Will Health Care Reform Spawn the Next Great Culture War?

When I turn 35 I will have my first mammogram.

In the United States, mammography is recommended for breast cancer screening every one to two years beginning at age 40.  The best available evidence suggests that mammography screening among women aged 40 to 74 reduces breast cancer mortality.

But due to a few minor risk factors, three doctors have suggested I undergo a baseline mammogram at 35. I’m not thrilled with the idea of having a technician I’ve never met manipulate my breasts into squishing position, but being felt up and flattened out sounds a lot better than being dead, so I’ll take my chances.

Of women who receive annual screening mammography beginning at age 40, six out of 10,000 over a decade will have their lives saved.  Breast cancer will be detected and cured in many more, but regular mammograms will only make a life or death difference for six of every 10,000 women in that group.  Mammograms are of extremely high value to those women and their families, but don’t offer much bang for the buck when it comes to the other 9,994 women.

And wringing more bang from every health care buck is reason enough for Canadian and British recommendations that women wait until age 50 to begin receiving screening mammographies.  In these countries where cost-effectiveness studies influence health policy and medical practice, six saved lives aren’t worth the substantial costs associated with all those extra mammograms and the false positives they sometimes produce.

Canadian women are offered routine mammograms every two years, but only from age 50-69 because “evidence is not conclusive” that routine mammograms benefit younger and older women.  Doctors have some leeway with regard to high risk patients.

In the United Kingdom, mammograms are recommended every three years beginning some time between age 50 and 53.  Based on guidelines developed by the Orwellian-named NICE (National Institute for Clinical Excellence), the National Health Service insists that for women under 40, “mammograms should only be used as part of clinical trials into screening and that they shouldn’t be used under age 30 at all.”  According to NICE, “Healthcare professionals should respond to women who present with concerns but should not, in most instances, actively seek to identify women with a family history of breast cancer.”

It is hardly shocking that the breast cancer mortality is 9 percent higher in Canada and 88 percent higher in the United Kingdom.  Nine of 10 middle-aged American women (89 percent) have had a mammogram, compared to less than three-fourths of Canadians (72 percent).  And British and Canadian patients wait for care about twice as long as Americans.

There are indeed valid criticisms American health care, but one area in which we excel is that we don’t base guidelines for care on cost-utility analysis. That’s why the U.S. ranks first in providing the “right care” for a given condition and has the best survival rate for breast cancer.

Obamacare may force Americans to give up those bragging rights.

The “right care” may soon be defined in part by how much that care costs. Health care reformers acknowledge the impossibility of implementing universal health care without introducing cost containment measures, and Democrats are enamored with a method used by the British called “comparative effectiveness research” (CER.)

AARP CEO and CER proponent Bill Novelli describes comparative effectiveness research as “a wonky term that just means giving doctors and patients the ability to compare different kinds of treatments to find out which one works best for which patient.”  And at its best, that’s just what CER does.  CER is not inherently bad.  For example, it can help doctors cut through seductive pharmaceutical advertising to identify older, less commonly prescribed drugs that are just as effective as newer, more expensive ones.

But with CER, the devil is in the details.

CER can lead to one-size-fits-all medicine and encourages a purely analytical approach to care that is not always beneficial to the patient. The mythical average patient overshadows the individual patient, leaving most of us with about as many options as a public school cafeteria at lunchtime.

And in the UK, NICE includes cost as a determining factor in the comparative effectiveness studies that inform clinical guidelines.  Determinations about whether citizens will have access to drugs, tests, and procedures are based on cost per quality of life year (QALY.)

The QALY score is a fairly crude metric that takes into account both the number and quality of years a medical intervention is expected to add to a patient’s life.  Here’s the upshot of using QALYs to determine cost effectiveness:

On the QALY scale, 0 means you’re dead, 1 means you’re in perfect health, and varying levels of debility fall in between. Imagine two groups of people, one with a QALY of 1 and the other with a score of 0.5. An expensive technology brings a year of life to both groups. But in the second, that technology would be counted as having provided only six months, and thus be twice as expensive. It may be deemed too costly for that patient group.

The older you are, the sicker you are, the more disabled you are, the less cost effective it is to treat you.  And if the cost per QALY of a medical intervention you need exceeds £20-30,000 (around $32,000 – 48,000), you’re out of luck.  Drugs, particularly end-of-life treatments, are routinely rejected for use due to poor cost-effectiveness.  And screening tests, like the mammograms American women take for granted, are severely restricted to ensure expenditures remain under the cost per QALY threshold.

