No good answer...

One of the manifold reasons why I haven't been posting much at all is trying to support a close friend with cancer treatments (esophageal). The outlook is problematic and I am deeply worried.

Suddenly as well, some information I had considered in abstract becomes more difficult to judge as well - for example, the cost of cancer drugs vs. their efficacy.

No one knew the price of Zaltrap at that point, but Leonard Saltz, who heads the gastrointestinal oncology group at Memorial Sloan-Kettering Cancer Center, had a sense of what was coming. Zaltrap’s effectiveness, in his opinion, was almost identical to that of Avastin, an FDA-approved cancer drug that had also been targeted at that same patient population. Several weeks earlier, Saltz had traveled to Chicago to inflict a little premonitory sticker shock on his medical colleagues. He reviewed the recent clinical results of both Zaltrap and Avastin when used as a “second line” treatment, after initial treatment had failed. As Saltz reminded the other oncologists, Avastin was modestly effective as a second-line treatment—it extended median overall survival by 42 days, the same as Zaltrap—but it cost about $5,000 a month and, like Zaltrap, would have to be taken for many months to achieve that modest clinical benefit. The overall cost was so high that Saltz devoted the end of his talk to a back-of-the-envelope calculation, delivered via PowerPoint, that recast the question in terms of health-care costs: If you extended the 42 days survival to a year, “what is the cost of Avastin for one year of human life saved?”
The answer was astounding, even to doctors who have grown inured to the zero-gravity economics of cancer pharmaceuticals. As Saltz worked his way through slide 73 of 78, he arrived at the bottom line: $303,000.
“Now, that’s essentially the cost of the bare-bones drug,” Saltz later explained to me in his office at Sloan-Kettering. “It’s parts, not labor. No money for doctors; no money for nurses; no money for pharmacists; no money for real estate, heat, and lights; no money for the needles, the IV tubing, the IV fluids, the anti-nausea medicines, the other chemotherapies that are given, because Avastin doesn’t do anything by itself. It has to be given with other drugs … I want to emphasize it’s not that we can have a year of life saved for $303,000. That’s probably less than half of what the actual cost would be when you factor in everything.” Zaltrap, he figured, was probably going to be in the same range.
Saltz’s message was not entirely unexpected. He has been warning about the danger of rising drug prices, to patients and to the health-care system in general, for the last decade. Having made this point to his colleagues, Saltz packed up his computer, took the next flight back to New York, and, after the FDA approved Zaltrap in early August, began to prepare—“not with great enthusiasm,” he conceded—the Zaltrap presentation he would deliver to the hospital committee responsible for approving any new drugs for Sloan-­Kettering’s pharmacy. [More well worth reading]

As we all get upset one way or another about Obamacare and the website issue, it is important to keep in mind that our status quo has some enormous problems - not the least of which is loss of consumer influence due to third-party payers. For example, my friend is looking at a second round of chemo, and I would almost bet he has no idea what it will cost - or the possible surgery either.

Say what you will about the ACA, but one thing I think is a step in the right direction is the introduction of consumer choices in how much they want to pay in premiums as well as out of pocket costs. Transparency will change consumer behavior, I think quickly. At the same time, many people insured by employers are finally getting some idea how expensive their medical coverage is.

Of course, this is not a discussion I would broach with my very sick friend, but it is clearly one of the biggest reasons we spend so much on medical care in the US compared to other countries.Cancer drugs have become a very big business, even though they serve what one expert has described as a “boutique” market. An estimated 1.7 million Americans will be diagnosed with cancer this year, according to the National Cancer Institute, and more than 580,000 people will die from some form of malignancy. In 2012, the overall market for “oncologics” reached nearly $26 billion a year in the U.S. alone, and annual global sales are projected to total $85 billion by 2016, according to the IMS Institute for Health Informatics.

What is sobering about this booming business is that, as a group of oncologists wrote earlier this year, “most anti-cancer drugs provide minor survival benefits, if at all.” They often (but not always) reduce the size of inoperable tumors, but they rarely eradicate the disease. For relatively uncommon malignancies like testicular cancer, some forms of leukemia, and lymphoma, drugs effectively cure the disease; for the common “solid tumor” cancers (lung, breast, colon, prostate, and so on), which account for the vast majority of annual cases, drugs buy some time—precious time, to be sure, but time usually measured in weeks and months rather than years. And even though many of the newer drugs are less toxic, they often still have to be given with older drugs whose side effects include nausea, hair loss, fatigue, and decreasing blood counts. One anti-cancer drug produces a skin rash so severe and disturbing, according to Saltz, that some patients have been asked by employers not to come to work. [Same]

We are rationing already of course, but informally, and generally by economics, rather than some measure of return on the dollar. The very thought is distasteful, but our squeamishness could direct our economy into one dominated by end-of-life health care. Good news for drug makers and caregivers, but not an optimal or even desired outcome in my view.

