New York Department of Health – Ass kicking or over-reaching?

New York City has long been a progressive place.  It has served as a laboratory for many proposals and policies.  Some have been brought to the national stage (think many New Deal initiatives). Some have been adopted by other municipalities (smoking bans in bars).  Some have started fads (no-trans fats).  Some have fallen on their face (congestion pricing).  But I have to say that the New York City Department of Health (Department of Health and Mental Hygeine to be accurate) has been on a role. Let’s count the ways:

1. Strong smoking bans in all indoor public spaces.  I think accurately it is any indoor place where a person might work. I don’t think NYC was the first, but it was early, strong, and a major leader in a trend that has hit NJ, CT, and much of the U.S.

2. A pack of cigarettes now costs $8.00 per pack due to huge taxes.  Consequently, smoking rates have been nose-diving.  And yes, it is due to the tax more than the ban. Plus, nicotine pacth giveaways all over the city!

3. Trans-fat ban that is hitting all restaurants this summer. 

4. Calorie count. Any restaurant that has more than 10 locations nation-wide must post their calories.  You may think twice about ordering that vente caramel…500 plus calorie latte or that 1,000 calorie Chipotle burrito.

5. Greener NYC.  Hybrid cabbies, 1 million new trees, cleaner buses, etc.  This may not be the Department of Health exclusively, but I’m sure they played a role.

6. Widespread condom giveaways.

7. The latest is that there is a push to test everyone in  the Bronx for HIV/AIDS (voluntary of course). Since the Bronx has the most deaths, not infections (I believe that belongs to Manhattan), they want to catch the disease early so treatment can be started.

So are these measures draconian or public health genius? Which ones do you like?  Which ones step on your toes?

Headlines – 6/17/08

• The Urban Institute put out a report on the Massachusetts health plan two weeks ago.  It’s findings were mostly positive.  More than half of the unisured in 2006 are now insured (greater than expectations), most people like the plan, access to care has improved, and out of pocket costs have dropped.  The bad side is that budget costs have run over budget (but so has national spending) and there is a shortage of primary care doctors.  For the NYTimes read here and here.
• ” Ben S. Bernanke, chairman of the Federal Reserve, told Congress on Monday that health spending would “rise relentlessly” unless lawmakers overhauled the health care system, and he recommended an eclectic approach.”  Read more here.
• Employer health care costs are expected to rise nearly 10% in 2008 and in 2009, respectively. Much of the extra expense is due to a hospital building boom and the cost of cross-subsidizing the uninsured and public programs.  The study comes out of PriceWaterhouseCoppers and was reported by the AP.

What a Perspective!

I believe one fundamental difference that divides perspectives on health care is the whether you believe it is the community’s obligation to take care of one another.  Some believe that with the exception of a few basics the government (community) should not interfere.  Basically it is every man or woman for themselves.  Others believe that a community must take care of its weakest. This debate has taken an interesting twist in several comments and posts of friends of mine regarding organ donation.  Organ donation (especially while alive and for a stranger as in a kidney) is quite possibly the strongest recognition that one can make that the community does in deed have an obligation to take care of its own.  Organ donation strips the  barriers that most people construct around their bodies.  Bodies are personal, private, not communal.  But a friend of mine is considering a more communal perspective so that her community can better take care of its own.  By giving of ones body to another (in the form of a blood donation, bone marrow, kidney) you are offering yourself (quite physically) to another in the community.  What a perspective!

Now if only more in our community would be willing to give up monetary resources so that all could access health care.  What a small sacrifice.  What a small perspective compared to those who give of themselves quite physically!

More Health Care Equals Better Health. Wanna Bet?

Quiz:

You are 80 years old and have two years to live.  Which hospital would you prefer, Bellvue (large NYC public hospital) or Columbia-Presbyterian (NYC academic private hospital)? 

I assume that most who know these hospitals would jump at Columbia-Presbyterian.  I think that is a safe assumption, but…(you knew it was coming)

I was listening to the Brian Lehrer show on WNYC (NPR) and was fortunate enough to listen to an interview discussing Consumer Reports findings (based on Dartmouth Atlas of Health Care 2008) in which consumer reports says that, especially at end of life (data comes from Medicare), more aggressive health care leads to worse outcomes.  Too many pricks, tests, procedures, hospital acquired infections, extensive recoveries, pharmaceutical mix-ups, etc.  Exposure to more health care can be bad for you. Sometimes conservative health care is better.  Sometimes the primary care physician is better than the specialist.  Sometimes the neighborhood hospital is better than the state-of-the-art hospital.  Bigger is not always better – a lesson Americans are slow to grasp.  SUV’s are not necessarily better than compact cars.  The 6,000 square foot mansion is not necessarily better than the 1,000 square foot apartment. The truth is that the private hospitals have perverse incentives to do more – to the point of harm.  The public hospitals might have incentives to do less.  Both extremes can be to the detriment of the patient.

Most health economics and policy makers grant that health care resources have diminishing returns the more you receive.  Meaning the first few interventions will have dramatic effects, but each additional resource used will have less and less impact until the care actually becomes harmful. Some patients reach that point in some of our hospitals. 

Overuse reaches the point where some states, hospitals, cities use 3x more health care resources than others with unmeasurable effects.  Why?  Because more is not always better, just richer. Health care needs to be smarter. Cars need to be smarter. We need to be smarter. However, getting back to the quiz…

With all that said I would still choose Columbia-Presbyterian, however, I would ask the questions to determine if the care proposed is really going to be good for me.   

Cesareans Lead to Higher Priced Insurance

Watch out!  If you have a Cesarean delivery you may find it more difficult and more expensive to find health insurance in the individual insurance market.  Go ahead and add Cesarean to the growing list of pre-existing conditions. Since the individual market is growing (18 million people) and the Cesarean rate is growing (31.1% of births or 1.2 million Cesareans a year) one could assume that many people have faced this issue.  You can read about a few women who have discovered this reality here.