Liberal proponents of health care reform accuse conservatives of paranoia and fear mongering about health care rationing.  Critics of CER are demonized as extremist spewers of far right talking points who don’t care about improving clinical effectiveness.  Surely a uniquely American flavor of a CER board would never become as proscriptive as NICE.

But it seems conservative anxiety (and perhaps a bit of healthy paranoia) is more than warranted by Washington Democrats singing the praises of cost-cutting comparative effectiveness studies.  Bear with me while I review some of the health care rationing talk in CER clothing coming from inside the beltway.

The stage for CER to become a significant component of health care reform was set when President Obama’s stimulus bill passed with a $1.1 billion appropriation for CER.  In April, Senate Minority Whip Jon Kyl (R-AZ) introduced a budget amendment to ensure that CER would be used appropriately:

Statement of Purpose:
To protect all patients by prohibiting the use of data obtained from comparative effectiveness research to deny coverage of items or services under Federal health care programs and to ensure that comparative effectiveness research accounts for advancements in genomics and personalized medicine, the unique needs of health disparity populations, and differences in the treatment response and the treatment preferences of patients.

The amendment was defeated 54-44.

Last week, members of the New Democrat Coalition proposed HR 2505, a bill to establish a new government bureaucracy called the Health Care Comparative Effectiveness Research Institute.  The Institute would prioritize research based on both clinical and economic factors, including “the effect or potential for an effect on health expenditures associated with a health condition or the use of a particular medical treatment, service, or item.”  This would not be a problem if there were safeguards to ensure that best practices are not interpreted to mean the least expensive practices.

Officials at National Institutes of Health (NIH) recently announced a stimulus-funded initiative to integrate cost-effectiveness into clinical research.   “Cost-effectiveness research will provide accurate and objective information to guide future policies that support the allocation of health resources for the treatment of acute and chronic diseases across the lifespan,” according to the call for proposals.

Back at the Whitehouse, President Obama has been paying lip service to the clinical benefits of CER.  At the same time, he recently lamented that “the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill … there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place.”  That, he explained, was part of the need for “some independent group that can give you guidance” on the ethical dilemmas involved with rationing end-of-life care.

During her Senate confirmation process, Secretary of HHS Kathleen Sebelius declined to voice her support for prohibiting the use of comparative effectiveness data to withhold care from patients. Her ideas echo those of Tom Daschle, the tax-dodging health policy wonk who wrote in his book that the U.S. “won’t be able to make a significant dent in health-care spending without getting into the nitty-gritty of which treatments are the most clinically valuable and cost effective.”

Then there’s Peter Orszag, Obama’s director of the Office of Management and Budget and a major player in crafting health care reform.  For the most part, Orszag’s commentary on CER has been limited to lauding its ability to improve patient care while reducing waste.  But when asked a few months ago if the Obama administration has a position on empowering the CER board to make reimbursement decisions, Orszag said, “Not at this point.”

But perhaps of greatest concern is a January House report that included the following statement on CER funding:

By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those items, procedures, and interventions that are most effective to prevent, control, and treat health conditions will be utilized, while those that are found to be less effective and in some cases, more expensive, will no longer be prescribed.

Sound familiar?  Cough, NICE, cough, ahem.

And as Jim DeMint explains, “CER is only one step in the Obama administration’s insidious plan to take over American health care … for our own good.”

But would CER really lead to health care rationing in the United States?  Of course.  That’s pretty much the point.  The debate is not about whether or not CER would be used for rationing, but rather, whether rationing is ethical and useful, and how far we’re willing to go to save a buck and level the economic playing field.

If health care reform shapes up as many Democrats anticipate, CER Institute guidelines will initially apply to the public insurance option expected to be the centerpiece of the Democrats’ proposal. But eventually they would slide down the slippery slope into the private sector. A public insurance option would also ride roughshod over the already anemic competition among overregulated private sector insurers, making the survival of private insurance unlikely.  As in the United Kingdom, recommendations will become rules and suggestions will become mandates in order to contain the costs of universal coverage.

To what extent will this result in government control of the doctor-patient relationship?  Ultimately, a bureaucratic board will determine when, how, and whether or not you and your family receive care.

Comparative effectiveness research will no longer be just a political hot potato; it will be the basis for the next great American culture war.  Instead of clashing over God, guns, and gays, we’ll battle over the monetary value of human life, the sanctity of doctor-patient relationships, the right to medical self-determination, and my favorite hot button issue, the duty to die.

