards).
We should do more to help the underclass and remaining desperately poor citizens to lift themselves up. But it's amazing what we've accomplished since 1969. Let's celebrate that.
> Now even people in the poorest US state have higher incomes than the UK.
Higher income does not mean higher quality of life.
I'm an American who has spent the majority of my adult life living abroad, and much of that time has been in developing countries.
I have no illusions about poverty and am not going to pretend that the US isn't a "rich" country. But I've also noticed a very stark trend in the past decade: fewer and fewer people express interest in emigrating to the developed world.
I currently live in one of the fastest-growing countries in the world. Its per capita GDP PPP is about a fifth of the America's and...the number of people I meet who say they'd want to live in the US is tiny.
People around the world are increasingly hip to the reality: the US is still the land of opportunity. But opportunity is more and more difficult to come by. The country is expensive, has massive social problems and lacks attributes (such as safety nets provided by family) that make life in poorer countries feel better to many people.
Even your idea that the "underclass and remaining desperately poor citizens" need to "lift themselves up" is a distinctly American idea. There are tons of working poor in the US. They are trying to "lift themselves up" but can't afford a $1,500/month apartment, $30,000 starter car, $5+/gallon gas, $5,000 health insurance deductibles, etc.
Hear, hear. It would be good for more people to travel abroad and experience firsthand how much better we have it in the US than most other places. The concern is that we actually have it better than most yet too many actually want to replace our current system with something else that has a horrible track record.
If many of our welfare programs actually helped their intended recipients we would be able to help those in need get to being self sufficient instead of the fraudsters stealing all that money.
Everything is America is about race
America does a better job at assimilating immigrants than most of the rest of the world. It’s just a very hard problem, and the US does more of it than anyone.
Not everyone in this country who isn't white has ancestry from an immigrant (or at least not a willing one).
Also, non white immigrants face discrimination.
People facing racial discrimination can and have overcome it, throughout our history.
People hold out willing non-white immigrants succeeding as proof there is no significant racial discrimination. But this ignores a large selection bias. People who voluntarily immigrate almost always have a great deal of drive and often some resources. Most of them would have been more successful then average if they had stayed in their home country.
I definitely wouldn't say my lineage had any call in "immigrating" into the US.
And yes, don't underestimate how such maneuvers are very indirect means of white flight. African Americans could only (legally) own a home in much of the US for 50 years. At the very best, that is 2 generations of wealth to accrue, which puts that demographic a good century behind what potentially could have been economically.
50 years would be 1976. Perhaps you're confusing it with the myth about women being legally prohibited from opening bank accounts. (1972 was when sex discrimination by businesses was outlawed at the Federal level, though there was never a law that prohibited a women from having a bank account, not directly, and not indirectly since the 1800s. Some banks discriminated against married women, but unless they lived in a one-bank town there were others that were happy to have their business.)
My timeline was loose, but I was specifically talking about the Fair Housing act of 1968: https://www.justice.gov/crt/fair-housing-act-1
So 58/59 years if we want an exact date. But a law passed de jure doesn't mean everyone throws their hands up and willingly complies, so the sand will still be shakey for a good decade.
Of course, YMMV per state, so it's not like the Midwest or west coast had the same level of discrimination as the deep south. But that's the line that this policy became federal.
Okay, but like with the banking myth there was no law or official government policy that specifically prohibited black ownership. And the only legally enforceable impediment after the 14th Amendment were racial covenants on private property (drawn up by property owners themselves by private agreement), which became void in 1948 after SCOTUS said it was unconstitutional for courts to enforce racial covenants.
Notwithstanding that they were examples of extra-legal discrimination (in the sense of not being direct legal prohibitions), racial covenants and red lining also didn't just effect black Americans, though nationwide they were disproportionately impacted. I only point that out because most people would say it was incongruous to claim Jews or Polish or Asians were legally prohibited from owning land in many areas.
I think it's an important distinction because there are vestiges of redlining that persist today. First time homeowner mortgage subsidies, the first major stepping stone for building wealth for most people, effectively exclude many kinds of multiunit housing, such as condos and, IIRC until recently, attached housing like duplexes. This disproportionately impacts prospective urban black homeowners, and quite deliberately. Likewise, IIUC prefabbed homes or similar are excluded, which disproportionately impacts poor rural whites and blacks alike. There are legitimate concerns behind those restrictions, such as developer and rental fraud, just as nominally there were legitimate concerns behind redlining, namely sustainability of property valuations. Though in all these cases it's obvious the reason they persist(ed) as-is is for largely discriminatory reasons, as the legitimate substance of the concerns could be addressed. At the same time, we wouldn't say they legally prohibit ownership; if you're wealthy enough they're no impediment at all, just like redlining and covenants were no impediment if you were wealthy enough (racial covenants could be overcome by just buying up all the adjacent property so there was no other property owner to enforce the covenant; the government couldn't by itself enforce such covenants, only adjoining property owner "beneficiaries").
Perhaps counterintuitively, black letter property law was one of the legal areas most resilient to both racial and sex discrimination. The 1800s saw some regression, but that didn't last long, often because courts themselves couldn't tolerate the illogic. People criticize it, but property is indeed sacrosanct to American legal and political culture, and it was very difficult to carve out exceptions that permitted blacks and women to be excluded without threatening the underlying principles of the system that secured owners' rights. That's why prejudiced treatment tended to come in the form of private, regulatory, or extra-legal discrimination, which arguably persists today in the form of restrictive zoning and related development policies which not coincidentally are impediments to free & clear property ownership, just enough to be tolerable to the well-off while disproportionately impacting the real targets.
This kind of thinking is how you get trump 3.0 after you blame and alienate people who want their lives to improve.
I don't know why you got downvoted. If you don't believe this, read "Dying of Whiteness" by Jonathan Metzl. Something like 30% of this country will reject quality of life improvements for themselves if they see that it will also benefit people of other races who "don't deserve it".
The entire social structure of the south was (and mostly still is) based on wealthy whites convincing poor whites to accept the situation because blacks are even worse off.
And those that haven’t lived in the south can’t comprehend that it really is the core animating belief behind the entire apparatus of government.
You shouldn't have to believe, because the various poor white guys who died for the south wrote plenty about how their driving motivation was that a black guy having the same social status as them was worse than death.
They literally wanted to kill northerners for daring to make them equal to black people.
Still do.
Then really shouldn't it be "everything is about money"? After all, it's clear that the actual lie is convincing a big group of people that they don't share a common cause. Racism has many causes, but using it as a divide and conquer tactic has to be one of the most disgusting ones.
It’s super easy to get whatever survey results you want by careful tweaking of wording.
Not to mention how often people misinterpret a survey and add their own bias to the results.
*Everything in America is about class, with race as a frequent proxy for class
Fixed that for you
Judging by the color of one's skins is one of the easiest and oldest ways to discriminate. Only behind by the contents of one's genetalia. But the latter at least has a biological need to care for one another.
It's a bit of a chicken and egg situation. At least when someone looks at someone who "looks like them" but is poorer, they see "potential" (there's a name for this effect, but I forget). But the end goal is getting theirs first and foremost.
True, but this effect tends to diminish at the highest levels of wealth.
At lower levels you have the “labor aristocracy” effect, which gives the more well-off workers a material stake in racism. And this division is useful to prevent organization.
> the end goal is getting theirs first and foremost
Seconded
Its also about language and colloquialisms. If you grow up poor, but go to a school with many wealthy children, you will learn to speak the "language" of the wealthy, which is, in my opinion, what mostly explains the "having potential" that the ruling class will see in your as you enter adulthood.
