[HN Gopher] Our main problem in health policy is overemphasis on...
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Our main problem in health policy is overemphasis on medicine
(2007)
Author : orborde
Score : 41 points
Date : 2021-12-03 02:20 UTC (20 hours ago)
(HTM) web link (www.cato-unbound.org)
(TXT) w3m dump (www.cato-unbound.org)
| jt2190 wrote:
| (2007)
| dang wrote:
| Added above. Thanks!
| orborde wrote:
| (OP here)
|
| This essay set may superficially appear to be another repetitive
| salvo in the interminable US healthcare political conflict, but I
| recommend reading a bit deeper. I think the perspective these
| essays offer (that, at the margin, medical spending doesn't
| affect people's wellspan much, at least not in the US) is both
| quite important and underrepresented in most discussions of
| healthcare.
| lambdaba wrote:
| I mean, why would we expect it too? Spending is about profits
| accumulating somewhere, so why would that have anything to do
| with optimizing healthspan? Note, I'm vehemently critical of
| the modern medical establishment, and a health loon myself (by
| necessity, was hit with a though illness early on in my life).
| Animats wrote:
| Bring back fat-shaming!
| [deleted]
| wkd415 wrote:
| Duh.
| paulpauper wrote:
| A lot of $ is spent on medicine because medicine works.
| Alternatives such as diet, exercise either are spotty in efficacy
| or do not work. Medicine offers a quick fix and in some cases the
| only fix. Someone who has cancer will need to be treated with
| medicine, not diet.
| NoPie wrote:
| Diet and exercise will work much better to prevent obesity than
| any medicine on market. It is just that long-term adherence to
| these things is very much determined by culture and will be
| much harder for Americans compared to Japanese, for example.
|
| There are new discoveries in diabetes medicines recently but
| again, you will do much better by not getting diabetes in the
| first place.
|
| The same goes for smoking which can cause, for example, lung
| cancer. Roughly speaking, once you get diagnosed with lung
| cancer you only have 40% chance living more than 1 year. Costly
| novel medicines often prolong the life by few months only.
|
| We really need better health economy education for everyone.
| lambdaba wrote:
| I mean, it's not complicated, when we allowed the tobacco
| industry to manipulate people for profits while hiding the
| disastrous health consequence of their products, people got
| ill in larger numbers
|
| It's the same for the processed food industry. It's time will
| come, soon, too, as healthcare systems everywhere are failing
| because of it.
| astrange wrote:
| Not "diet and exercise", just diet. Exercise doesn't
| contribute more than ~10% to weight loss (it helps for many
| other things but not that) - and if you're having trouble
| with the diet then it makes it more difficult because you get
| hungry, which sometimes cancels the entire thing out.
| lambdaba wrote:
| IME exercise (combined with appropriate diet, mind you),
| actually reduces food intake for me. Or at least, makes it
| so I eat less net calories after removing the expenditure.
| But otherwise agreed, diet is the foundation.
| lambdaba wrote:
| this is such a strange comment for me, and I beg people not to
| reflexively downvote and instead join in for a discussion, but
| I'm part / have been part of communities where people ROUTINELY
| achieve remission from disease the medical establishment deems
| incurable
|
| I can go in further details if people ask, but lifestyle
| intervention has DRAMATIC results for many people, myself
| included, and results not provided by drugs or any commonly
| available medical intervention
|
| Let me give you an example, RE: cancer and diet, look up
| "Andrew Scarborough brain cancer" and you'll find a detailed
| account of someone treating incurable brain cancer with diet
| and lifestyle; and this is someone working in the medical field
| (actually, precisely in oncology)
| danachow wrote:
| > and this is someone working in the medical field
|
| Well, yes, even a crackpot can claim to be working in the
| field.
|
| This in no way supports your claim of "routine" cures through
| diet. There is no evidence that a fucking keto diet will cure
| cancer* and it doesn't pass any sniff test as at the end of
| the day your body still runs on glucose. This is pretty much
| an insult to anyone not fortunate enough for their cancer to
| go spontaneously into remission - and looking at the loon you
| posted, both he and a family member had some amount of
| treatment before diet, confounding any claim that diet was
| responsible for remission.