Would cases like Terry Schiavo’s be decided based on financial considerations?

Where will fetuses fall on the QALY scale?  How about the elderly or people with Down syndrome?  Will they automatically receive limited treatment due to limited resources?

Will smokers be eligible for chemotherapy?  Will overweight people have restrictions placed on cardiac care?  Will we feel differently about those decisions when we’re footing the bill for everyone?

And you thought the abortion debate was contentious.

Obviously these questions address the most extreme examples of what could happen if we continue on our current path toward universal health care.  But government efforts at cost containment through CER may push us toward debating these issues sooner than we think.  Hopefully we’ll never see the day when questions like these go beyond an academic exercise.

Meanwhile, I’ll be saving up for a date with a mammography machine in one of those thriving medical tourism meccas.  I hear Costa Rica is a breathtaking location for a 35th birthday celebration.

Using the Poor as a Scapegoat for Gun Violence

Like a lot of kids raised in liberal New York City, I was taught that anyone who wants a gun is probably the last person who should be allowed to own one.  I learned to consider the Second Amendment a quaint throwback to less civilized times and had it drilled into my head that only psychos, criminals, and men with small penises carry guns. Most gun violence could be blamed on economic inequalities created by Reaganomics, according to the elementary school teacher who made sure a Mondale/Ferraro sticker was affixed to each student’s binder.

Then I grew up, read the Bill of Rights, and married a gun nut.

Across the country in Phoenix, Meghan McCain was brought up with a more informed view on the right to bear arms.  Her brothers were avid hunters and she developed a deep respect for the Second Amendment.  Today she’s an NRA member with a lifetime of positive gun experiences under her belt.

I confess I have a soft spot for Meghan McCain.  I don’t agree with all of what she writes and I wish she’d add something new to the national political conversation instead of recycling a mishmash of talking points.  But I admire her practical decision to milk her campaign fame for all it’s worth, and I think she’s wise to go the contrarian Republican route.  Controversy sells, as evidenced by her six figure book deal.

McCain and I agree on the Second Amendment issue.  But while her devotion to gun rights confirms her bitter clinger bona fides, she appears to have absorbed a different kind of liberal humbuggery on the issue of gun violence.

The real solution to preventing gun violence is not taking away the tools, but tackling its causes: poverty, inadequate health care, mental illness, joblessness, inadequate housing, and poor education. Desperate people will make anything a weapon. We need to eliminate desperation, not guns.

Translation: guns don’t kill people, people with less money and education than Meghan McCain kill people.  (And sometimes the mentally ill do it too.)

Way to scapegoat the impoverished!

I was under the impression that identifying poverty as the root cause of violent crime was no longer in vogue – after all, that would let guns off the hook – but apparently President Obama feels otherwise.  Eight days after the 9/11 attacks, Barack Obama attributed the tragedy to the terrorists’ lack of empathy stemming from a “climate of poverty and ignorance, helplessness and despair.”  And in a 2007 speech, Obama called poverty “a disease that infects an entire community in the form of unemployment and violence.”  Obama’s first pick for Commerce Secretary, Bill Richardson, shared similar thoughts during the 2007 NAACP Presidential Primary Forum when he said, “the key in eliminating gun violence is eliminating poverty, eliminating hate.”

Perhaps Meghan McCain is simply repeating liberal talking points, but it seems to me that even among the political left, violent crime is usually approached as a complex phenomenon caused by a multitude of sociological and psychological factors.  Many recognize that it reeks of classism to suggest that poverty creates desperation-fueled violence.  It’s also unsupported by evidence.  While a correlation exists between certain crimes and poverty, research has not proven a cause and effect relationship.  There are simply too many variables.

Even Marxist criminologists don’t attribute crime to poverty, but rather to relative deprivation like income inequality.  But both are silly assumptions: if all of the poverty-stricken or people who find life unfair engaged in violent criminal activities, the world would be in chaos.  But clearly most of the world’s have-nots eke out their years without erupting into violence.

Instead, couldn’t it be that violent crime perpetuates poverty?  We see this on an individual level among both victims and convicted criminals.  It is also evident on the community level.  Neighborhoods decimated by gun violence fail to attract entrepreneurs who might help the areas prosper.  Crime also keeps property values low and drives up insurance premiums.

It may well be that poverty has little to do with being deprived, and everything to do with being depraved.  And it isn’t economic poverty, but moral poverty that is to blame for gun violence.

