Ezra Klein makes his call on how health care reform will play out

Ezra Klein makes his call TKTK:

I think health reform is going to go the way of stimulus.
The stimulus was a huge and important accomplishment. If you had told liberals in 2007 that they were going to pass an $800 billion dollar spending bill that made good on decades of promises about infrastructure rebuilding and comparative effectiveness research and train construction and broadband internet and green energy, they would have laughed at you.
But by the time the bill actually wound its way through Congress, most liberals were frustrated by the outcome: A few Senate moderates had lopped $100 billion in spending off of the total and done so for no apparent reason. Top economists said that the legislation, though helpful, would not be enough to close the output gap and should thus be larger. The stimulus was a historic legislative accomplishment that nevertheless left liberals frustrated because they made concessions they didn’t see any reason to make and ended up with a bill that they knew would not fully solve the problem.
That, I’d bet, is how health reform will close out as well. We will spend a trillion or a bit more covering the un- and underinsured. We will regulate a fairer and more decent insurance market into existence. We will expand Medicaid and build out subsidies to at least 300 percent of poverty and create health insurance exchanges. We will fund all this through sharply progressive taxes. We may even have a public plan. In 2006, it would have been a great deal. But as the legislation winds its way through the Senate, there will be unpleasant compromises, and unconscionable omissions, and the constant knowledge that though this is progress, it is not sufficient, and the people who stand in the way of a better bill are frequently incoherent or disingenuous. And that will be terribly frustrating for supports of the effort. The result will probably be a historic win when compared to the status quo, but I doubt it’s going to feel like that for supporters of the initiative.

I hope he has it pretty much right. Obama’s performance at the presser today gives me hope.

Splendid sea photos by Nick Cobbing

Perhaps because I so enjoyed the time I spent at sea learning about fish, I particularly enjoyed this collection of Nick Cobbing’s photos of ice, sea, and people who work them — scientists, fishermen, adventurers. Cobbing has a great eye for color and form, particularly those of the icy north and the sea; his study of the Greenland ice, fast fading, is particularly stunning, and I very much like his photo account of the voyage of the Nooderlicht, pictured above — a 100-year-old schooner restored and then sailed from Svalbard to Greenland. And don’t miss “The Watch Keeper,” which is about navigating at sea; it makes me ache to go to sea again.

Is lobbying money killing the public-plan health insurance option

I can’t claim to be ‘objective’ or neutral on health-care reform — but who can? Everybody needs health care, some more than others. I need it less than most, as my family and I are, knock on wood, generally blessed with good health. Even so, we laid out $18K last year for health care, still owe money — and no one in the family ever entered an ER, got a scan, received a prescription costing more than $100, or got admitted to a hospital. And we’re among the lucky ones who can (supposedly) afford insurance. (We pay $10K for a plan with a $5K deductible.) This is one of several reasons I’m profoundly dissatisfied with the health-care system we have and recognize what should be obvious: We need major health-care reform in this country.
So why, as a country, do we seem so determined NOT to get it? Or rather, why does Congress seem so determined to not fix something so clearly broken? If a foreign government were causing 45 million Americans to go without health care while driving tens of thousands of others into bankruptcy, we’d be on this thing. Apparently it’s okay, however, if we do this to ourselves. And as of this week, the buzz is that Obama’s efforts to reform health-care are in serious trouble because of a lack of Congressional support. (Never mind htat polls show the public overwhelmingly supports his efforts.) Why is Congress falling down?
Nate Silver at FiveThirtyEight, the site that rose to prominence handicapping the 2008 presidential race, has a very illuminating piece on suggesting at least part of the answer. He breaks down how different health-care special interest money appears to affect the support given the public-plan options by different types of politicians (i.e., liberal dems v mainline dems v ‘centrist’ dems v centrist GOPers). Bottom line: the money seems to have the most sway over ‘centrist’ or ‘mainline’ Democrats who are from regions with high per-capita levels of health-care spending.