|
| * whether such a diet can have some survivability benefits or
| some better or worse outcome is an open question, which has
| nothing to do with your crackpot claims.
| lambdaba wrote:
| Also, re: this caricature you make of these "keto" diet
| cancer plans, it's not true that the "body still runs on
| glucose", in fact only 25 grams of glucose are manufactured
| by the liver per day in the absence of dietary
| carbohydrates. And I don't claim to know the mechanisms,
| but I know FOR SURE that human beings (and no other animal
| for that matter) evolved to live on candy bars and sugar
| water, and that replacing one's diet with something
| species-appropriate and nutritionally replete is bound to
| have some effect.
| [deleted]
| lambdaba wrote:
| Third point, and I'm going to end it here: I myself
| suffered from Multiple Sclerosis when I was younger; it was
| retrospectively very easy to correlate, at least in a large
| part, with diet and lifestyle. The changes I had to make to
| be in remission were DRAMATIC but worth it. I don't think I
| would've been insulted to read about people in similar
| situations experiencing remission from lifestyle
| adjustments, in fact, I would have been extatic to find out
| I'm not condemned to slowly drift into being eventually
| wheelchair-bound, as my doctors were predicting.
| [deleted]
| lambdaba wrote:
| I am only replying to your incendiary comment to say that
| your characterization is insulting and wrong, "fucking keto
| diet"(s) are having results for many people, whether you
| like it or not
|
| Others, please research this person further, he's not a
| "loon" / "crackpot" just a regular smart young person who
| also happens to be a cancer researcher.
|
| BTW, keto also cures epilepsy, and that's known since the
| early 20th century, is that also triggering to you?
| gahn wrote:
| Had to login just to counter the epilepsy part of this
| comment, though I think it applies to the rest of the
| topic wrt cancer as well. Keto diets can, in some cases,
| help epilepsy patients, particularly those with certain
| seizure types or genetic basis. But, like with cancer,
| epilepsy is complicated both in presentation and cause
| and to pretend that keto is any way a cure for epilepsy
| outside of a small minority of patients isn't true. See
| https://www.epilepsy.com/learn/treating-seizures-and-
| epileps... for high level overview.
| lambdaba wrote:
| It sometimes is enough, sometimes not. But it does have
| SOME undisputed efficacy and it's an area of legitimate
| research.
| danachow wrote:
| Lol "sometimes is enough, sometimes not" is a bit of a
| backpedal from definitively putting cancer into
| remission.
|
| If it's an area of legitimate research for cancer
| treatment, then why do you lead with a reference to an
| individual crackpot - instead of even a poorly designed
| peer-reviewed study in a low impact forum.
|
| Of the millions of possibilities, why do you assume that
| it was the keto diet of this individual that lead to
| their remission? Do you lack the imagination that it
| would likely be something else?
| lambdaba wrote:
| I was referring to epilepsy.
|
| I will not get into further arguments with you re: the
| "crackpot", insult. Have a nice day.
| danachow wrote:
| Right, you went from routinely driving cancer into
| remission, to, meh sometimes it might help epilepsy. I'll
| call that a backpedal.
|
| I do find the the thought process interesting - this one
| dietary trick that is supposedly based on how our ancient
| bodies are supposed to work that can cure cancer - yet
| it's stifled by the big bad pharma industry... Like
| cancer is not a new disease, it's existence was clearly
| documented by the Egyptians and Greeks and probably known
| to older civilizations whose artifacts are
| lost/undiscovered. Certainly they would have figured out
| that the "evolved" keto diet they were supposedly eating
| already would have had a benefit routinely driven cancer
| into remission.
| anonuser123456 wrote:
| The efficacy of cancer prevention via fitness, diet and
| lifestyle far exceed the efficacy of cancer treatment by
| medicine.
