Grow and Hide: The History of America's Health Care State

Grow and Hide: The History of America's Health Care State by Colleen M. Grogan

The United States spends huge amounts on health care, but only achieves middling health outcomes. Despite heavy dependence on private companies, American government spends more on the health system than many countries that have fully funded government health systems. This book details the history of public healthcare and the way that the system has been steadily grown, while the true government involvement has been hidden.

At the outset, public health improvements were tied closely to sanitation improvements. Garbage collection and sewage handling were key areas of public health. Alas, this was al done in city governments, which were beholden to patronage systems. Doctors did not want to be beholden to random patronage employees, so worked to separate out public health from areas like trash collection. There was also a difference between "public health" and "individual health". This was deemed important and would lead to much of the "hiding" of true government health expenditures.

The health care system has continued with this grow and hide since. The healthcare industry is eager to take government funding when offered. The industry will even work to write regulations to their benefit. Then they will complain about state interference when it gets in the way. Both Democrats and Republicans are guilty of expansion of this super expensive highly-regulated healthcare system. the current "privately funded" healthcare system has become a means where the maximum number of private entities can extract government money. Investors, such as private equity have realized this and swept in to get their share of the healthcare bonanza. All in all, ths US likely spends more public money on healthcare, yet also requires citizens to spend a huge amount of private money to top it off. With so many feeding at the trough, reform has become difficult, and attempts often lead to more benefits for the entrenched interests. (See Obamacare). The book does a great job of identifying the problem and its history, which alas, has few easy solutions.

Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again

Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again by Eric Topol

Health care is in a bad state now. There are huge numbers of people working in the field, yet doctors only spend a few minutes with their patients. They spend time working with (proprietary) medical record systems. They are encouraged to maximize the value units that they produce. There is an emphasis on treating conditions without a focus on the overall quality of life. Doctors are also people and more likely to see what they know or have seen recently.

How can technology help? Currently, technology has allowed for all sorts of fancy testing, images and procedures. But these may be done excessively. AI can help with some of the more tedious parts of health care. AI is getting good at transcribing conversations and can enter medical records. AI can also provide various bots for interacting with patients. (People are even more willing to share details with AI than with real people.) AIs can also take over much of the "grunt" work in radiology. AI can identify many of the suspected issues. Radiologists would then focus on the more unique aspects. They would also have more time to speak with others. AI can also help in scrubbing medical records to help provide more accurate diagnosis. 

In the ideal world, AI will come to take over much of the routine aspects of healthcare, leaving doctors to focus on the personal interactions. Will this come to fruition? Or will AI bots just come in as a substitute way for the health industrial complex to make more money?  Can the system really pivot to focus on overall health and quality of life? 

Hype: A Doctor's Guide to Medical Myths, Exaggerated Claims, and Bad Advice - How to Tell What's Real and What's Not

Hype: A Doctor's Guide to Medical Myths, Exaggerated Claims, and Bad Advice - How to Tell What's Real and What's Not by Nina Shapiro and Kristin Loberg

Healthcare is filled with hyped up fads. Many of these are based on the flimsiest of evidence. It can be hard to distinguish hype from valuable practices. This book mentions a number of not so good medical practices, and has a few general guidelines. One positive from the book is acknowledgment of the placebo effect. Placebos can provide benefit - even if you know they are only placebos. As long as it doesn't cause harm, we can still use it. For others, it gets complicated. Smoking was once argued as beneficial by doctors, while drinking was condemned. Now smoking is universally identified as bad, while moderate drinking is sometimes seen as beneficial.

People can be a little stupid when it comes to probabilities. A parent may drive a long distance to get organic produce. The driving has a greater probability of harm than the possible organic benefit. There are many other cases where we are drawn into hype. Many processed foods start with healthy ingredients, but process much of the benefit out of it. Screenings such as Mammograms and X Rays may identify conditions, but they also cause harm in themselves and can result in false positives that result in harmful treatments.