In the US there's an extreme attitude of "I'm not paying for someone else...", and any sort of preventative care, like a heart score test, would fall into that category. This attitude is grounded on the personal responsibility mindset, that every person is responsible for taking care of themselves. So, for the 800K people that had heart attacks, the attitude in the US is largely, "They should've been proactive on their own, gotten the $100 test. Their heart attack is their own fault."
I don’t entirely agree, but it’s not inconsistent. The idea is that government is supposed to protect you from bad guys (criminals or enemy countries) but it’s not their job to protect you from yourself. If somebody wants to shoot you, the government is supposed to stop them. If you want to eat an entire cake for lunch every day, that’s your own business.
> What I've never understood is the weird dichotomy of preventive and reactive governance in the minds of US citizens.
When the underlying economic model of CONSUMPTION = GOOD is viewed as a religion or universal law of nature, it's actually not surprising that people are irrational about this.
People being free to destroy their bodies with food has nothing to do with everything else you mentioned.
Big assumption that the average citizen’s opinion has any effect on what the government spends money on. It’s pretty easy to campaign on not doing X and then proceed to do X once you’ve won the election.
If you keep in mind that the median voter in a primary is 65, then the government we have seems to do a pretty good job of reflecting the opinions of the politically engaged subset of the population.
I’d argue government investments are extremely exposed!
Consider that the majority of Americans do in-fact vote. In doing so, they literally delegate the power of the purse to the representative was most supported in their local community.
Look at the work put into ‘communication’ about those budgets also. In addition to having comptrollers to monitor the auditors or whatever.
The UK Expenses Scandal was funny, but Thatcherism is still doing too much residual harm to laugh about.
Promising x and doing y is a winner-takes-all democracy problem. Coalition governments solve this by sexing-up y as the natural outcome of the public vote. This also makes technocracy easier / more normalized.
Follow the money; lots of wiggle room for fraud and quid pro quo in an emergency
So we have to perpetually live in emergency mode to create liquidity
If we could all just live our lives there would be no reason to shift large sums of capital around for the usual hands to get their cut
Historically post office and social security ran surpluses; boring and predictable. All that was phased out to create the current shit show of a virtual economy for the youth
Sam Altman isn't concerned with efficiency except his own line go up
This is just a longer version of "If we can spend so much on defense, why can't we do X?". The OP is compelling enough in understanding the tradeoffs of medical prevention vs. treatment. No need to rope in your pet peeve du jour.
I won't speak for other countries, but in the US, the answer to "Why do we spend so much on X" is typically because X is in large part a jobs program for special interests who are really good at lobbying, whether it is healthcare or defense or any other industry.
Representatives like high employment in their districts and employees of X like high salaries. It's an incentive-compatible equilibrium.
Fine. So your pet peeve is waste and you'd reframe it as "If we can waste so much money, why can't we do X?".
Overconsumption means enormous profits, that's the whole logic to it. Gotta keep numbers going up and shareholders happy.
It's easy to understand. US optimizes for whatever helps with more overall spending. They can print money and export inflation to others. All this new money then goes to the companies that hold power through lobbying.
> and project a presence of power to deter acts of terror/war
uh? That's literally what causes terror and wars lmao
While I agree the US meddling in the Middle East has caused wars/terrorism, the general US military presence globally is a massive benefit for the entire world. Once the US starts pulling back more (as they seem to want to do) we'll see more and more regional chaos that grows into trade disruptions and wars. Regional tomfoolery like the South China Sea stuff will occur all over the world and will escalate into wars.
> we'll see more and more regional chaos that grows into trade disruptions and wars
Every accusation is a confession, as they say. How can you say this with a straight face given the current situation in Iran lol? They keep pulling the same shit and NPCs keep licking the boots, it's insane...
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From the article:
> "As an example, consider a hypothetical 2-year wellness program that costs $400 per month per person (say, $13 per day for healthy food) and reduces the risk of heart failure by 1 percentage point, from 5% to 4%. For the first 90 days alone, heart failure treatment is much more expensive at $22 000 than the wellness program, but that doesn’t mean that the wellness program saves money. In this case, 100 people must participate in the 2-year program to reduce the incidence of heart failure by 1, from 5 people to 4 people. In other words, the number of people who must be treated with the prevention program to avoid 1 heart failure is 100 (NNT = 100)"
1. Why is the person's food cost attributed to the wellness program, instead of the person's food budget?
2. Most people are overweight or obese. I would expect $400/person/month of healthy food to lead to weight loss as part of the intervention. This skim-read study of 5000 people[1] concludes that "Modest weight losses of 5 to <10% were associated with significant improvements in CVD risk factors at 1 year". The hypothetical uses 1 percentage point, which sounds insignificant.
3. This Novo-Nordisk page[2] says: "According to a post-hoc analysis from the Look AHEAD trial, individuals with type 2 diabetes who lost ≥10% body weight had a 21% decrease in 4-point MACE incidence (defined as CV death, non-fatal acute myocardial infarction, non-fatal stroke, or hospitalisation for angina). A weight loss of 5% has significant health benefits". Again relatively small weight loss shows significant improvements.
(Comparison: someone 300lbs losing weight at 1 lb per week takes eight months to lose ten percent of their bodyweight. Healthy weight loss is often discussed at twice that rate or 2 lbs per week. In the TV show My 600lb Life Dr Nowzaradan gives morbidly obese people targets of 5-10lbs/week initially. The hypothetical wellness program is two years?).
The improvements from healthy diet which leads to weight loss ought to be more than just reduced risk of heart attack. Reducing hypertension (high blood pressure) leads to reduced risk of stroke and chronic kidney disease. Reduced body fat and healthier diet leads to reduced risk of Type 2 Diabetes and its complications (vision loss, neuropathy, slowed wound healing, worse immune function). Reduced weight leads to reduced risk of back pain, knee pain, sleep apnoeia, non-alcoholic fatty liver disease. Reduced body fat leads to reduced risk of some cancers, better diet reduces risk of other cancers. The hypothetical only considers treatment for heart attack in the savings but there should be a lot more savings.
The hypothetical only considers the treatment cost of a heart attack for 90 days but is that all the treatment they need? Are they not on regular drugs and checkups long term? And someone who survives a heart attack is at increased risk of another heart attack from all the same reasons they had the first one. American Heart Association says "about one in five people who have had a heart attack will be readmitted to the hospital for a second one within five years"[3].
And avoiding the prodcutivity loss from all the time off work from heart attack, back pain, sickness, medical appointments and treatments over years and decades. Intervention may not save money, but it may lead to increased ability for the economy to generate more money than it cost.
There's probably a point in that article, but why use such an easily criticised hypothetical to try and make a point? Not even going into $13/day vs 'beans and rice' or saving a person money on takeaway, cigarettes, alcohol, gasoline, or the costs to a person of moving to a walkable area or joining a gym, or all that kind of lifestyle intervention.
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC3120182/
[2] https://pro.novonordisk.com/disease-area/cardiovascular-dise...
[3] https://www.heart.org/en/news/2019/04/04/proactive-steps-can...
In the limit, one would expect that to be the case: at some point the marginal cost curves will intersect. I’m quite surprised that we are already at that point. I suppose more things are at the efficiency frontier than I had imagined.
Thanks for the link. Will have to read it later.
I would read the comments on that article. The conclusion you've come to seems murky at best.
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It's because of racism. No, seriously.
If something disproportionately affects black people negatively, it has a significant amount of support from certain voters. The whole origin of the anti-abortion movement in the 19th century was double-pronged to displace midwives (who were often minorities) and that too many white women were getting abortions, which was labelled "race suicide" [1].