| colinmhayes wrote:
| This is why we need medical payments to be capitated, not fee for
| service. The way medical care currently works has horrible
| incentives. Medical providers have an incredible informational
| advantage so patients just do whatever their doctor tells them.
| Since doctors get paid for doing things they routinely tell
| people to do things that are proven to have little efficacy.
| Medical providers should instead be paid per patient they cover.
| Especially now that hospitals are so consolidated it's relatively
| easy to tell if health outcomes are better or worse than average
| over the group of patients they cover. By punishing providers for
| achieving bad outcomes and sharing the savings they obtain by
| cutting waste we can drastically reduce healthcare costs.
|
| Medicare and Kaiser permanente are leading the charge with this
| style of insurance and have already shown it to be cost effective
| while not reducing the quality of outcomes.
| nradov wrote:
| The healthcare industry is gradually shifting from a fee-for-
| service model to a value-based-care model. This will take a
| long and we'll probably always have a hybrid model with varying
| levels of financial risk spread across insurers, providers,
| patients, and government.
|
| As an incremental step forward bundled payments are a good
| approach. For common interventions like a hip replacement the
| insurer gives the provider a single lump sum for everything
| instead of having separate line items for surgery, anesthesia,
| medical device, antibiotics, hospital stay, physical therapy,
| etc.
| michaelbuckbee wrote:
| This is tricky to implement as it introduces other perverse
| incentives: namely that health care providers stop treating
| very sick people. You see this in some cases with surgeons
| already that have a very high success rate. They'll only opt
| for surgery if it's a relatively minor need, but if it's
| complicated or there are potentially complicating issues
| they'll pass.
| colinmhayes wrote:
| Outcomes for very sick people being worse is taken into
| account so providers aren't punished if their success rate is
| lower for those patients. We have all the data we need to
| know what the outcomes should be for a provider over the
| course of a year. Anyway, providers have to precommit to
| their pool of patients, so it's not like they can just pick
| the lucky ones.
|
| Capitation is admittedly a much more complicated way to
| administer health care, but fixing the incentives is
| absolutely worth the pain we may face in the short term.
| Which we might not considering how well these programs have
| been shown to work.
| clairity wrote:
| you're not fixing the distortive incentives with this
| scheme, just transforming them. 'capitation' incentivizes
| hoarding of patients, most obviously by incentivizing the
| minimization of treatment times and associated costs but
| also through outright fraud (by falsifying records, etc.).
| so you're essentially trying to maximize patient outcomes
| by capping costs, which is a terrible proxy metric all
| around.
|
| to actually improve healthcare, we'd need to _increase_
| spending per person (by an order of magnitude or more,
| using more team-based medical care rather than 1-on-1), for
| not only direct care costs, but also research and
| development. what we absolutely need none of is deadweight
| losses, like profit-maximizing medical administration, big
| pharma, and the whole medical insurance industry. medical
| 'insurance' has become a complete misnomer, as it no longer
| serves to mitigate the distasterous effects of low
| probability, high impact events, but as a socialization of
| routine medical care, which is not _insurance_ at all.
| RSZC wrote:
| Huh, I didn't expect to come across something I have such
| direct knowledge of.
|
| I used to work with this data directly - I worked with
| MACPAC to prepare reports for the CBO on the efficacy of
| pay-per-performance programs, especially as it pertained to
| the possibility of switching Medicaid from a fee-for-
| service model to a pay-for-performance model. (6-9 years
| ago)
|
| I just wanted to chime in on this one quote:
|
| > We have all the data we need to know what the outcomes
| should be for a provider over the course of a year.
|
| The data here is exceedingly low quality, especially for
| Medicaid. Medicare is in a better state due to being
| centrally administered. We do *not* have all the data we
| need to make pay-for-performance more than an extremely
| rudimentary approach. Is that rudimentary approach still
| better than fee-for-service? Maybe - that's a complicated
| question I let the public health PHDs write very long
| reports on.