I Get Mail, Child Exploitation Defender Edition

More than a year ago, I wrote an article about two cases involving librarians, library patron privacy, and the moral responsibility to protect children from pedophiles.  The piece was originally published at Red Alerts, and recently appeared on Afrocity’s blog.

A few ardent defenders of the right to browse child porn in public showed up to comment.  One by the name of “Chimp” feels that librarians have no business reporting suspected criminal activity when they witness it at work.  Chimp’s basic argument, punctuated by ad hominem attacks, was that it is “factually wrong that ordinary citizens are obllgated [sic] to report a crime of any sort.” Chimp is apparently unable to distinguish between legal obligations and the topic of the article, moral obligations.

Now an angry Chimp has contacted me via the contact form on this site, writing:

what happened to the child porn library story from Lindsay?

Was the fact that you were starting to get intelligent comments on this and other blogs cause for taking it down?

Since I have little interest in giving Chimp at chimp.island@yahoo.com my email address, I will respond in this space.

Chimp, in answer to your first question about what happened to the story, kindly put down the crack pipe and follow the links in the first paragraph.  You’ll see that the article still exists, as do your comments. It has never appeared on JennQPublic.com in any form.  If you’ve read and commented on the piece on two different sites, why do you need to see it here?

Regarding your contention that I removed the article from this and other blogs because I was “starting to get intelligent comments,” see the first answer. And just as an aside, I did receive many intelligent, thoughtful comments, but none of them were from you.  If you review the comment sections on this site, you will see that I am happy to engage in civil debate with people whose viewpoints differ from mine, but I don’t have the time or inclination to suffer through your logical fallacies when they add nothing to the discourse.

Oh, and one more thing: eat a dick.

The Meaning of a Girl in Uniform

Ask most kids to draw a picture of a veteran, and you’ll get crayoned combat boots and digital camo gear, almost invariably topped off by a high and tight haircut.  In other words, a man in uniform.

One little girl brought tears to a female veteran’s eyes with a different vision:

An Army LTC [Lieutenant Colonel] was at the event in uniform. “I have to share this with you,” he told a group of us. He explained that a local teacher asked her students to draw pictures of what the word “veteran” meant to them, and lots of students drew american flags, others drew soldiers at war. So she asked him to come into her class to talk to the students about what it means to be a veteran. But among all the other drawings, there was one that stood out.

The LTC pulled it out and showed it to us.

It was a drawing of a pretty, smiling girl in an Army uniform.

Mind you, as an Army vet, I have been well-trained in the philosophy of “suck it up and drive on.” I can speak to hundreds of people calmly.

But when I saw that drawing, tears filled my eyes.

Read the whole story by Kayla Williams at The New Agenda.  She is one of more than 1.8 million women vets who deserve greater public recognition for their service.

Lies, Damned Lies, and Military Sexual Assault Statistics

Statistics inspire confidence and can lend an air of legitimacy to anecdotal evidence. But as the saying goes, torture the numbers and they’ll confess to anything.

Torturing the numbers is something Columbia University journalism professor Helen Benedict knows a little something about.  She’s got the military sexual assault data on the rack and she’s ratcheting up the tension as high as she can to promote her new book on the abuse of female soldiers.

Consider these statistics published by Benedict in a recent Huffington Post piece:

Nearly a third of military women are raped, some 71 percent are sexually assaulted, and 90 percent are sexually harassed.

Benedict’s piece is entitled, “The Pentagon’s Annual Report on Sexual Assualt [sic] in the Military, or, How to Lie with Statistics,” and how to lie with statistics is exactly what she demonstrates.

The sexual assault figure is the most preposterous, and spelling assault wrong doesn’t get her off the hook.  It is an outright lie that some 71 percent of military women are sexually assaulted.

The statistic comes from a study of PTSD sufferers published in Military Medicine in May 2004.  The research sample was not, as Benedict would have you believe, culled from a general pool of female veterans or current servicewomen.  Instead, participants were selected from “an eligible pool of 4,918 representatively sampled veterans seeking VA disability benefits for PTSD.”

Helen Benedict is fully aware of the proper context for this statistic on sexual assault.  In a 2007 Salon essay she noted that the study was limited to veterans “who were seeking help for post-traumatic stress disorder,” but since then she has repeatedly cited the statistic out of context.  She mentioned it in a Huffington Post interview this month, a recent BBC News piece called Women at War Face Sexual Violence, and a 2008 essay in which she suggests that soldiers rape because Bush lied to justify the illegal occupation of Iraq.