Need more? Infant mortality skews heavily by a state being red or blue and by the racial makeup [2]. Iowa is a red dot in a sea of blue because it's particularly white. Compare the US to other developed nations [3].
So this particular issue is with heart disease. And guess what? Black people are disproportionately affected and have worse outcomes [4]. Shocking.
Many people have a shallow view that racism is using slurs. It is not. Racism is systemic. And it's not as direct and nefarious as people in a smoke-filled room getting together to try and create worse heart disease outcomes for black people. It's a series of steps taken such that this problem isn't solved. It's just not prioritized.
You see the same thing with medical misogyny and medical racism. Symptoms are downplayed and ignored. This has been thoroughly tested where doctors have been given a file genders changed and there are statistically different outcomes.
[1]: https://sociology.northwestern.edu/documents/faculty-docs/fa...
[2]: https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ...
[3]: https://www.americashealthrankings.org/publications/reports/...
[4]: https://pmc.ncbi.nlm.nih.gov/articles/PMC9310198/
I'm too young for medicare, but when I asked my dr. to prescribe the heart scan, he kept stalling. When I followed up, he said my insurance wouldn't pay for it. Then I checked into pricing and it was $130 lol. If I have a family history, why would he assume I didn't want to pay the $130? I later found out that the his medical practice gets penalized by the insurance company for recommending "too many tests." So that plays into it.
If you want a CAC scan you can just go directly to an imaging center that offers it and order it yourself. It doesn't require a prescription. In most cases it won't be covered by insurance for screening purposes.
It varies. At the largest medical provider in my region they stipulate "To self-refer for a Heart Scan, you must be male between the ages of 40-65 or female between the ages of 45-70 and have a qualifying risk factor."
That's if you're going through insurance. They'll scan anyone with a check in their hand.
nope, some will reject. I had to go through 3
There are probably other imaging centers in your region.
CAT scanners are of variable cost and resolution.
Yes, what's your point? A CAC test doesn't require the most expensive CT scanner.
Wow, I would have expected something like this to be $thousand$ but a quick check with AI claims that in the U.S. the self-pay rate is anywhere from $100-$400. Still not cheap, but much more affordable than I expected.
I once tried to get some pills at CVS. I was charged something like $500, and asked for my insurance information. When I told them I had no insurance, they told me to go talk to a person a few meters away so that he can help me... I got the pills for $30.
I am not asserting that it applies in the above instance, but...
In broader medicine, one basis that can lead to the above sort of dynamic is compassionate protocol ("we are losing a little money on this deal, but you are in-need and we're here to help everyone"), as opposed to greed protocol ("we medicos are here for the big insurance money, and only charge the True Low Cost when forced").
And on balance, the nature of the people who choose the occupation of medicine tends towards the former.
drug companies themselves often have programs to offer them to the uninsured at copay or greatly reduced cost.
A lot of doctors are willing to cut their rates if you're willing to pay cash for the full amount. It's the paperwork that inflates insurance costs. I'm sure AI will cut through that and make it less a problem though. /s
Beware that some providers are in contracts prohibiting them from taking cash payments if they know a patient is covered by the contracting insurance carrier. I don't know the specifics of the business justification for these terms but they do exist.
I've had providers tell me they'd have been happy to charge me less, making less than their insurance reimbursement, but not have to mess w/ billing my insurance, but they were unable because their contract with my insurer did not allow it.
>A lot of doctors are willing to cut their rates if you're willing to pay cash for the full amount
Are pennies okay? Sorry, they're not rolled. Just let me know if it's not enough.
If you're willing to pay cash?
This sounds more like tax evasion than paperwork avoidance.
"Paying cash" doesn't mean literally that in this context. Cash, credit card, check... "Paying cash" just means paying directly without involving insurance.
Could be that. Could be they don't want to pay 3% to a middle.
It also means not paying credit card fees, not having to chase down bounced checks, etc. Cash means the money is there, which has value.
When I "pay cash" for a medical procedure it's actually with a credit card.
Just means I'm paying them directly instead of making them deal with my insurance.
I mean pay 100% of the cost yourself rather than relying on insurance. You can use a bank card or credit card.
Coronary CT calcium scans are getting more popular. But before getting one, I'd do these simpler tests first:
- ApoB - about 20% of people with normal cholesterol results will have abnormal ApoB, and be at risk of heart disease.
- Lp(a) - the strongest hereditary risk factor for heart disease.
- hs-CRP - inflammation roughly doubles your risk of heart disease
- HbA1c - insulin resistance is a risk factor for just about everything.
- eGFR - estimates the volume of liquid your kidneys can filter, and is an input to the latest heart disease risk models (PREVENT).
These are simple blood tests. You can get them for <$200 through my company or others:
https://empirical.health/product/comprehensive-health-panel
Imaging is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.
But you know the result will be recommendations for diet, exercise and statins so why not skip the tests and just do those?
A few reasons:
- If you made a dietary change (e.g., more fiber and less saturated fat), the tests tell you whether it actually worked.
- Statins are dosed based on the LDL or ApoB reduction you need. The most powerful statins cut cholesterol by 50%, but at higher doses the risk of side effects does go up.
- Other medications like PCSK9 inhibitors and ezetimibe exist, and whether to use them depends on the other numbers. For example, PCSK9 inhibitors have a secondary benefit of lowering Lipoprotein(a), and statins and GLP-1s have a secondary benefit of lowering inflammation.
- If blood pressure, HbA1c, etc is high, then there's a slightly different set of diet advice and a very different set of medications. For example, lowering blood pressure through diet is mostly about reducing sodium and increasing potassium.
Behavioral changes can only do so much to lower ApoB. It is a meaningful marker and may trigger additional workup. It may also signal that you should at least consider a statin.
ApoA is completely out of your control and will not change with behavioral modification.
So, no, you're incorrect that these tests are superfluous and all you need to say is "diet and exercise". Besides, even if that was always the answer to these results, you should still have a baseline to see if behavioral modification is doing anything.
"Why not just skip the HbA1c tests? After all, you know they'll give you insulin. Just start taking it."
Do you think everyone with poor blood test indicators is aware of how unhealthy they are? How quickly they need to reverse course? Or do think there might be some possible validity to discussing your results with an actual doctor and understanding how acute your symptoms actually are? Do you think there are no side effects to statins and everyone should just be on one at all times, forever? Do you think there might be some value, for those patients, in discussing GLP-1s? Or nah, everyone can just like, go run 10 miles tomorrow because some 20 year old in SV said so?
I'm always deeply confused by people who think all medicine is "just repeat whatever ChatGPT said as if it's profound, like, duh - I'm smart and invincible and can't quite figure out that other people aren't me", in spite of them not knowing anything about medicine in the first place.
Because for the same behavior, risks are going to be very different on the other side. In my family, for instance, we need significant interventions to get a reasonable risk due to all the bad genetic factors. In my wife's family, not so much. So knowing how serious the risk seems much better than just handing statins to absolutely everyone.
Because everyone's heard that advice, but people don't tend to take action until they have evidence that they, personally, are at risk.
Because I’ll know how much I can slack off.
apob and lpa i believe are relatively stable even outside of diet.
Lp(a) is stable since it's mostly genetically determined.
ApoB is very responsive to diet and medication--you can lower it by about 85%.
ApoB is no doubt responsve to medication, but my understanding is that diet and exercise can't get anywhere close to achieving that 85% number.
Because people are lazy enough that they will pay money to be told they need to stop being lazy lmao
Anyone know of companies in the UK that offer this kind of testing inexpensively?
Its the fundamental problem of our age: everyone is building pieces of a system, and almost no one is actually looking at how those pieces fit together into a system.