| dadjoker wrote:
| This is true of COVID too. Instead of actually looking at stats,
| and realizing that, for instance, 75% of all "COVID deaths" (a
| bloated stat if there ever was one) were obese people, stressing
| being healthy and losing weight instead of assuming vaccines (the
| ones that don't keep you from getting or spreading it) were the
| miraculous cure would have made a world of difference.
| tux3 wrote:
| Fit, healthy, people are dying left and right.
|
| There are risk factors, but don't start thinking you're
| invicible for not having them. The adaptive immune system is
| slow, vaccines prime it to react faster with more specific
| antibodies.
|
| Dying of pneumonia does not feel good. It makes grown men cry
| and beg. Strongly recommend against.
| lambdaba wrote:
| But those "fit, healthy" (the genuinely so, I'm not sure I
| even agree with the characterization for many of the
| mediatized cases), are OUTLIERS. Yes, you are never
| invincible, but it's 100% correct to characterize Covid as a
| disease of the metabolically dysfunctional. Sadly, this is a
| HUGE percentage of the population of the world nowadays,
| which seems to be the point of the article (disclaimer: in
| true HN tradition, I haven't read it)
|
| Traditionnal post-downvote comment:
|
| Covid affects those:
|
| - on immunosuppressant medication most often for a
| PREVENTABLE "lifestyle" disease
|
| - otherwise negatively affected by said disease, particularly
| in the vascular system, we know that Covid kills most those
| that have hypertension, long-term vascular damage from
| chronically-elevated blood sugar, etc.
|
| - nutritional deficient / malnourished (low vitamin D,
| absence of sunlight, etc. etc.); this is also very common
| whoopdedo wrote:
| > this is a HUGE percentage of the population of the world
| nowadays,
|
| And thus make up a sizeable amount of COVID patients. I see
| nothing noteworthy here. Having a preexisting condition
| makes you suffer more when you contract an infectious
| disease. I'd expect the same things you said could be
| repeated for influenza, pneumonia, or anything else. For
| that matter, how much worse do obese patients fare when
| recovering from a broken leg? Are fractures then a disease
| of the metabolically dysfunctional, as you put it?
| lambdaba wrote:
| What's noteworthy is *vascular* health is particularly
| important, thus chronically-elevated blood sugar which is
| *eminently* resolvable by lifestyle intervention, is the
| main culprit. So I don't follow your comment.
| tsimionescu wrote:
| Jumping from vascular health to blood sugar level is a
| non-sequitur. There are many other aspects of vascular
| health.
|
| And nothing is easy about a lifestyle intervention, it is
| in fact one of the hardest and least likely to hold kinds
| of medical treatment.
| lambdaba wrote:
| chronically-elevated blood sugar is quite probably the #1
| cause of vascular problems (heck, it's highest
| association is with hypertension, these go hand in hand),
| hypertension is itself often associated with a common
| magnesium deficiency (stiffness is what happens when
| magnesium is insufficient and calcium is overexpressed, I
| mean this is the basic role of magnesium in the cell,
| "relaxing" the contraction brought on by calcium), this
| is schematic and a layman view but I believe basically
| correct
| gahn wrote:
| What lifestyle diseases are you thinking of that are
| commonly treated with immunosuppressants? Diseases like
| psoriasis and rheumatoid arthritis are commonly treated
| with immunosuppressants and are not considered lifestyle
| diseases.
| lambdaba wrote:
| these both OFTEN have dietary triggers that are possible
| to discover with certain elimination diets
|
| again, I'm not here to go on long arguments while being
| called a loon, which I'm bound to when touching this
| subject
|
| sticking closer to home, tldr; I had MS, treated it with
| an elimination diet and other lifestyle changes, barring
| this intervention, I'd be on immunosuppressants
|
| but I didn't intend to make this the larger part of my
| argument, as the main issue is with people facing blood
| sugar control problems brought on by "extremely western"
| (sugar|processed|junk)-food-laden diets
| bpfrh wrote:
| But vaccines ARE the miraculouse cure, at least in my country
| the high case load is because of unvaccinated or not fully
| vaccinated people.
