TrumpCare vs. ObamaCare

I posted quite a few articles on D2L related to possible changed to the Affordable Care Act.  There are more after President Trump's State of the Union.  I read a transcript with sidebars to offer a fact check and more detailed explanation.

I think the recent New Yorker article on Donald Trump learning that healthcare is "complicated" offers some very good links, include the Kaiser News Health Tracking Poll, which I also posted on D2L.  The "complicated" article is telling.  "I have to tell you, it’s an unbelievably complex subject,” President Donald Trump told a group of governors at the White House yesterday. “Nobody knew that health care could be so complicated."

Posted on 2/28, Ryan Lizza deciphers it for us:

“Nobody knew” is Trumpspeak for “I just found out.” Large-scale reform of the American health-care system is one of the most complicated policy issues the government faces, as all of Trump’s modern predecessors learned.

“The health care reform story illuminates almost every aspect of the presidency,” David Blumenthal and James Morone write in The Heart of Power: Health and Politics in the Oval Office, a 2009 examination of how eleven Presidents, from to Franklin Roosevelt to George W. Bush, grappled with the issue. “Because health reform is excruciatingly difficult to win, it tests presidents’ ideas, heart, luck, allies, and their skill at running the most complicated government machinery in the world.” (The book is on Amazon, and you can Read Inside.)

Lizza discussed the dived in the Republican party and ends noting that in their history of health-care reform, Blumenthal and Morone conclude with eight conditions necessary for passing major reform. The first, and perhaps most important, is “passion.”

“Major health care reform is virtually impossible, difficult to understand, swarming with interests, powered by money, and resonating with popular anxiety,” they write. “The first key to success is a president who cares about it deeply.” Any President who is just learning the basic fact that health care is “complicated” has failed the passion test. And without that, little else matters. 

The title of the post is based on another New Yorker article in the March 6 issue by Atul Gwande on
TrumpCare vs. ObamaCare. In his commentary, Gwande points out that Republicans in Congress are facing the wrath of constituents who don’t want to lose those gains they now have with Obamacare.
But even if there is a stalemate in Congress, insurers must decide by April whether to offer a plan for the exchanges in 2018, and at what price. That requires certainty about the future. Pitchforks have their uses, but crafting health-care policy calls for more delicate instruments. The basic functioning of the health-care system and American lives are at stake.

Also today, 2/28, I read an NPR Health Shots article about the portability of health insurance.  In that article, it asks,

Why should a health plan be tied to where you work or live? The answer, of course, is "it's complicated." As Republicans debate ideas for repealing and replacing the Affordable Care Act, portability might play a central role in their plan. So how would that work?

The problem is that portability Is hard to define.   The notion of "portability" means that consumers can stick with the same insurer, the same benefits and the same coverage limits, even if they move or change jobs. In the current policy discussion, though, portability is more likely to be viewed as a means for consumers to get access — possibly with the help of a tax credit — to a variety of health plans.   But, the author (who is with KNN) says that "if keeping the same plan is the goal, that would be very tricky. The health care system is just not built that way."  Read more to find out why.

I thought I would post this on the blog for you to comment, as well as add articles here for you to read.  I did not pick these articles just to be critical of President Trump, but, as you know, when it comes to healthcare, it takes passion, careful consideration, and thoughtful policy discussions.  Feel free to add your own thoughts, or your own readings.

Proposal Draft

I asked you to submit your proposal on D2L.  In addition, you should update your personal blog (or shared blog), so we can all follow your work.  Alternatively, you can post a comment here about what research questions you want to pursue as a way to focus the objective for your research, either as a group or individual.  If you have ideas for data, let me know.  I will also post data links on the blog.  Comment here about specific data you would prefer, or like to have for your project.

Same But Different

Subtitle:  How epigenetics can blur the line between nature and nurture.

We briefly discussed the nature vs nuture phenomenon with genes, and as I mentioned Siddartha Mukherjee, author of The Gene: An Intimate History, had a mother and aunt who were identical twins.  The article points out that in the late 1970s a team of scientists in Minnesota set out to determine why identical twins are similar, i.e., how much these similarities arose from genes, rather than environments—from “nature,” rather than “nurture.”  The question Mukherjee pursues is this:

Why are identical twins different? Because, you might answer, fate impinges differently on their bodies. One twin falls down the crumbling stairs of her Calcutta house and breaks her ankle; the other scalds her thigh on a tipped cup of coffee in a European station. Each acquires the wounds, calluses, and memories of chance and fate. But how are these changes recorded, so that they persist over the years? We know that the genome can manufacture identity; the trickier question is how it gives rise to difference.

The genome is not a passive blueprint.  When one twin breaks an ankle and acquires a gash in the skin, wound-healing and bone-repairing genes are turned on, thereby recording a scar in one body but not the other.  This article goes into some fascinating detail about how David Allis and many other scientists, figured out over decades that  protein systems, overlaying information on the genome, generated the bewildering intricacy necessary for a cell to build a constellation of other cells out of the same genes, and for the cells to add “memories” to their genomes and transmit these memories to their progeny. “There’s an epigenetic code, just like there’s a genetic code,” Allis said. “There are codes to make parts of the genome more active, and codes to make them inactive.”