This is not about (just) the healthcare system ... it's the core problem with:
- our legal system (millions of laws and rulings and zero effort spent reconciling them into a good system that treats everyone equally)
- our economic system (we reward people who create true wealth in many different ways ... but those rewards are wildly disproportionate to how much true wealth they add)
- our tax system (again, millions of laws, and yet the people who should be paying the most pay the least because of how they fit together)
- our electrical system (although, due to its centralization, this one is actually catching up much faster than the rest)
- insert any other system here
Individual people claiming to have a superior Big Picture for humanity is basically what big politicians are. We assign them, then give them 3-4 years to remake the world in their vision.
And once we have a few dozen of them in a room together, it's the recipe for endless passionate arguments about exactly what Truth is, and what Value is, and what Goodness is, about anything and everything.
One of the biggest challenges is that rules are set by experience, but every new rule is also the start of a new story we've never read (called 'The Future'). And humanity changes pretty fast!
Yet the systems that have attempted to answer those questions on a holistic basis have failed.
What does that tell you?
The argument made in the article seems inarguable, but I don't see how a coronary artery calcium score is going to prevent a heart attack. You gotta do statins, exercise, and eat right basically no matter what. FWIW I had a coronary artery calcium score ordered by my doctor at my last checkup. It was $120.
I assume they mean.. have the test and then act upon it with diet/exercise/medicine to prevent the heart attack If you never had the test, maybe you don't know you are at risk and don't make any changes and then you get the heart attack
It’s also not just a “treat or not” decision. I have a family history and high test results so was already treating on the assumption I’m high-risk, but the scan revealed that we needed to be more aggressive. (And hopefully in a few years a scan will show we’re reversing the progression.) Personal data is always better than population data for treatment decisions.
The score will tell you that you do need to worry about lifestyle.
Whether or not people actually follow through is another story. There weren't any cigarette smokers who didn't know how bad it was for them...
I have been disabled on medicare for 23 years. I have often told my doctors that if they spent the time and money to look at my biology more closely it would have saved the tax payers so much money from medicare and likability payments.
Health care is actually sick care.
I obviously have a genetic condition because it runs through my mothers side of my family, but they refuse to look at my genetics. So, did. I found things. I begged a researcher to test me for a special sort of immune deficiency (ADA Deficiency) . The tests shows I have a partial immune deficiency. I showed it to my doctor and nothing.
When my condition flares up (Too mush ATP and GTP) it effects my brain and nervous sytem and I have to be institutionalized. Five times now. I keep telling them my mood problem is caused by an immune deficiency but now one cares.
Sorry, end of rant.
Insurance, and I presume Medicare in particuar, will generally only pay for the standard of care. They don't care about you as a unique patient, you are instead an average one.
Have you tried contacting Every Cure to see if they could help with identifying an existing drug which might be effective for your condition?
https://everycure.org/
This is a little bit misleading.
'Preventing a heart attack' means taking life long medication to reduce the absolute risk of heart attack by about 1%, which is worth doing, but complicates the maths a little bit. The scan doesn't magically eliminate heart attack risk
Sources? That 1% number is in my understanding wildly incorrect for statins, if that's what you're referring to. Are you comparing use of statins for people who already are low risk for heart attack over the next 10 years?
Just vaguely remember what my cardiologist told me. This is absolute, not relative. Which, and I'm definitely not saying it's insignificant.
By one percent, do you mean 3% of people per year in a high risk category turns into 2.97%, or 2%? Because that’s a big difference
It is a big difference and definitely worth doing
Insurance was invented to pay for emergencies. Your home insurance doesn't pay to perform routine maintenance on your roof, but neither will it pay to repair "normal" wear and tear. Your home insurance pays when a tree falls on your roof.
Our healthcare system has co-evolved with insurance in a sort of partial free-market, partial heavily regulated environment. Arguably we get the worse parts of both: Kafka-esque beaurocratic mazes and shareholder value optimization for private firms.
There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
Can the invisible hand do this when providers are offering mainly treatments with token preventative care visits thrown in?
>There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
You're criticizing health insurance but payers are far more incentive-aligned with patients on lowering total cost of care than the providers. They carry the risk and have to pay out claims. Providers, on the other hand, have an incentive to provide lots of expensive reactive care that's bound to expensive labor.
I agree with the sentiment of your "only for emergencies" point and wish direct care was more affordable. The problem is providers charge insanely high rates for services because a) they can get payers to cover it, and b) they're covering the cost of labor that's getting increasingly expensive with no commensurate increase in productivity [0].
For prices to come down substantially in the US, we'd need a much greater supply of doctors or more automated care. The former is against the financial interests of current doctors and the latter is an uphill battle against FDA regs, state medical boards, and billing codes from CMS to make it reimbursable.
[0] https://en.wikipedia.org/wiki/Baumol_effect#Healthcare
Payers are bound by law to spend at least 80% of premiums on healthcare. So if they can drive up healthcare costs across the board, they can profit more (by taking the same 20% of a bigger pie).
Yeah MLRs removed an incentive for payers to fight long run rate increases as long as they can model the risk effectively and pass on the cost to members via premiums, but they still tend to fight rapid increases because they break their models and retroactively misprice existing plans. Otherwise we wouldn't see contentious contracted rate negotiations between commercial insurers and providers, but we do.
Absolutely not here to praise US health insurance companies, but they're not the ones using regional leverage to negotiate higher rates - that's the providers.
> There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
Value-based care, e.g. Medicare Advantage.
The idea is that the government gives you $X for the care of a patient, with multipliers on risk factors. The government's goal is for that to be basically exactly what care costs. The provider is incentivized to treat you for less. Which sounds perverse, but if they, for instance, deny all care, a patient will end up in the hospital and cost exponentially more than they would have through proper preventive care. It is not perfect, and it should be broader, but it is a strong optimizer for providing the right care to keep a patient healthy, without providing hundreds of unnecessary tests (and especially imaging) that are medically unnecessary.
It is absolutely a system that should be rolling out to more and more patients.
Value-based care is a good idea in general in terms of better aligning provider incentives with patient best interests and controlling costs. But it doesn't necessarily equate with Medicare Advantage. Many MA health plans still operate largely on a fee-for-service basis with perhaps some minor VBC aspects.
I agree with the concept and idea expressed; paying for prevention is good and wise and we do far to little of it.
I don't like the title. I can't believe it is really $100. Even if the scan is $100 that doesn't fix things itself. There is the cost of whatever the treatment is etc. There are likely added expense from false positives (or similar idea), where it flags someone as needing more testing, new interventions when in fact they didn't...
I wish the article was more detailed on those costs (or at least not claim the cost is $100 when it is much more in reality, unless I am wrong about that and the fixes are free somehow). It feels like a biased promotion of this thing we like and/or have a financial interest in so lets make exaggerated claims that hopefully people won't notice.
It is $100 if nothing is wrong. If something is found correcting it is cheaper than a heart attack. Statins are not expensive and knowing how bad things are leads to how aggressive you perscribe them.
Certainly it seems likely treating it for those instances where a heart attack would result is cheaper.
But there is no evidence presented that say for every 1,000 of these test we correctly find 1 that wouldn't have been found (and we have zero false positives) or whatever. So then 1,000 * 100 = $100,000 and saves $50,000. Even in this case there are benefits beyond the expenditures (if you save someone from the $50,000 you probably give higher quality of life...).
Basically my issue is not with the idea that more testing and preventative action would improve our current system. I believe that.