|
| If about 80% of the population took it, we wouldn't have any
| problem.
|
| Of course previous health issues matter when you get sick and
| of course we should encourage healthier living, but we won't
| change this in the next 6 Months, for that we have a vaccine.
| RobertRoberts wrote:
| Vaccines won't help _at all_ if your immune system is
| completely compromised by other health issues.
| Robotbeat wrote:
| They absolutely help if everyone else gets vaccinated,
| which is what the person you're replying to said.
| RobertRoberts wrote:
| To be accurate, there are no COVID vaccines by the official
| definition. There is only pharmaceuticals being labeled as
| vaccines.
|
| Real vaccines induce immunity.
| orborde wrote:
| The US adult obesity rate is 42.4% [1]. To get to 75% of deaths
| being obese people, you'd need about a 4x death rate of obese
| people compared to non-obese people. Most obese people find it
| extremely hard to stop being obese and often fail despite
| immense effort.
|
| Meanwhile, getting a COVID vaccine reduces the chance of death
| by >10x at a cost of <$40 per person. My impression is that
| vaccines are unusually cost-effective medicine and that the
| low-impact medical spending is elsewhere in the system, but it
| is nonetheless thought-provoking to consider this specific
| example.
|
| [1] https://www.cdc.gov/nchs/products/databriefs/db360.htm
| NoPie wrote:
| It could be true that obese have 4 times higher death rate.
| Note that obesity often comes together with diabetes and
| cardiovascular diseases which increase the risk even more.
|
| Vaccines are effective, they reduce death rate approximately
| 10 times. It still seemed quite high that several EU
| countries have reintroduced restrictions despite good
| vaccination uptake.
|
| Besides this is about long-term issues, not just covid or
| something we can fix in 1 or 2 years.
| brigandish wrote:
| > Most obese people find it extremely hard to stop being
| obese and often fail despite immense effort.
|
| I used to help out at a slimming group. Like many self-
| improvement quests, the effort waxes and wanes. Much as I
| wished for people to achieve their dream of being slimmer,
| and even though their wishes and often their attempts were
| laudable, I wouldn't call them "immense". They're people,
| most wanted an easy fix and struggled to remain dedicated
| when faced with the harder bits.
| lambdaba wrote:
| This. It's not hard to make the necessary changes if
| sufficiently motivated. In fact, formulating the motivation
| is kind of the only step, everybody, and I mean *EVERYBODY*
| can achieve appropriate weight and even above-average
| fitness if following the right precepts.
| tsimionescu wrote:
| Why do you assume this is a matter of motivation, or that
| motivation is not itself a component of obesity as a
| disease?
|
| Our urges to eat and be lazy are also a consequence of
| our health and diet. They are not coming out of some pure
| rational willpower plane.
| lambdaba wrote:
| Sorry, I'm not sure I expressed what I meant clearly so
| I'll try again: I mean that it's sufficient to be
| motivated WHEN armed with the proper knowledge; I think
| many people fail DESPITE being motivated because they are
| simply misinformed as to what works.
|
| Yes, reading my comment again it doesn't seem I was
| saying that. Anyway, I don't think that much motivation
| is required, and if a diet / lifestyle change is hard to
| stick to, it's often because it's a misguided strategy.
| For illustration, counting calories while not making
| qualitative changes in the composition of the diet is
| just simply never going to work, long-term. Some foods
| are just too hyperpalatable, too prone to form emotional
| / addictive associations, but conversely that also
| implies those dietary changes will have to confront some
| emotional regulation issues as well. It sounds
| complicated, but I don't know, I think looking at how
| widespread the overweight issue is nowadays we have to
| conclude almost all of us are doing something wrong wrt
| to diet and lifestyle.
| 908B64B197 wrote:
| > Most obese people find it extremely hard to stop being
| obese and often fail despite immense effort.
|
| Calories in vs calories out. Simple as that.
| Robotbeat wrote:
| You're fighting a billion years of evolution screaming at
| you to bulk up in case there's a famine. Good luck.