Medical treatments can be trickier. We can try to identify the current best practices. However, these may change. How do we know if our "alternative" treatment is quackery or the future of medicine?  Perhaps the best bet is to take it all. "Complementary" medicine can be helpful. Traditional medicine can also be helpful. If we can easily identify the expected benefits and harms of both we can make good decisions. Alas, getting the data can be challenging. The book did point to a source for probabilities, but finding it is challenge.

America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System

America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System by Steven Brill

The United States spends significantly more on health care than other countries, yet does not have better health outcomes. One way to look at this is a subsidy from the rich to the poor. Americans pay high prices for drugs to support research that benefits all the world. This could explain a small part of the problem. However, it gets much worse than that.

The roots of the American disfunction dates back to World War II. There were strict wage and price controls. To counter this, unions negotiated additional benefits, such as health insurance. This benefit was tax-free thus adding value. After the war, much of the world introduced government-run health care. However, the unions did not want to give up their health-care perk, and the government was loathe to offend one of their key bases. Eventually, the government did step in with Medicare and Medicaid. These programs were targeted to the poor and elderly and thus didn't interfere with union perks.

Then things got worse. The government health plans set low payment rates. Health care providers made up for this by setting ridiculously high list prices.set up ridiculously high list prices. Most people with insurance paid a lower "negotiated rate" that was still higher than Medicare rates. However, the only way to really get insurance is through an employer. Employer-provided insurance is tax free, while self-paid insurance is after tax. Self-paid insurance is also difficult to obtain as it requires individual underwriting, while employer provided insurance is a group policy for everyone. This leaves a number of intermediaries between the patient and the payment. For most people, this system worked relatively well. However, for those without employer-provided insurance could often be hit with ridiculous bills.

The many players makes reforming the health care system difficult. There are doctors, hospitals, health plans, companies, drug companies, medical device manufacturers, health laboratories and more. While it would be great to remove the "fat" from the system, attempts can often be passed on. Attempts to squeeze insurer profits may instead result in doctors getting paid less. Health care also suffers from the "crisis" mentality. Abstractly, it sounds great to reduce spending when somebody is near death. However, when your loved one is near death, you are willing to spend whatever is needed to possibly prolong the life even a short amount of time. 95% of the expense may be wasted, but how do you make sure you don't cut into the important 5% that will help?

This is the background for the quest for Obamacare that is detailed here. There had been a few tries before. Hillary Clinton tried a reform during Bill's term, but failed miserably. In Massachusetts, Mitt Romney led a successful health care reform effort with mandatory insurance. Obama campaigned against Hillary's failed effort. Yet, he set out a priority of reforming health care along the Romney model. This proved quite challenging. There were twin desires to expand health care and reduce costs that had to be balanced against impacting current care and companies. How can fat be reduced while still maintaining a robust system?

There was a lot of back-room wheeling and dealing involved. A lot of shenanigans were needed to get it into place. Unions didn't want "cadillac taxes" on expensive plans. Drug manufacturers rejected price controls. Reduced reimbursements were off the table. Eliminating the tax break for employer-provided insurance was also dropped. The primary benefit was an "exchange" to provide health care for individuals to purchase insurance. This included income-based subsidies as well as eliminated pre-existing condition restrictions. The insurance was better than what could have been obtained previously, however, still not nearly as good as what could be obtained by an employer.

The roll out of Obamacare was less than ideal. The web site was implemented by people that were more experienced in politics than software development. It essentially went through a "public QA" process for the first months after rolling out. The law was complex and contained numerous drafting errors. This left it vulnerable to lawsuits. Some of the regulations were not defined for years after the law passed. Is are health care system better than it was before then? Possibly. Is it cheaper? Probably not.

Nine Pints: A Journey Through the Money, Medicine, and Mysteries of Blood

We all depend on blood to allow us to live. Nine Pints is more a collection of "short stories" about blood, rather than a continuous narrative. It goes through leeches, plasma donation, AIDS, menstrual periods and other things. There is not much of a flow from topic to topic. 