Regardless, I know I cannot think rationally about this right now, but wish I could. Grief mixed with protracted suffering makes it hard to think well. And then I get angry for feeling sorry for myself, instead of Dan.

We are exactly the same age as well. Funny how that coincidence rivets your attention as well.

Well, enough sniveling. What I need to do is figure out actions what might ease his struggle, not mine.

The oatmeal-Obamacare connection...  

In what may be one of his best columns ever, Rex Huppke at the Chicago Tribune connects two widely spaced dots to sound the alarm for "rill 'Mericans":

Fortunately, there's something we can do about this desecration of an American breakfast tradition. And it can be done while also trying to prevent millions of people from getting health care, thus killing two — or possibly 30 million — birds with one stone.
A brave group of tea party Republicans has decided that the best way to get rid of Obamacare — since voting to repeal it 39 times doesn't seem to be working — is to not fund the law. Heroes like Sen. Mike Lee of Utah, Sen. Marco Rubio of Florida and Sen. Ted Cruz of Hateseverythingistan say they'll oppose any budget that gives money to the health care law, even if that means risking a government shutdown.
This is similar to when Abraham Lincoln famously avoided an American civil war by holding his breath until the South agreed to free the slaves.
The tactics of Cruz and company have been praised by many Republicans, including North Carolina Sen. Richard Burr, who called it "the dumbest idea I've ever heard."
In a recent speech, Cruz said that the Obama administration's tactic is to "get everyone addicted" to Obamacare, thus making it impossible to abolish. He's right. Outside of caffeine and cocaine, there are few things more addictive than access to affordable health care.
My guess is this is the same trick Jamba Juice has up its hemp sleeve. The company — clearly a radical left-wing group of nutrition Nazis — has co-opted something all Americans want (oatmeal) and is using it to get us hooked on smoothies that will turn us into dope-smoking pacifists.
So today I call on Sens. Cruz, Rubio and Lee to not just demand the defunding of Obamacare, but to hold the country's budget hostage until Jamba Juice promises to take its mitts off our oatmeal.
Because if there's one thing that's worth risking the full faith and credit of the United States over, it's anything that might possibly make us healthier. [Read the whole thing to start your day right in multiple ways]

The defund movement has gathered enough big names (all the assumed GOP presidential timber - which says something about the field) to make it newsworthy for that fact alone. But saner voices are coming forward to point out some flaws with this strategy. Like lowering expectations.

SK: What do you expect the Obamacare rollout to be like this October?

TC: I don’t know. What I do know is if you do say it;s going to be terrible, terrible, terrible as Republicans have been saying, and it’s only one terrible, it’s going to look good. We shouldn’t overhype things. We should just watch. The fact that they’re going to do everything they can to get as many people as possible to participate matters. [More]

I have a sad suspicion we are heading toward a total meltdown on the right as the divisions in the GOP make any legislative action impossible.

This includes a farm bill, BTW.

Interstate health insurance...  

And other free market tinkering for healthcare reform.

A commenter suggests other reforms would have been better than Obamacare:

"It seems absurd to me to say Obamacare will bring us toward a freer market. If we all recognize a free market with consumers being aware of real costs and allowed to make a decision on their own that would collectively drive the market, than why not recognize that the conservative position of eliminating interstate insurance purchases would have been a great first step to introduce market forces. The other aspect you ignore that has been well-documented in many studies is that the reason US health care is expensive is in large part the built in costs and extra testing associated with our lack of liability reform. That was purposely omitted from Obamacare. Many democrats said they would deal with that separately, but of course they've forgotten all about that given the huge donations they get from trial lawyers."

Let's take these two ideas in turn. First the idea that if competition is allowed it will occur. There is no evidence for this whatsoever.

Allowing insurance sales across state lines comes up perennially as a way to drive down the cost of health care.
Conservatives argue that allowing a plan from a state with relatively few benefit mandates – say, Wyoming – to sell its package in a mandate-heavy state (like New York) would give consumers access to options that are more affordable than what they get now. 