The data Benedict cites on military rape and sexual harassment are also misleading.

Nearly a third of military women are raped?  No.  While not as glaring as Benedict’s sexual assault deception, this is, at best, an inaccurate representation of military rape data published in the American Journal of Industrial Medicine in 2003.  Researchers found that 30 percent of a self-selected sample of 558 female veterans reported experiencing one or more rapes or attempted rapes during their military service.  The study was limited to women who served between 1961 and 1997, and does not take into account the impact of numerous sexual assault awareness and prevention programs instituted in the last 12 years. And because the study relies on self-reporting of retrospective data, recall bias is of some concern.

I don’t expect Helen Benedict to dissect every flaw each time she cites the study, but how about something like this:

A 2003 survey of female veterans from Vietnam through the first Gulf War found that 30 percent said they were raped in the military.

That quote comes from The Private War of Women Soldiers, an article by none other than Helen Benedict.  Yet again, we see that she can indeed place numbers in their proper context when the mood strikes.

The 2003 article from which Benedict gleaned her military rape statistic also indicates that 79 percent of women surveyed recalled being sexually harassed in the military.  Benedict frequently cites the rape research in that article, but rejected the companion stat that places sexual harassment at 79 percent in favor of the 90 percent figure reported in a 1995 Archives of Family Medicine study.

Again, Benedict shows a reckless disregard for the truth.  In addition to obvious flaws such as the age of the study and recall bias of the participants, Benedict’s readers might find it relevant that the research included rape and attempted rape as types of sexual harassment.  But in her Salon article, for which she won the James Aronson Award for Social Justice Journalism, Benedict wrote that the 90 percent figure included “anything from being pressured for sex to being relentlessly teased and stared at.”  It should also be noted that the article significantly misquoted one of the subjects, and required several corrections.

What motive could Helen Benedict possibly have for inflating rape and sexual assault statistics at the expense of her reputation and credibility?  The more shocking the statistics, the more media coverage Benedict gets for her book.  And the more books she sells, the more attention she gets for her anti-war, anti-military agenda.  For Benedict, outrageous and dated statistics about military rape are an opportunity to smear American troops and criticize the war.

Do the reasons soldiers rape have anything to do with the nature of the wars we are waging today, particularly in Iraq?

Robert Jay Lifton, a professor of psychiatry who studies war crimes, theorizes that soldiers are particularly prone to commit atrocities in a war of brutal occupation, where the enemy is civilian resistance, the command sanctions torture, and the war is justified by distorted reasoning and obvious lies.

Thus, many American troops in Iraq have deliberately shot children, raped civilian women and teenagers, tortured prisoners of war, and abused their own comrades because they see no moral justification for the war, and are reduced to nothing but self-loathing, anger, fear and hatred.

She follows with a list of recommended reforms that would presumably stop so “many” troops from committing atrocities.  Ending the war in Iraq is “last – but far from least.”

Let me make clear that I find rape an inexcusable atrocity; even one sexual assault is one too many.  I fully believe that sexual assault and rape are underreported in both civilian and military life, and understand that reliable data on sex crimes can be elusive.  But that doesn’t excuse Helen Benedict’s agenda-driven falsehoods and emotionally manipulative sophistry.

Benedict forces us to spend time disentangling fact from fiction instead of addressing how we can reduce sexual assault.  And each time she trots out methodologically questionable rape data and self-serving hyperbole, she undermines the credibility of the publications that carry her writing and the writers who trust her intellectual honesty enough to quote her rape prevalence statistics.  Helen Benedict has dragged valid scholarship into a twisted game of telephone, purposefully garbling data into an almost unrecognizable mutation of what the researchers intended.

When assault statistics are manipulated and exaggerated for use as a bludgeon against the American military, actual experiences of rape are trivialized. It sends the message that smearing the troops as rapists is more important than addressing the very real occurrence of rape.  At the same time, it creates what may be overblown fear among female soldiers and potential enlistees.  We know that there are too many rapes in the military – too many rapes, period – and torturing the numbers harms both women and men in uniform.

Feminists have been accused for years of lying about rape – perhaps it’s time to disown Helen Benedict before she cries wolf again.


To read the studies referenced by Helen Benedict, see:

Archives of Family Medicine. 1995;4(5):411-418

American Journal of Industrial Medicine. 2003;43(3):262-273

Military Medicine. 2004;169(5):392-395

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