But in order to make that argument in a specific case you need more complete data. Things get complicated so I understand why people don't want to do that for a simple story. But the problem is when you leave off all sorts of costs, issues (false positives, treatment options), etc. the statements you make are not very compelling to those that know a test that tells you something bad is more likely for this person is not nearly sufficient to claim why this test is good.
Yeah the headline is a bit glib and misleading. But the point still stands. Statins are dirt cheap too.
Medicare isn't here to make you healthy, its just another conduit for private healthcare to suck as much money out of the system as possible.
Prevention Vs. Cure...
(aka Proactive Vs. Reactive)
((aka Present Responsibility Vs. Future Response))
"An ounce of Prevention is worth a pound of Cure" (as the old expression goes...)
Observation: Most health insurance policies today, whether they are government or private corporation, national or regional, are based on the idea of paying for medical/health problems AFTER the onset of the health problem...
Prevention, preventative health, preventative medicine, and preventative programs -- would not only do a lot to preempt future health problems, but it would also save a ton of money (a ton of taxpayer money if the health insurance is a government sponsored one), as the above article so eloquently makes clear!
Observation: Some insurance policies do include some preventative health aspects -- but as medicine is complex and there are always new discoveries, there is always another step up, another higher level in what could be delivered...
In other words, these could always be improved...
"An ounce of Prevention is worth a pound of Cure" (as the article implicitly suggests...)
Anyway, great article!
>Observation: Most health insurance policies today, whether they are government or private corporation, national or regional, are based on the idea of paying for medical/health problems AFTER the onset of the health problem...
There's a lot wrong with health insurance in the US but this problem is largely on providers, not payers.
Insurance claims submitted by providers are effectively itemized using standardized Current Procedural Terminology (CPT) codes. Those codes are written by the American Medical Association (AMA), the lobbying group for physicians. Doctors make more money when services are expensive and require a doctor to be involved. As a result, reimbursable services tend to be reactive (i.e. more lucrative), rates have a tendency to go up, and CPT codes tend to favor reimbursing for physician time rather than patient outcomes.
In fact, there's a whole category of preventive health companies (e.g. Virta) that sell to insurers because the insurance companies bear the financial risk and benefit from a healthier member base. Insurers will pay for these programs on their members' behalf and try to get them to enroll so they don't have more expensive problems later. Providers make a lot less money when prevention works.
I don't think it's some grand conspiracy by evil doctors, just incentives gradually reinforcing bad patterns at scale.
Some excellent points!
>There's a lot wrong with health insurance in the US but this problem is largely on providers, not payers.
How would you fix it?
You need to decouple care from labor as much as possible or you'll just end up trading off between cost and quality without meaningfully moving the frontier.
Healthcare in the US is mostly gated on physician labor. Physician labor is scarce. Scarce labor is expensive.
Physician labor shows negligible productivity growth over time. Wages have to increase to compete for labor against high productivity growth sectors (e.g. software). On top of that, institutionally managed bottlenecks on labor supply prop up high wages (e.g. limited residency slots artificially constrain the number of doctors entering the market). Training more doctors would supposedly compromise patient safety because it would mean lowering the bar for admissions and straining existing staff that need to train them. Even if you could admit and train them all, supplying enough doctors to meet market demand would cause a wage collapse breaking the ROI of med school expenses. So the labor is not going to get cheaper.
So care requires labor that's expensive and only getting more expensive. If you want to reduce the cost of care without reducing the cost of labor, you need to deliver more care per labor-hour (i.e. get more efficient). Provider orgs that employ doctors try to boost efficiency by squeezing every last ounce of time and energy out of their doctors and booking impossibly full schedules. They have a strong incentive to make this work, yet the doctors get only marginally more efficient (and way more burnt out).
To meaningfully move the cost/quality frontier, the majority of care cannot be handled by a human.
8VC laid out a vision [0] that I strongly recommend reading and mostly endorse. It's a long series of hard technical problems but I think the harder problem is actually winning over the institutional gatekeepers (FDA, state medical boards, CMS, AMA). I can't tell exactly what doctors are supposed to do in this envisioned future but the answer will have to be something that sways the gatekeepers even if it's not what's best for patients.
[0] https://8vc.com/resources/ai-healthcare-vision
A series of excellent points!
Hopefully future healthcare policy makers (both in the public and private sector) will read them, and get some good advice from them...
>"Training more doctors would supposedly compromise patient safety because it would mean lowering the bar for admissions and straining existing staff that need to train them. Even if you could admit and train them all, supplying enough doctors to meet market demand would cause a wage collapse breaking the ROI of med school expenses."
There seems to be a vicious circle in place between too much medical regulation requiring a corresponding amount of long and expensive education, and the high cost of medical education in general...
Which one is cause and which one is effect I do not know...
It would seem to the casual observer, that both aspects might feed into one another...
One thing I do know is that doctors from foreign countries, especially if they are third-world countries, typically have had to pay less, sometimes a whole lot less, for their medical education, compared to their U.S. counterparts...
Is that medical education as good as a U.S. medical education? Well, I don't know! Maybe it is in some cases, maybe it isn't in others...
What is known though is that foreign medical educations frequently cost less, sometimes a whole lot less -- than their U.S. counterparts...
Is hiring foreign doctors the solution or part of the solution?
I don't know that either, but I do know that there are a lot of foreign doctors (and previously foreign doctors before becoming U.S. Citizens) in the U.S., and certainly many more abroad...
Is AI the solution, or part of the solution?
It's definitely a wildcard with promise at this point; it'll be interesting to see where it goes in the future...
Anyway, you make some excellent points!
Hopefully future policy makers will read them and act on them...
Tangentially related: I'm about to turn 65 and would be punished if I continued to pay for my own healthcare. My Obamacare/ACA insurance here in the state of Washington costs me $70K/year with premiums, deductibles, meds, etc. That's just for me and my wife.
And you know what? It's totally worth it to me. This year I had 4 operations+10 ER visits and my wife had 3 brain surgeries+radiation and 2 ER visits. About $2 million worth of treatments, quite good care overall. So I'm willing to continue paying for private insurance. I am fortunate I can pay for it and would like not to make you good folks pay for it.
But Medicare won't let me without penalizing me permanently more an additional 10% for every year I don't go on Medicare. Luckily Washington has phenomenal Medicare. But it would be nice if I weren't punished for trying not to be a burden to the dwindling population of taxpayers.
My goldilocks heart (not)
Same insurance company denied authorization for CAC twice; once bc I wasn't sick enough and once bc I was too sick (ie, just start taking a statin). All this happened in the last year.
I paid for it after the second denial. CAC = 175
All after the same Dr. told me my heart had "extra protection" every year since 2009.
I have a hypothesis, from my own interactions with sports medicine/healthcare, that medical tests which are in-line with more expensive and specialized procedures performed within the same medical group/hospital are easier to get and cost less.
Medicare could be paying younger people to do the things necessary to prevent them from encountering the healthcare system later on in life. Really, if you're only going to cover part of the population based on age, you should want to cover the part of the population that 1) still produces economic output and 2) has fewer and less-expensive medical needs.
You should also just pay $100 yourself? I think the bigger issue is just ease. They should deregulate these so they are simple to get
Is regulation an obstacle here? From a quick search it appears you can just find a place that performs these scans and book an appointment.
a little bit on the standard of care. also friction, and also knowledge
I got one covered by Cigna a few months ago. I said I had a mild chest pain and they did it plus some bloodwork. Nothing turned up but I didn’t have to pay anything extra.
I really can't believe there's anyone left who thinks deregulation solves anything. Everywhere it's tried it is a demonstrable failure. It's just an excuse for an uptick in profits at the expense of safety, the environment, etc.