So, why are twins different? Well, because if you sequence the genomes of a pair of identical twins every decade for fifty years, you get the same sequence over and over. But if you sequence the epigenomes of a pair of twins you find substantial differences: the pattern of epigenetic marks on the genomes of their various cells, virtually identical at the start of the experiment, diverges over time.

I know this is a long New Yorker article, but the science is fascinating for those interested in reading further, or get his book, or read a review about the book.

The beginning of the Personal Genome Project (PGP)

I found the original video from George Church in 2007.  His initial vision moved the dial on understanding and engineering years later.   It is fascinating to look back on the beginnings.  Take a look.



Also, here is the link to the video. The other two videos following this one (Webisode 2 & 3) tell the stories of two people who decided to share why they chose to post their personal genome with the public.

Tending the Body’s Microbial Garden

Here is an excellent overview of the microbiome, we briefly mentioned in class.

For a century, doctors have waged war against bacteria, using antibiotics as their weapons. But that relationship is changing as scientists become more familiar with the 100 trillion microbes that call us home — collectively known as the microbiome.

No one wants to abandon antibiotics outright. But by nurturing the invisible ecosystem in and on our bodies, doctors may be able to find other ways to fight infectious diseases, and with less harmful side effects. Tending the microbiome may also help in the treatment of disorders that may not seem to have anything to do with bacteria, including obesity and diabetes.

These links are worth investigating to learn more about the Human Microbiome Project (HMP).   Judging from a flood of recent findings about our inner ecosystem, that appears to be happening. Last week, Dr. Segre and about 200 other scientists published the most ambitious survey of the human microbiome yet. The Human Microbiome Project is based on examinations of 242 healthy people tracked over two years. The scientists sequenced the genetic material of bacteria recovered from 15 or more sites on their subjects’ bodies, recovering more than five million genes.   This project and other studies like it are revealing some of the ways in which our invisible residents shape our lives, from birth to death.   Here are some NIH  demonstration projects at the HMP.   

In this article, one interesting study (of many mentioned) is that a baby’s microbiome continues to grow during breast-feeding. In a study of 16 lactating women published last year, Katherine M. Hunt of the University of Idaho and her colleagues reported that the women’s milk had up to 600 species of bacteria, as well as sugars called oligosaccharides that babies cannot digest. The sugars serve to nourish certain beneficial gut bacteria in the infants, the scientists said. The more the good bacteria thrive, the harder it is for harmful species to gain a foothold.   

As the child grows and the microbiome becomes more ecologically complex, it also tutors the immune system, however ecological disruptions can halt this education.  Read more on how experiments on mice reveal how this happens.

Antibiotics kill off harmful bacteria, but broad-spectrum forms [of antibiotics] can kill off many desirable species, too. Antibiotics are likened to herbicides sprayed on a garden. The herbicide kills the unwanted plants, but also kills off the tomatoes and the roses. The gardener assumes that the tomatoes and roses will grow back on their own.   In fact, there’s no guarantee the microbial ecosystem will automatically return to normal.

Please read this article and the links attached to the article (under Related Coverage).   As you do so, let me know what you think.

Obese patients and smokers banned from routine surgery

So you not I'm not kidding about this. Hospital leaders in some cities in the UK, including London, said that patients with a body mass index (BMI) of 30 or above – as well as smokers – will be barred from most surgery for up to a year amid increasingly desperate measures to plug a funding black hole. The restrictions will apply to standard hip and knee operations.

A bit of background on this first.  The National Health Service (NHS) was launched in 1948 as a combined payer and delivery system to replace a longstanding mix of private, municipal, and charity insurance. When introducing the bill which was written by the economist William Beveridge (hence the Beveridge Model in T.R. Reid' chapter), to the House of Commons in July 1948 - almost 60 years ago! - the newly appointed Secretary of State for Health, Aneurin "Nye" Bevan argued that the NHS would “divorce the ability to get the best health and treatment from the ability to pay.”  Here is what T.R. Reid said about the NHS (pp. 104-105):

The NHS is dedicated to the proposition that nobody should ever have to pay a medical bill. In the NHS, there is no insurance premium to pay, no co-payment, no fee at all, whether you drop by the GP's office with a cold or receive a quadruple bypass from the nation's top cardiac surgeon.  The doctor's bill is paid by the government, and the patient never thinks about it.

The Brits do pay for medical care, of course.  They pay through a network of taxes that would make Americans cringe; the sales tax in the UK is 17.5% on anything you buy, while income and social security taxes are higher than America's in every income bracket.  The Brits pay by foregoing treatments and medications that the NHS won't provide.

Now you might see where this is leading.  The NHS controls its budget by controlling the range of medications, tests, and procedures it will pay for.  Should a 49-year old patient get a hip replacement?    Combining insurance and delivery of care in the NHS fostered a rational approach through the formal evaluation of therapeutic benefits against treatment costs. Yet because the NHS budget covers everybody, the money saved on one patient can be used to treat another.

Moreover, as the NHS secured annual increases averaging 6.3% during the 2000s, it grew to 20% of the government budget by 2009.  As British government debt rose from below 40% of GDP in 2007 to 72% in 2010, worries emerged that above-inflation spending had saddled the country with unsustainable commitments.

Now when you read the The Telegraph's article, it should make more sense why there is rationing - and to expect more. 

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