Liberals tend to argue this is a bad idea, contending that it would create a “race to the bottom,” where insurers compete to offer the skimpiest benefit packages

A new paper from Georgetown University researchers suggests a third possible outcome: Absolutely nothing at all will happen. They looked at the three states – Maine, Georgia and Wyoming – that have passed laws allowing insurers from other states to participate in their markets. All have done so within the past two years. 

So far, none of the three have seen out-of-state carriers come into their market or express interest in doing so. It seems to have nothing to do with state benefit mandates, and everything to do with the big challenge of setting up a network of providers that new subscribers could see. [More]

Avik Roy argues it will just take longer, but so far the results are: nada. This idea also would not touch the "uninsurable" problem, which grows with each new diagnostic test.

As for tort reform, I think the idea is obscured by an availability paradox. We read about multimillion dollar settlements and see the lawyer ads, but don't have a handy comparison to total health care costs. The CBO checked this claim.

Elmendorf wrote that newly available research prompted CBO to update "its analysis of the effects of tort reform." The agency's conclusion: A package of reforms that included a $250,000 cap on damages for pain and suffering and a $500,000 cap on punitive damages "would reduce total national health care spending by about 0.5 percent."
The federal government would reap a substantial portion of those savings, the CBO said, primarily through reduced Medicare costs.  [More]

Tort reform isn't chump change, but it doesn't really move the needle. At about $5B per year saved it's really not a biggy. (At least that's what we say when they want to reduce crop insurance by a similar amount.) Keep this number in mind: $3T. That is our total health care cost estimate for 2014. (I picked that year because it's a round-ish number.)

Another issue is, as economists of all stripes point out, when you are paid per procedure (Fee For Service), you tend to get more procedures, regardless of "defensive" medicine or not. Personally, I also think American consumers want something done or prescribed, rather than hear, "You'll survive, just outlive it." Most doctor visits are for self-limiting or chronic complaints. Think of the antibiotic overuse (especially in children) that farmers point to when feeding antibiotics is linked to resistance.

I support both ideas. But because Republicans refused to negotiate during the passage of the ACA the ideas never got looked at seriously. When obstruction is your primary goal, why should your ideas be included? Davis Frum agrees. Much of Obamacare, and certainly the mandate, was a conservative idea back when I was a mainstream conservative.

“Nobody was saying that it was creeping socialism or unconstitutional at the time. A lot of conservatives were for it,” former GOP senator Bob Bennett told me yesterday, looking back to the 1993 fight against “Hillarycare.”

The roadmap for what was then the signature Republican approach to health-care reform was provided by the once quintessentially Reaganaut think tank, the Heritage Foundation, which now denounces “the cancer of Obamacare.”  The offending document was written in 1989, at the dawn of the first Bush presidency, and its rationale for the individual mandate was as follows:

1989 Assuring Affordable Health Care for All Americans
 [More]

There is no Republican plan for reforming our healthcare problem, and the two items listed above are good ideas, but hardly an answer. Besides, watch immigration reform. The right now has only one political skill/agenda: stop anything from happening.

Perhaps a little light...  

Maybe the rhetoric will flame out or just dull in the heat wave. Then we can talk about what the health reform law actually is doing and will do. An ordinary guy at Reddit plodded through the bill and came up with the best summary I have found.

Okay, explained like you're a five year-old (well, okay, maybe a bit older), without too much oversimplification, and (hopefully) without sounding too biased:
What people call "Obamacare" is actually the Patient Protection and Affordable Care Act. However, people were calling it "Obamacare" before everyone even hammered out what it would be. It's a term mostly used by people who don't like the PPACA, and it's become popularized in part because PPACA is a really long and awkward name, even when you turn it into an acronym like that.
Anyway, the PPACA made a bunch of new rules regarding health care, with the purpose of making health care more affordable for everyone. Opponents of the PPACA, on the other hand, feel that the rules it makes take away too many freedoms and force people (both individuals and businesses) to do things they shouldn't have to.
So what does it do? Well, here is everything, in the order of when it goes into effect (because some of it happens later than other parts of it): [Please read the succinct summary here]

Posting about the ACA is toxic, like climate change only meaner, and right now (drought) I really don't need that. Nor do rational arguments seem to gain much traction. Haidt's book made it clear to me why.

But I want to help readers when I can to at least be irate over real stuff, not pure lies. It isn't the biggest tax increase in history. People aren't dying because ACA has cut off their dialysis.

I don't want to add irritation to anyone right now, but a little light might help.