Safety regulations are written in blood. They exist because people died because the industries could not and cannot be trusted to regulate themselves.
The most generous interpretation is that people conflate regulation with rent-seeking. These are two entirely different things.
>Safety regulations are written in blood. They exist because people died because the industries could not and cannot be trusted to regulate themselves.
This sort of absolutist rhetoric is why people waste so much time arguing against maximal regulation and zero regulation in the abstract, neither of which is actually popular or sane.
Many regulations are good, necessary, and effective. Many of them are short sighted, over-specified, or written by lobbyists against citizens' interests (shouting that rent-seeking and safety regs are mutually exclusive doesn't make it so).
And of course the people writing things in blood are always intelligent, well informed people making strictly rational, unbiased decisions which perfectly balance the needs of all in perpetuity.
You're really missing the point. There are no regulations preventing anyone from ordering a CAC screening study if they want it. You can pay out of pocket and get it at any imaging center.
Obviously the regulations regarding ionizing radiation exposure still have to be followed as with any x-ray procedure. No one has seriously proposed deregulation on that.
We are getting very close to this with cheaper and cheaper glp-1 drugs. Soon they'll be free for any overweight American.
I have to wonder what the longer term consequences of modifying peoples essential biological drives chemically will turn out to be in the long run.
That isn't to say this might not be the best solution for many people but I still wonder.
The biological drive for high calorie food and fat reserves are the problem in a environment where food-scarcity is not an issue.
The sort of food people are going for doesn’t even exist in the natural environment. Good luck finding so much refined sugar in one place or processed fat. Never mind the various preservatives that play the cognitive dissonance game of being a hostile environment for foreign microbiota but hopefully don’t do anything untoward to your own gut microbiota.
It isn’t just playing our systems, but hacking them and giving them inputs they would never usually see for far stronger effects than would be possible.
I modify my biological drive chemically every time I wake up and drink my daily coffee. Seems fine and we've been doing that for a long time now.
People also do it with smoking, and the only reason that is bad is because of the cancer, not the drive changes.
I guarantee the Unhealthy Snack Industry has their top scientists hard at work trying to find some kind of formula to make people on GLP-1 drugs go back to craving the soda and doritos.
They already do that. Zero calorie sodas on grocery shelves now that specifically advertise they have supplemented them with protein, which glp-1 users seek much like a vampire to blood.
The most tenuous of the health concious vc efforts are the nonaloholic beers though. They are eating their own industry. Bars and beer industry does not exist off people getting 2 drinks and going home. They depend on the whales who drink 10+ beers in a sitting who subsidize all the 2 drink and goers. Alcoholics make bars and the beer industry work. It is an open secret. No one is going to buy a 12 rack of Athletic NA Beer and drink the entire thing in front of the bears on tv. No one is ripping a 6 pack of athletic in the parking lot before they go into work. Bars aren’t going to be able to stay open with everyone buying just 1-2 $12 Athletic pints.
If you thought that was bad you have all sorts of drugs that affect libido negatively. In evolutionary terms that’s as good as a poison pill, reproductive fitness of zero.
Same for diet and exercise.
They'll use flawed research to claim diet and exercise don't work for obesity, then the general public uses that research and claims, "Diet doesn't work for fat people."
Soon, everyone is convinced every guy with a trivial amount of weight to lose needs to be on GLP-1s.
> They'll use flawed research to claim diet and exercise don't work for obesity
Who is "they"? Who is saying this?
The pharmaceutical companies advertising GLP-1s for one.
This is always the most boring part of any health thread. Both sides of this have airtight arguments. The diet/exercise people will talk about thermodynamics, and the "it's more complicated" people will talk about epidemiology and the fact that "diet/exercise" hasn't worked as a population-level intervention at any point in modern memory. It's a classic axioms vs. empirics battle and it will never go anywhere useful.
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I've never ever heard anyone say diet and exercise don't work. Is this something a real person has said to you in real life? Not on the internet?
I have known at least two people, who while not making the claim that it doesn't work, do make the claim that it doesn't work for them.
To me this is just subconscious denial/defending of their food addiction.
Ok but if they acknowledge it's an addiction, that's still a medical issue requiring treatment. Maybe that means going to food addiction anonymous meetings but if GLP-1 is like methadone for food, why not do it?
GLP-1 will prevent you from eating so much, but it won't make you eat healthy. You can and likely will still fill yourself up on junk, and will deal with the risks associated with that. Albeit it won't be enough to make you fat, but that's only one slice of health.
Learning to control your diet solves both problems.
I'd also argue there's a lot of value in learning to not be dependent on medication to control your behavior, because it's not available in most situations.
You can't take an exercise pill.
You can't take a career success pill.
You can't take a "hard, but necessary conversation with my partner" pill.
Those all require you to consistently do things you at times don't want to do, just like avoiding junk food.
No, they don't acknowledge it. To them their body is different and being large is just how it is.
Hence the "if".
If you are in a place where you truly can't control your habits then of course GLP-1s are an amazing tool. However, if you don't adjust your life-style you will relapse when you get off, so the real solution is to adjust your life style. Also, there are benefits to exercise that aren't connected to losing weight. In my experience, 100% of the people I know on GLP-1 drugs are not exercising. I'm sure I'll get 1000 responses of people who do, but in my experience they don't. So you put yourself in a position where you're not addressing the actual problem, you are on a drug for life, and you aren't being healthy in other capacities. Are there times where these drugs make sense? Yes. Of course. Spare me the lecture. Everyone I know on these drugs are middle class people who absolutely could be healthy but don't want to put in any work.
Exercise does very little for weight-loss. You can fill up on calories far faster then you can exercise them.
Thats like saying running the car does little for gas burning because you can fill up in 5 mins.
You have to actually kick your ass when you exercise. Most people don’t push that hard. Michael phelps ate what 6k calories a day or something crazy to maintain his prime form with the amount of caloric burn he was doing in training. If he continued to eat like he did in those crazy olypmpian training years, he’d be morbidly obese. If he ate like he does now in those years, he’d starve.
I think the "you can fill up in 5 mins" analogy is apt and reasonable, actually.
For the average person it's much harder to exercise out of a bad diet than just change the diet. I think it's an easier "sell" for most people to start off trying to eat less than to keep eating the same way and jump right into "kick your ass"-level exercise.
The killer with exercise is that it makes you hungry, proportionally to how hard you worked out.
It's a real killer for "calorie blind" people to go on a 750 calorie hike, and then stop by for a "treat" on the way home. That treat being a 500 calorie blueberry muffin with 200 calories of butter on it. Then they go home and have dinner.
Blame evolution. For 99% of our 300,000 year history, starvation not obesity was what killed homo-sapiens.
Diet and exercise tells people what to do, but not how to do it.
Knowing that you should do something, doesn't necessarily mean can do it. There's still the question of exactly how.
E.g., diet is heavily influenced by hormones/hormonal cycles and access to quality food choices, which vary significantly between people. The glp1s available now are a big help with the hormonal part of this, but they are not within reach of a large proportion of people.
> To me this is just subconscious denial/defending of their food addiction.
If you have to make up unobservable phenomena to explain plainly visible facts, it's usually a sign to look for a different overall model.
Trust me, these people aren't broke and uneducated. They're white collar upper middle class. You don't have to apologize for them
Quitting isn't easy, but fooling yourself to avoid it is on you.
"Food addiction" is perhaps not the most helpful way to describe something that every human would die without.
people don't die from lack of excess calorie.
I can't think of another thing that is called addiction yet requires this very specific wording. Can you give me another example of something that is required for life, but too much is called an addiction?
