Healthcare Politics Nutrition

David Katz, MD and Marion Nestle, PhD

Worry not, people, the Food Revolution Summit is almost over! I’m tuning in to just two more speakers from Saturday, so the last update may be Monday morning. Today, though, there were two great speakers, named above.

David Katz, MD

Dr. Katz is the President of the American College of Lifestyle Medicine and someone I frequently retweet, so his name may be familiar to some because of that.

Most disease is caused by environmental toxins (tobacco), poor diet, and lack of exercise. He went on to expound on Dan Buettner‘s work on the Blue Zones project and how that applies to lifestyle medicine. If you’re not familiar with Dan Buettner and the Blue Zones, take a moment to familiarize yourself. It started as a fascinating National Geographic project to find the people who live the longest on the planet and how they are similar. Dan took this work and is now trying to proactively apply it to communities. Cool stuff. Anyway, combining the Lifestyle Medicine work with the Blue Zone work Dr. Katz has a list of 6 keys to health and longevity:

  1. A primarily whole food plant-based diet (in the Blue Zones they usually supplemented with small amounts of pork, but not beef or seafood)
  2. Minimize toxins (primarily tobacco)
  3. Stay physically active (note, this does not mean “cardio”, but simple walking will suffice (although Blue Zoners often walked 10+ miles per day)
  4. Get lots of sleep, regularly
  5. Minimize your stress when you can
  6. Stay very active in being social; family, friends, groups, community

“Dinner is destiny”. I love that, simple and profound. The point is that it’s what you do every day that matters the most.

“The 2015 Dietary Guidelines are a national embarrassment”. He went on to say that the report from the Dietary Guideline Advisory Committee was actually quite good, but as I noted in my previous post, the Big Food interests and their lobbying power stifled the important messages and make the final product worthless. He also noted, as others have (including me) that the real tragedy is that the Guidelines are the basis of public policy. BTW, if you want to look at the Advisory Committee report, can do get the full 571 page report here to look at and download to your heart’s content.

Lastly, as Dr. Katz and John Robbin’s discussed optimal diets and the continual swirl of controversy and confusion, they both agreed that Michael Pollan probably said it best:

“Real food, not too much, mostly plants.”

Marion Nestle, PhD

I have seen Marion Nestle speak (in videos) several times and I have been a reader of her website and blog for several months. She is an amazing woman who has been virtually the “lone voice in the wilderness” for many years when it comes to discussing the politics of food and shining the light of truth onto the subject. She talked mostly about CocaCola and Pepsi and their battles to maintain themselves as legitimate and vital concerns now that the truth about high fructose corn syrup (HCFS, see Wednesday’s post with Mark Hyman) and it’s links to obesity and cardiovascular disease have become so widely known. She was a memeber of the 2015 Dietary Guidelines Advisory Panel and one of the principles in getting the New York City ban limiting the size of soft drinks to 16 ounces, a move that is being challenged in the courts by Big Food. She has also been instrumental in exposing Coke and Pepsi’s attempts as anonymously funding efforts to ban GMO labeling, among other nefarious deeds.

Why would Coke and Pepsi give a rip about GMO labeling? Back to the high fructose corn syrup. Apparently almost all of the corn in the US is now GMO corn, so if there is a labeling law, all soft drinks would have to carry the GMO label. As usual, it’s all about the money. This is just another blatant attempt to maintain corporate profit selling a product that is demonstrably bad for your health. But corporations are people, as the Supreme Court has ruled, and so as long as they keep making money for their shareholders they can spend however much money it takes, either publicly or anonymously, to hide the truth and raise a small level of uncertainty and doubt as to the science. It’s just like Big Tobacco and Climate Science all over. It’s the same playbook every time and we keep falling for it.

Much of the spending in New York state trying to defeat the soda ban is being done by the National Restaurant Association. So, what’s their tie? As always, follow the dollar. According to Ms. Nestle, restaurants and movie theaters pay about 1¢ for each fluid ounce of soft drink. That’s the cost, all in (i.e. the cup, the syrup, the water, the CO2 tank, the cooling and the staff to serve it). Now imagine you just bought a soft drink at a movie theater. Say you got a 20 ounce cup and the theater is one that allows “free refills”. The theater is out 40¢ for your purchase. You probably paid $3 for it. That’s a 650% profit margin. So, yeah, they have a good reason to fight this. Guess what; no soda machine in my restaurant. 🙂

Healthcare Politics

U.S. Healthcare: A Kobayashi Maru

For those somehow unfamiliar with the term, The Kobayashi Maru is from the Star Trek universe and is an exam giving to Star Fleet Academy cadets. It exposes the cadets to a no-win scenario to test their problem solving under pressure. This no-win scenario is precisely what has become of healthcare in the United States.