| tsimionescu wrote:
| Ok, how does that explain why some people want to eat even
| when they're full, while others feel full after eating a
| grape (exaggerating)?
| paulpauper wrote:
| even bariatric surgery seldom produces thinness. It only
| makes a very obese person only mildly obese, optimistically.
| The diet and fitness industries are worth billions of
| dollars, with pitifully poor results to show for it. Biology
| is fighting all efforts to make humans thinner.
| umvi wrote:
| "An ounce of prevention is worth a pound of cure" - old proverb
| tom_bombadil wrote:
| > "The right says governments produce a much inferior baby"
|
| Too many Cesarean sections over centuries will yield more narrow
| female hips.
|
| You will like small butts, and you will lie. [0]
|
| Russians expose their newborns to the cold on purpose, to build
| immune systems so as to not eventually need as much "Big Pharma".
| [1]
|
| [0] https://www.youtube.com/watch?v=X53ZSxkQ3Ho
|
| [1]
| https://www.reddit.com/r/interestingasfuck/comments/qinla7/b...
| [deleted]
| ABeeSea wrote:
| This is a 14 year old article (pre ACA) from an associate
| professor in economics who doesn't have a degree in economics.
|
| Sigh
| dang wrote:
| Those aren't good reasons to reject an article. Would you mind
| reviewing the site guidelines? Note that they include: "
| _Please don 't post shallow dismissals, especially of other
| people's work. A good critical comment teaches us something._"
| Also: " _Don 't be snarky._"
|
| Older articles and historical material are always welcome on
| HN, if they're interesting. Often they're more interesting than
| the latest $thing about $current-hot-topic.
|
| As for which credentials professors do or don't have, that
| seems irrelevant to whether or not the article can be the basis
| for a substantive, interesting discussion, which is what we
| care about here.
|
| The main reason to consider this article offtopic for HN would
| be that it's on a classic flamewar topic. However, those aren't
| automatically bad. It depends, again, whether the article
| contains enough interesting information be different (https://h
| n.algolia.com/?dateRange=all&page=0&prefix=false&so...), and
| can sustain an interesting discussion. After skimming it a bit,
| I think it probably clears that bar.
|
| I've changed the title from the original, though (because it's
| provocative and therefore flamebaity) to a representative
| sentence from the article body, which says what the article is
| about.
|
| Of course it's still up to HN users to focus on the interesting
| parts and discuss them thoughtfully, rather than use it as a
| diving board to spring into pits of hellfire from.
|
| https://news.ycombinator.com/newsguidelines.html
| NoPie wrote:
| 14 years old article is a good reason to take note of it as
| it shows it is not just some fad but important long-term
| issue.
|
| I don't think the issue itself is controversial. I was taught
| at university that our life expectancy is determined roughly
| speaking one third by our genes, one third by our lifestyle
| and one third by healthcare.
|
| And then it became apparent that most healthcare
| interventions (childhood vaccinations, antibiotics, most
| medicines) that have a big effect are relatively cheap. The
| most costly interventions have the least effect. We could
| easily cut the health budget in half with only a marginal
| decrease of actual outcomes. But it would be very hard to do
| due to politics, the structure of incentives etc. But we
| really need to critically examine and educate people that
| expecting more and more from healthcare despite progress in
| this field can only lead to diminishing results.
|
| We cannot change our genes (yet) but we need to think more
| about our lifestyle (obesity, drug and alcohol use) which
| could provide considerable potential as well.
| dang wrote:
| (The classic flamewar topic I was referring to is the U.S.
| healthcare system)
| nradov wrote:
| I generally agree but public sanitation measures including
| water purification, food inspection, garbage disposal, and
| sewers also have a huge impact on average life expectancy.
| Maybe even more than healthcare.
|
| In other words, vaccines are wonderful but if I had to pick
| between vaccines and clean water I'd take clean water every
| time.
| orborde wrote:
| What specifically has changed since this essay set was
| published that would render it moot? If "the ACA", what
| specific ACA policies?
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