I hear this all the time to the point where I don't even mention looking at a person's diet and exercise because I expect they'll be shot down
It's something I've read a few times. Most of the studies I've seen say it's effect is modest at best. At least if it was a drug there wouldn't be enough evidence for it to get FDA approval (especially with all the "side effects" such as injury)
Arguably this is a limitation on how the studies were done, as nobody is going to pay for extensive studies since you can't patent exercise.
The studies can’t really prescribe very intensive excerise either. I mean they have to take people where they are. They might have them on a treadmill for a 30 min walk and call that the excerise component of the study. No one is making them squat heavy to failure or clean and press anything. No one is running them on the track until they puke.
Bodies are all different. Diet and exercise can work for one person and not another. But the type of person who wants to believe all fat people are slothful, all unemployed people are lazy, and so on, will invent in bad faith the straw man argument that we think diet and exercise do not work at all. They're not worth engaging with.
Incorrect. There is no person a diet and exercise won't work for. You can not run a caloric deficit and gain weight. The laws of physics apply here.
Humans are not bomb calorimeters. The physics is undeniable and straightforward, but the biology is messy and hard.
According to the nasty, nasty fights I've had with people about this topic there are, apparently, some people whose bodies are actually perpetual motion machines and I'm various kinds of insensitive for even bringing-up physics as it relates to weight. >sigh<
These must be the phenotypes the robots in The Matrix were using as fuel cells.
Are you claiming that some people are exempt from the laws of thermodynamics?
You realize that's a colloquial way of saying that white knuckling through diets has a major adherence problem, right?
A $100 test for an existing condition is NOT what prevention is. The issue is already there.
I expected an article on actual prevention, but I suppose it'd unthinkable to consider not eating trash and moving oneself in any other way than by motor vehicle.
It’s only $100 without insurance. Hospitals charge about $2500-$4000 when it’s “covered”. I know from personal experience just getting one and the hospital erroneously filed it as covered originally.
> The CAC scan, which detects calcified plaque in the arteries, is recommended for adults with borderline or intermediate risk of coronary disease for whom the decision to start preventive therapy such as statin drugs remains uncertain.
That is such incredibly bad advice. DO NOT WAIT until a CAC tells you to start a statin. You know you need to start if your LDL is high right away.
My doctor referred me to get a self pay ($100 at the time) CAC 9 years ago. It was completely clear.
However last year I had a cardiac ultrasound and it showed calcification.
In reality the CAC caused a false sense of security. My LDL had been high the whole time and not managed with any intervention despite having been tested multiple times and showing high over that time. This was a failure by my doctors IMO. (No it’s not diet or weight related before people give advice).
I didn’t need a CAC to tell me everything was fine. I needed to be on a low dose of statin that whole time.
A clear CAC doesn’t mean you are safe. And a positive CAC is already too late and is not really telling you anything useful.
What people need to do is just watch your LDL regularly starting from any age (yes even some 20 year olds need to check this). Don’t wait to middle age. And no matter your age use whatever methods you prefer to get that down as low as possible. Think of it as cumulative exposure over time that matters.
(There are new oral PCKS9 inhibitors out now which is cool, but the reality is all the misinformation about statins has been bullshit, don’t be afraid of them.)
And a CAC somehow magically prevents a heart attack?
In borderline cases it can tip the scale to prescribe statin rather than not. But telling you what has happened to your heart doesn't prevent heart attacks.
Fully agree. Medicare should pay for:
- Gym memberships
- National park passes
- Exercise equipment and sports equipment
- Subsidies for heart-healthy foods
Medicare should also:
- Fine employers if their employees are working more than 40 hours a week, pay the fines out to affected employees tax-free
This is the ultimate case for AI. Intelligence is partly scored based on predictions/planning, so if AI is really intelligent it should be able to tell what remediations are worth it and then lower your insurance cost based on following its recommendations. and back it up by backing those premiums itself.
Home insurance can benefit from this too. I just got a quote on a property i looked at with a $20k/yr premium, partly because of being in CA with a slope and age of the property.
At $20k/yr, there should be some economic way of an insurance company essentially saying "instead of $20k a year in premiums, here is a $300,000 30 year loan to do preventive measures on the property, and if you do them, your policy will drop to a more normal $3k/yr" or something along those lines.
I think author of the article doesnt understand how America works. Its not about helping the public its about money, just look at the numbers in the title.
My scan was $170 out of pocket last week with insurance covering none of it.
It looks about 30 seconds. But it came back with a score of zero so I guess I shouldn't complain.
it is only scanning hard plaque so be mindful of your LDL overall
$100 does not "Prevent It". A $100 test detects atherosclerosis. Further treatment is required. I have no idea what the treatments are or their costs.
I'm interested in this intersection of technical problems where we already have the tech to solve it, but the bottlenecks are social/legal/financial incentive.
Recently there was an old lady in the family that had an appendicitis, an ambulance rejected her, and the next day it got worse, and at that point she was accepted, but it was a bit too late.
One hypothesis is that triaging is hard and there's a lot of demand so things only go in when it's bad enough (considering there was medical insurance, they aren't charging per patient, so there's no incentive to take on more patients). But if that were the case, then preventive measures would actually reduce the total burden on their system.
The more cynical hypothesis that I'm holidng is that that health system is maximizing for work, if there's 10 appendicitis per month, and they are all handled in time, that's maybe like 5 hours of billable hours per patient? But if the appendicitis becomes bad enough and there's a puncture, then you have infections, complications, the patients have to stay for weeks and often come back for checkups, we are looking at maybe 100 billable hours? So the financial incentive is there.
In that sense what I want to add is that the title would be completely wrong, the solution is not for the hospital to pay 100$ for prevention, but for prevention to be more accurately priced, we should be paying 50k, and maybe even 100k for prevention, because we value it more than emergency action.
In a broader economic sense, there's a lot of cases where there's a huge difference between the cost and the value, Shkreli got a lot of heat for surging up medicine prices, but I don't think it's immediately obvious that something should be valued in proportion to what it costs. Maybe if we price heart prevention at 100K, there would be more incentive for everyone involved to just get a fucking pill to those in need, imagine how many people would jump at that opportunity to make it happen, call centers, bureocrats, NOC support, legal teams, all dedicated to making sure a pill gets to the patient before a heart attack does.
Nobody likes to say this out loud, but because the US healthcare system is largely based on “fee for service” billing, it is true by definition that the sicker the patients are, the more profit the providers make. So incentives for actually making people healthier have to be imposed in indirect ways.
There are some pockets of “per capita” payment, where the provider gets a fixed amount per person and is thus encouraged to reduce treatment costs, which indirectly should encourage preventative care, but also encourages just refusing to treat people.
We could remove these weird constraints by making health care a government service rather than a highly contorted pseudo-market, but that would not be the American way. It has to at least look like a market, even if it’s an ineffective, inefficient, opaque, corrupt one.
> We could remove these weird constraints by making health care a government service rather than a highly contorted pseudo-market, but that would not be the American way. It has to at least look like a market, even if it’s an ineffective, inefficient, opaque, corrupt one.
It is still a market (and a single-payer one, ultimately) in these places, but it is not a government service. It is the best solution: the government funds the appropriate cost of care, the provider group is financially responsible for meeting it, and they are incentivized directly to get it right.
The left needs to stop shrieking about Medicare-for-all and the right needs to stop pretending like it can even spell healthcare. There are good solutions.
> but also encourages just refusing to treat people.
It categorically does not. It would be foolish to do so.
>It categorically does not. It would be foolish to do so.
Foolish hardly implies categorically false. It's a well-documented incentive for other risk-bearing entities (see insurance claim denials). Why are providers under capitated contracts categorically immune to refusing treatment to protect margins?