The numbers on this should be reasonably familiar to anyone who is paying attention at all. Like this graph from The Commonwealth Fund showing that US Healthcare is 17.1% of our (very large) Gross Domestic Product (GDP – the total value of all goods and services produced in a country over the course of a year) compared to an average of 10.6% for other “developed” countries.Squires_OECD_exhibit_01

But, with all that spending, we must be getting something really great, right? Maybe it’s because we have so many doctors, or we go to see the doctors so often. Nope, that’s not it.

Squires_OECD_exhibit_03The same study shows (above) that the US has among the fewest practicing physicians per 1,000 people of population and a fairly low number of physician visits per year.

Well, maybe our health care is so expensive because we have more hospital beds or more hospitalized patients. Again, no.

Squires_OECD_exhibit_04As you can see, we are again below average in the number of hospital beds and the number of hospital discharges.

OK, it must be the doctors. The doctors are really raking it in and that’s our high cost of health care in the US, right. And again, nope.

DoctorPayThis graph, from Forbes in 2013 is especially interesting. It appears, from the first column, that US physicians are quite overpaid in comparison to other developed countries, averaging almost twice the pay. But, as the article points out, that’s not an “apples to apples” comparison. The US has about 30% primary care physicians and about 70% specialty physicians, a ratio that is almost opposite all of the other countries surveyed. Specialists earn, on average, more than primary care docs, so the concentration of higher earning specialists in the US skews the overall averages. Column 2 is the ratio of earnings of specialists to GDP per capita and it is still above other countries, but not as much as the combined specialists and primary care docs. Column 3 compares the earnings of specialist physicians to “high earners”. The article explains: “the more relevant comparison is not to the average worker but to members of the talent pool from which American physicians are recruited. When specialty earnings are compared to those of high earners—i.e., those in the 95-99% of the earnings distribution—it turns out that physicians in nearly all other countries, not just the U.S., are paid reasonably well“. By this same comparison, US primary care docs are slightly underpaid, but not grossly so.

OK, we don’t have more doctors or visits to the doctor. We don’t have more hospital beds or patients in the hospital. Our doctors are not really grossly overpaid and certainly not to the extent to explain our wildly out of line health care costs. It must be that we’re just getting better care, right? Sadly, this is not true either.

TCFchartThis chart from a Forbes article (reporting on The Commonwealth Fund‘s article) shows that US healthcare ranks 11th out of the 11 countries surveyed. Most worrisome, at least to me, are the last three measures; Efficiency, Equity, and Healthy Lives, where we rate dead last. Efficiency scored poorly because: “The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing.” We are last on equity because: “Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year”. And we rated last on Healthy Lives because: “The U.S. ranks last overall with poor scores on all three indicators of healthy lives—mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60″.

Note that the actual cost of services isn’t really discussed. But, as reported by PBS, the prices for many common procedures is higher in the United States compared to other countries. But, like with physician pay, the magnitude here is not enough to explain the huge discrepancy. US_prices_for_certain_procedures_are_much_higher_slideshowSo what is going on? How did our health care costs get so out of line and why, if we pay so much, so we get such poor care and leave so many people without care? The answer, I believe, is two-fold. First, the simple answer is profit. Second, we’ve lost sight of our priorities.

Let’s look at profit, first. Many of the countries named thus far, besides the US, have nationalized health care. That is to say that all citizens of those countries receive health care as a part of the rights they have for being citizens. Of course it is funded through taxation and many countries offer additional perks for those with the money to buy them. But everyone gets healthcare. The United States health care system is, of course, based upon profit. Physicians have been given an incentive to do more because doing more means getting paid more. Hospitals were given incentive to provide more services because they were able to make more money. It was not some evil conspiracy that created this, it’s just the way our system evolved. On the flip side, we have evolved private insurance companies who are given incentive to provide as little care as possible for those that buy their insurance because doing so maximizes the profit for the shareholders of the companies. And make no mistake, if you’re looking for the biggest hoard of money in medicine, look no further than health care companies. The revenue of the top 5 insurance companies in the US for 2014 is illustrated below. That’s about $350,000,000,000.

insurance profitsThat represents a lot of profit. And don’t think that just because you live in a state like Minnesota (like I do) where health care insurance is mandated to be provided by not-for-profit companies that they aren’t raking in the money. The St. Paul Pioneer Press reported that in 2012 the HMOs in Minnesota had cash reserves of $1,900,000,000. Yes, that’s 1.9 billion dollars. With cash reserves of $1.9 billion I have a heard time understanding why health insurance premiums in Minnesota rose, in 2014, 19% when the cost of living increased less than 3%. Did the cash reserves need to get bigger? And out of Minnesota, if United Health Care is earning around $5,000,000,000 in profit each year, why do their health insurance premiums keep going up? The answer is that UnitedHealth is not in the business of taking care of patients, it’s in the business of making money for it’s shareholders. And it’s all about profit.