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Universal coverage, comparative effectiveness, and the muddying of the healthcare debate

A key component of health-care reform — and saving our ass from going bankrupt and sick from spending too much on lousy treatments — is establishing comparative effectiveness measures, otherwise known as “actually knowing WTF works and what doesn’t.”
This idea terrifies companies who don’t want such objective measures. It also generates a lot of fear, partly via confusing or intentionally frightening arguments. Yet making sure we don’t pay for stuff that doesn’t work is key to reform — a point made in this Times op-ed from libertarian economist Tyler Cohen, keeper of the blog Marginal Revolution.
Cohen argues that the main problem is, as he puts it,

the financial incentives for doctors and medical institutions to recommend more procedures, whether or not they are effective.

These were discussed vividly in Atul Gawande’s recent New Yorker piece, and they are clearly a part of the problem. I think Cohen lets industry off a bit too easily when he says that drug-company profits aren’t really part of the problem, for expenditures on drugs that either do little good or do little better than far less expensive drugs are costing us many billions as well; over the last two decades, for instance, we’ve spent scads of money on modern antipsychotics that cost 20 times as much as the drugs they replaced — and only recently gathered enough data to show they work no better than the old ones.

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The (Illusory) Rise and Fall of the “Depression Gene”

Big psych news of the day is that a big JAMA study debunked the “depression gene” — that is, this big new study (by Risch et alia, in JAMA, today) found that, contrary to a famous earlier big study (Caspi et alia, in Science, 2003), the short (“bad”) form of a particular gene called 5-HTT does NOT make a person more vulnerable to depression. Or, to flip it:: Caspi 2003 had found that having a short version of 5-HTT, which affects processing of serotonin, put someone at more risk of depression if they experienced (as adults) repeated stressful life events. Risch 2009, crunching data from a bunch of studies (including Caspi 2003) to ask the same question — Does the short version of 5-HTT make you more vulnerable to depression if you suffer stressful events as an adult? — found the answer was No.

The headlines are predictable enough, “Sad News for Depression Gene” being perhaps the funnest.

But wait; not so fast. Has an empire crumbled here? A hypothesis evaporated?

You need only look at this briefly, I think, to see that the question addressed by both papers is fairly limited, and does not, crucially, cover variations in how early life experiences might amplify any risk conferred by the short 5-HTT allele. (Caspi & Moffitt clearly did not include such events in theirs excluded such early experiences from some of their analyses, and in fact took measures in some of their measures, such as removing from analysis anyone who suffered depression before age 21, that would be likely to exclude some people who suffered particularly rough early years.. And unless I missed something in reading the Risch paper, it too makes no effort to look at early experience in particular — and, since it pulled Caspi’s data from Caspia, would reflect the same possible filtering out of such early-onset depression cases.)

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The PharmacoScientific Creation of Well-Being

Neuroskeptic offers an elegant unpeeling of a study seeming specifically designed to find a marketing-friendly distinction for a drug — Abilify — otherwise undistinguished.

Suppose you were a drug company, and you’ve invented a new drug. It’s OK, but it’s no better than the competition. How do you convince people to buy it?
You need a selling point – something that sets your product apart. Fortunately, with drugs, you have plenty of options. You could look into the pharmacology – the chemistry of how your drug works in the body – and find something unique there. Then, all you need to do is to spin a nice story to explain how the pharmacological properties of your drug make it brilliant.
On an entirely unrelated note, aripiprazole (Abilify) is an antipsychotic marketed in the US by Bristol Meyers-Squibb. A Cochrane meta-analysis finds that it’s about as good as any other antipsychotic in terms of efficacy and side effects. As good, but no better. However, uniquely, aripiprazole is a D2 receptor partial agonist. Other antipsychotics work by blocking D2 receptors in the brain, switching them off (full antagonism). Aripiprazole also blocks D2 receptors, but it activates them slightly in the process (partial agonism).
Is that a good thing? A paper just published says yes – The relationship between subjective well-being and dopamine D2 receptors in patients treated with a dopamine partial agonist and full antagonist antipsychotics. The research in question was funded, by the way, by Bristol Meyers-Squibb. Let’s see if it holds up.