The Medicare “star system” attempts to compensate for this, but somewhat perversely by giving higher reimbursement rates to providers with higher quality. Logically, they should be getting lower rates because they’re more efficient at providing the service. But because the only real incentive is their profit margin, it has to be that way. And of course the star system definitions end up being a constant target of lobbying and stat-gaming.
IIRC this gets gamed by patterns like refusing to readmit patients following complications to hack low readmission rates and preserve higher reimbursement rates? Feels like so much in healthcare where you have a well-intentioned patch trying to solve deep incentive alignment issues and creating more problems.
Completely agree with your characterization of the current system but why does making healthcare a government service necessarily lead to better outcomes vs current state or a more sensibly constrained market?
Seems obviously right in terms of total cost to the median patient (less obvious for individuals in higher tax brackets), so I'm not disputing that. More curious about incentives to improve care delivery for better long-term outcomes.
Healthcare as a government service is one approach to the actual goal, which is healthcare that maximizes the quality of life and productivity of the citizens, rather than maximizing the profits of the providers.
When goods are discretionary and there are no externalities, it’s fine to have a purely autonomous market solution. Healthcare fits neither of those criteria. There’s a reason we don’t (or at least shouldn’t) have private subscription markets for baseline levels of law enforcement, fire prevention, public transit, food and drug quality enforcement, etc. etc. That same reasoning applies to healthcare.
Capitated reimbursement is a hybrid approach that helps a bit, but you can see from Medicare Advantage how the private sector relentlessly games the system because that’s how the incentive is inherently set up by the for-profit nature of the providers.
Yeah capitated reimbursement moves the risk but doesn't seem to effectively encourage innovation on care delivery when it's relatively easy to just cut costs at patients' expense because they have no agency and meaningful recourse.
Your criteria for when a market is (not) a good solution seem reasonable. My biggest concern is there's a fundamental problem with scaling labor-driven services that's exacerbated by entrenched interests constraining the labor supply to support wage growth. Care delivery needs to change if you want to fix both cost and quality, and I have a hard time imagining monumental changes to care delivery from a government service. Care will be expensive as long as it's constrained by scarce labor. That means either costs will balloon at the taxpayers' expense, service quality will decline to cut costs, or more likely both.
The way you fix that is either a) dramatically increasing the supply of qualified clinicians, or b) automation. Clinicians don't want more clinicians because it lowers their wages, so it will be fought at every level in the name of patient safety. But they also don't want automation to decouple care from their labor, so automation, too, will be fought at every level in the name of patient safety.
Most of this is opaque to voters who are largely under the impression that it's all health insurance executive greed, so there's not much of a political incentive to impose meaningful changes.
Where's the way out?
> "fee for service"
> "per capita"
I don't quite get the difference, patients pay a fixed amount for insurance, hospitals charge "fee for service" to the insurance. Both systems coexist, it's not one or the other.
To be clear, I'm not suggesting changing the whole system, I think that's infantile sorry to be blunt, I'm proposing a more down to earth (and commercially appealing approach) of increasing the price (and thus financial incentives) of medical goods that have low cost but high health values.
My economic theory clearly isn't as strong, because how much should a CT scan and a pill be priced at relative to a heart attack response with a 1 week hospitalization and a bunch of work. Because the cost of a CT scan and a pill is low (100$), the value of it is high (50K$ lower bound), and the cost of treating a heart attack is clearly around 50K$, but the value of it is clearly lower than the preventive treatment (perhaps stochastically adjusted).
So should we be pricing by cost or pricing by value? The naïve approach is pricing by cost, so that everything is cheap, the first issue with this approach is that it disincentivizes research, which is why legal systems widely recognize patents, copyright and intellectual property.
I looked into Shkreli's case a bit deeper, and he was a stupid kid of course, but it's what comes to mind when thinking of 'raising prices' of medicine, there's not many faces to that idea.
That said, I'm not saying that prices SHOULD be hiked, just that I'm not convinced that medicine pricing should be cost based, or that it should be value based, or that some supply-and-demand principle would magically find a value in the middle. I'm just saying that it can be either way, and I just don't know which way it ought to be.
And ultimately, it's a decision that every actor in the industry can make, what they price their products and time at. And to reiterate my thesis, pricing your product as cheaply as possible might counterintuitively reduce it's impact, since there is no incentive for intermediaries (or even yourself) to work on it. So I'm not saying that prices should be maximalized either, just that the relationship between price and value contributed to society is not linear, if you price your medicine at 0, you go bankrupt, that's not helpful obviously, and evidently pricing a CT scan and a heart attack pill at 100$ is not cutting it either, hike that up.
>I don't quite get the difference, patients pay a fixed amount for insurance, hospitals charge "fee for service" to the insurance. Both systems coexist, it's not one or the other.
I think their reference to "per capita" here is referring to a capitated payment structure where a provider organization is given a fixed amount per patient up front instead of billing for every service they provide. The software analog would be something like a flat subscription fee vs usage-based billing. While it's not the default in the US, it theoretically encourages providers to provide cost-effective care rather than just racking up bills on unhealthy patients.
The mechanism here is who bears the financial risk. The model you're familiar with is one where the payer (commercial insurance or medicare/medicaid) is the risk-bearing entity. They want more cost-effective care so they can protect their margins while the provider is incentivized to push a high volume of expensive care so they can boost their margins. Don't have it handy but the data on this shows providers are winning this battle with healthier, growing margins vs insurance companies whose margins generally aren't great.
Insurance companies generally have regulated profit margins. Healthcare providers don’t. However, note that this is all percentages — if the total cost of healthcare goes up, providers and insurance companies both win in absolute dollar terms.
Yeah absolutely re regulated profit margins (indirectly through MLRs - their actual margins are way below the cap due to expenses) but that only reinforces my point that providers are having more success growing their margins (on a relative basis, anyway).
Great point on bigger pie increasing both shares. I didn't mean to imply it's zero sum.
Oh the irony of MLRs encouraging insurers to provide terrible service (opex recovery boosts profits) and let providers push fees ever upward (bigger pie, bigger premiums, bigger net profit on constrained margin).
Medicare and medicaid are as a much a gift of revenue for the healthcare industry as it is socialized medicine.
The incentives align well -- people get healthcare for free and and healthcare service provider gets a nice, fat government check.
That's why we don't do preventive care -- our current sick care model is much more profitable.
There are a lot of misaligned incentives in the US healthcare system, but Medicare and Medicaid health plans generally offer similar preventive care benefits as commercial plans.
https://www.healthcare.gov/preventive-care-adults/
https://www.medicare.gov/coverage/preventive-screening-servi...
It's not healthcare mostly, it's medical care.
Otherwise we would tax added sugar out to wazoo and use it to pay gym memberships.
New Amsterdam TV Show is a great insight into this POV imho
look at the author bylines:
* Arthur Agatston * Oren Mechanic
Good luck getting any kind of scan from your doctor/hospital for $100.
I had one a few months ago for $75. Insurance didn't cover it but they took my card.
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Rugged Individualism. The Hero's Journey. Jesus Christ. The ethos of the one weird man and the one weird trick. None of these have anything to do with prevention. The myths of the western world are all about story arcs: conflict + resolution. And this is very much embedded in any venture, whether private-sector or public-sector. We much prefer to read the harrowing article of a poor brave man saving someone from a ridiculous dangerous situation than preventing it to begin with.
This truism, "an ounce of prevention is worth a pound of cure", is so true...that like so many truism, it has become a minor, persistent annoyance of thought. It can be safely filed away with the Austrian school of economics.