The Premonition: A Pandemic Story

The end of The Premonition drives home the big problem with our current public health system. In the mid-1970s the US public health authorities anticipated a deadly swine flu outbreak. They chose to institute a max vaccination campaign. Unfortunately, the local health infrastructure was not up to the task and was only able to vaccinate a fraction of the population. Some of those vaccinated died. Even though many of the deaths were not related to the vaccine, the presence of deaths together with the no-show of the deadly outbreak lead to a piloring of the health officials. Today, public health policy tends to be led in a cautious manner. People are concerned more about protecting their image. Government appointments are often made with regard to "optics" rather than expertise. Altogether, this leads to slow and inadequate reactions. Actions that avoid a deadly epidemic will be judged harshly if a few people had died. Meanwhile, positive improvement after a deadly epidemic are more likely to be praised.

The book traces the experience of a few key "behind-the-scenes" people that are doing the work to protect us. One person had worked as an administrator for the veterans administration. His hospital suffered greatly in the realm of public opinion because some of the patients had died. He later helped drive planning for pandemic response. Another key player worked as a public health official in Santa Barbara County, California. There she welded great power with limited resources. Then she accepted a state position where she was stuck behind bureaucracy when the covid pandemic played out. The third prong of the story focuses on research labs that have done work to identify and trace disease. They offered free, fast covid testing - yet bureaucracy slowed the uptake. (There were a variety of reasons - some places had relations with other vendors or could not bill $0). The lab also had the ability to rapidly identify different contagions. They even used this to identify drugs that could help cure things. Alas, these skills were often used. The government would even recommend a non-working treatment rather than the one that worked.

We do have great skill for responding to public health crises. We just can't necessarily take advantage of it.

Food Allergies: The Complete Guide to Understanding and Relieving Your Food Allergies

[July 2003] This book would make a great magazine article. Though it does contain some interesting information, the book seems to be written for somebody with the IQ of a donut. He starts by detailing all his education, and then continues to talk down to the reader. He also repeats himself without adding any detail. (Yes, we learn that he really likes corn on the cob!) The contents of the book could easily be boiled down to 10 pages without missing anything important. Also, don't expect to find much of anything concerning 'classic' food allergies here.
As a saving grace, there are a few nice charts and tables at the end to help pinpoint MSG content in fast foods and elsewhere.

Trick or Treatment

[August 2009] Is alternative medicine bad? Well, the authors of this book certainly think so. And they have a strong belief that scientific reasoning will prove it is bad. Unfortunately, while they spend a lot of time explaining "science", they spend very little time using it to back up their arguments.

The book focuses on four alternative medicines: Homeopathy, Acupuncture, Chiropractors and herbal remedies. Homeopathy is viewed as purely bogus, while the others are seen as having some very limited value. Significant space is devoted to the history of each of these alternatives (as well as a history of modern scientific medicine.) These histories are easily the best part of the book. Their biggest fault is the writing style, which comes across as juvenile and condescending.

The analysis of alternative medicine is where the book really falls apart. A typical analysis will provide some anecdotes that appeared to show it worked. Those will be brushed off as "anecdotes", and then some studies showing success. Those will then be brushed of as "invalid" and a "metastudy" will then show that the "alternative" is of very little value. Finally anecdotes will be used to show that harm can occur when using the alternative remedy. Very little data is given to back up the statements given (not even a footnote with a paper citation!) Do the metastudies include studies by alternative medicine practitioners? Or are these studies filtered out in favor of studies by conventional doctors? How would a more conventional treatment stand up to similar scrutiny? (Is a study with a doctor performing "fake" acupuncture any more reliable than one with an acupuncturist performing "fake" surgery?) The over-reliance on anecdotes is also problematic, as it could just as easily be switched to provide negative anecdotes for conventional medicine, with positive ones for the alternatives.

It is obvious that the authors have a distaste for much of alternative medicine and have produced this book in an attempt to persuade a large audience of their belief. Unfortunately, by using the "snake oil" arguments that they claim to be fighting, they provide very little of value to the debate.

After reading it, I came away with much less respect for traditional "evidence-based" medicine. Is it really all that good if they have to do so much to twist the data to fit their model?