Some clean and clear-eyed writing follows, in which Neuroskeptic educates us about dopamine receptors even while exposing a cleverness of study design — the study manages , absurdly but “not unreasonably,” to find a possible lift in well-being without any measured correlations — that comes close to provoking wonder.
“I leave it to the reader to evaluate this claim,” Neuroskeptic concludes, “and to consider how likely we are to progress in our understanding of the brain when so much of the research is funded by organisations with a direct financial interest in certain theories.”

The best bang for the stimulus dollar: Insulate! Insulate!

What we know, Bill speaks:
I already knew, from my own modest experience installing and paying for installation of insulation and other energy-saving upgrades in my house, that such work is highly labor-intensive — and so employs a lot of people per dollar spent. When we had our basement insulated, the material cost was perhaps $400; the total bill over $3000. Some of the difference was in equipment, but that was probably fairly modest. The big cost was clearly in paying two or three guys to make racket spraying goop in our basement for 3 or 4 days.
So it stands to figure that a good way to spend stimulus money is on energy-conservation measures on buildings. At Bill Clinton’s press meeting today, he laid out the numbers:

For every billion dollars you spend on a coal-fired power plant, it creates about 870 jobs. Every billion dollars you spent on solar power – depending on whether it’s photovoltaic cells or a solar thermal power plant, a big centralized location which you can only build in a few places – gives you between 1,850 and 2,000 jobs. Every billion dollars you spend on windmills, wind energy – if you manufacture the wind mills in the country where the windmills were put up, gives you 3,300 jobs. Every billion you spend on building retrofits, gives you 6,000 jobs.

Hat tip to Tapped.

Quick dip: Fish hatchery mischief; health-care-reform sabotage; wiki science; and maple seeds

SciAm ponders evidence that fish hatcheries are watering down the trout and salmon gene pool.
Matt Yglesias looks at one of many lies being told by those opposing health-care reform — confirming Salon’s prediction that the opponents of reform are not going to play nice. See also The American Prospect on How Big Pharma Intends to Kill the Public Option. I should add this campaign is having an effect: On the radio this morning I heard NPR Steve Insky Inskeep vigorously press the “public plan as trojan horse” attack on Kathleen Sibelius; I can only hope he’ll as vigorously ask people such as Mitt Romney what exactly is wrong with offering more attractive insurance options to the almost 75 million people who are un- or under-insured.
And if somehow you missed it, do see Carl Zimmer’s fine post on Swine Flu Science: First Wiki, Then Publish and Brandon Keim’s fascinating look at how Maple Seeds Ride Self-Generated Tornadoes.

What if you could predict PTSD in combat troops? Oh, who cares…


Photo: Tyler Hicks, via Scientific American

What if you could predict which troops are most likely to get PTSD from combat exposure — and takes steps to either bolster them mentally or keep them out of combat situations? A new study suggests we could make a start on that right now — and cut combat PTSD rates in half by simply keeping the least mentally and physically fit soldiers away from combat zones.

The study was part of the Millenium Study, huge, prospective study in which US Department of Defense researchers have been tracking the physical and mental health of nearly 100,000 service members since 2001. This is the largest, most thorough, robust, and sizable study of troop health being done — though, for reasons I’ll touch on in a minute, many of its results are going ignored by the larger research community and the press. Its great value is that it’s big, and it began tracking the health of these servicemembers in peacetime, so it is in a prime position to track actual changes in health brought about by military service during wartime.

In this case, the study set out to

Determine if baseline functional health status,… predicts new onset symptoms or diagnosis of PTSD among deployed US military personnel combat exposure.

In other words: Might we already have measures of mental and/or physical health that let us predict which service members are most likely to get PTSD from serving in a combat zone?

The answer is a fairly emphatic Yes. The study found that the least healthy 15% of the troops in the study who saw combat accounted for well over half — 58% — of the post-combat PTSD cases, as indicated by either the study’s own criteria or by self-report of a PTSD diagnosis from the soldiers during follow-up.

This is a pretty stunning result. And it certainly suggests that, as the study put it, “more vulnerable members of the population could be identified and benefit from interventions targeted to prevent new onset PTSD.” The beauty of this finding is that fairly general measures of health are the indicators, so you can predict a lot from fairly simple and easy-to-collect data. Obviously not all of the 15% who scored lowest on PTSD; but that bottom 15% accounted for more cases than do the entire remaining 85%. So at a time when we are much concerned with reducing PTSD in combat troops, it seems fairly plain that we could cut the PTSD rate by more than 50% simply by keeping the least healthy 15% — as measured by fairly simple health questionnaires we already have in any and — out of combat zones.

The paper doesn’t discuss how we would go about doing that. The two most obvious options are to either not accept people who score low on health measures or to accept them into the military but make sure they are given noncombat area assignments.

Strangely, and despite a river of news stories on PTSD this finding has gotten virtually no press attention. One reason may be that it was published in a British journal — the British Medical Journal, or BMJ. Why is a study funded by the United States, conducted by an ace team of US Department of Defense researchers, and having to do with the physical and mental health of US soldiers published in a British journal rather than an American journal?

This is a rich and dangerous question. I’ll offer one possibility: this study appeared in the British Journal because its more fundamental finding — that the overall PTSD rate caused by service in Iraq and Afghanistan was much lower (7.3%) than the rates that, though based on questionable studies and contaminated by the conflation of symptoms with disorder, have been reported and insisted upon by those who dominate the study and treatment of combat PTSD. (I noted this discrepancy in my Scientific American feature on PTSD this April; that story has much more on this tension about PTSD rates in our soldiers.)

Note that I offer this as a suggestion rather than as documented fact. I do not know the submission history of this paper, or of the same authors’ more substantial paper on PTSD rates found in the Millenium Study, published by the same researchers early in 2008; that study found that PTSD rates in veterans of the Iraq and Afghanistan wars were running at around 6 to 8% rather than the 20 to 30% found by other studies. (That study too was published in BMJ and ignored by the US press and the VA.) I twice attempted to reach the researchers to ask whether they had submitted the earlier paper to any US journals, but I was not able to get a response from them or from the DOD public information officers. So it is conceivable that for some reason — though I can imagine what — these US researchers studying PTSD in US soldiers chose to submit their US-funded research findings to a British journal rather than to one of the obvious US journals, such as the Journal of the American Medical Association, the New England Journal of Medicine, or the American Journal of psychiatry.

I suspect it more likely, however, that this paper was submitted to at least some major American journals and then turned down because of damning comments by peer reviewers from the US PTSD research establishment, which has been energetic in its attacks on any findings that contradict with its own, much higher assessment of rates. I’d love to hear a more plausible explanation of why these studies ended up at BMJ. But even such an explanation wouldn’t really explain why these studies are going so roundly ignored here in the U.S.

In any case, these findings on gross health-status predictors for PTSD risk should in theory be helpful aside from arguments about overall rates. It’s a shame this finding — and many others from this robust long-term study — is getting neglected.

Does TV make you hyper? dumb? lazy? distracted? What was the question?

Jim Schnabel has an interesting story at Nature, free to all viewers, on the tetchy difficult of assessing how TV affects kids. I’ve often wondered whether the rise in ADHD diagnoses was due at least partly to TV. This story looks at a researcher who — amazed at how riveted his infant son was by TV — found this seems to be the case.

Christakis decided to try to address these questions with research. Together with several colleagues, he examined a database called the National Longitudinal Survey of Youth. After analysing some 1,300 children for whom the appropriate data were available, they found that on average, a child who had watched two hours of television per day before the age of three was 20% more likely to have attentional problems at the age of seven, compared with a child who had watched none.

That was back in 2004, in a study in Pediatrics. Christakis then did a follow-up, drawing on a different long-term sample, showing that

the link to later attentional problems was particularly strong for cartoons and other entertainment programmes watched before the age of three. For educational programs, such as the gently paced US series Mister Rogers Neighborhood, they found no such link.

(Mister Rogers. Man could do no wrong.)

Sounds pretty conclusive, no? But the story goes on to describe how foggy and inconclusive the research on TV is — partly because too few studies get follow-up, and because funding them is surprisingly difficult. The logical problems are pretty complicated. And in addition, any talk of regulating TV content — or even studying the facts — runs into freedom of speech issues.

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