Let’s take a minute to look at priorities. Obviously, the priorities for profit is a problem, but it’s not the only problem. Back to those that actually provide care to people, doctors and hospitals. First, they still get paid, to a large extent, by what and how much they do. There is a movement to slowly change the system to pay for outcomes (i.e. pay for keeping people healthy), but it will take a very long time for this to become the norm. A large amount of the payment that doctors and hospitals receive is also based upon “patient satisfaction” or HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems). But does anyone see the fundamental flaw in asking patients about their experience of care? What if the care you received was first rate, but it wasn’t what you wanted to hear? Who rates their experience of finding out they have cancer, heart disease, diabetes, or any other serious disease as good? And if your doctor came to your bedside and told you that you had bad heart disease and you needed to immediate adopt a low fat vegan diet if you wanted to live, would this be a good experience for you? What if you had successful triple bypass surgery? That might be good, but it hasn’t addressed the issues that clogged your vessels in the first place and it won’t really extend your life, but you feel like something good has happened and will probably relate that as a good experience. And now you’re just as much a part of the problem.

So what can be done to fix this depressing health care mess? Honestly, I don’t know. All I can do is take care of myself as best as possible. For me, that means a vegan diet. Actually, for most people that means a vegan diet, but I can’t make you eat right any more than I could get you to exercise regularly, quit smoking, quit drinking to excess or any of the other lifestyle choices that make such a difference. But I do know that if we don’t figure out a way to rein in our health care costs, it will be nothing but trouble in the future.

Healthcare Politics

“Obamacare” and Health Insurance Premiums

As a rule, I try to stay away from political discussions. As the saying goes, opinions are like assholes, everyone’s got one and they’re generally not pretty. More to the point, quoting, politicians are like diapers; they need to be changed often and for the same reason. But every once in a while I hear something that just makes me shake my head. Last week it was the “I was vegan for a month” article. Yesterday it was this doozy. “I’m planning to vote for Trump because Obamacare has made my health insurance too expensive”. Ugh. Really? I get that I have a little more time on my hands than most, but this is such a lazy and untrue thing to say, that I feel I have to share my 3 minutes of Google results.

When you first Google this, one of the leading political numbskulls of all time (mortifyingly from my own state), Michelle Bachmann, shows up prominently blaming President Obama:

We are seeing huge increases in these premiums, not only in the Obamacare exchanges, but in the private market. Because remember, a lot of times it’s the private market where we are getting health care through our employers. It’s the private market that has to offset government programs, whether its Medicaid or whatever government program. So the costs are going through the roof.

Not surprisingly, this is from a Fox News show. (Disclaimer, I copied and pasted the transcript. I can’t stand to listen to her talk, it makes my head throb.) It should go without saying that watching Fox News demonstrably makes you less knowledgeable about the world, but that’s not the point. The point is that Ms. Bachmann and her ilk can and do make these claims and most people are too lazy to do minimal fact checking.

Let’s back it up a bit. In 2009, the year that President Obama was inaugurated for the first time, this article ran in Time magazine, showing that health insurance premiums during the Bush administration had increased 131%. For those a little rusty on the math, if your health insurance cost you $2000 a year when President George W. Bush took office, it cost you $4620 when he left. To be sure, that’s setting the bar pretty high for President Obama. The same article noted that premiums were expected to increase 166% in the next decade.

But in 2015, right around the time Ms. Bachmann was spouting her inanity on Fox, this embarrassing piece was published by the insurance industry no less, showing just a 3.2% increase in health care premiums for 2015, the lowest increase in over 20 years. That doesn’t mean that insurance companies are taking that lightly, though. For an industry that is used to hiking rates 10% every year, a down year like 2015 where they just got a cost of living increase must seem like a disaster. And so, yes, health insurance companies are seeking huge premium increases for 2016, as reported in the New York Times. But let’s be clear, this is, pure and simple, corporate greed. It is not the Patient Protection and Affordable Care Act that raises premiums at all. It’s the companies that sell health insurance and who, for the most part, are accountable to their shareholders and not to their customers. The boom in profitability for health insurance companies is well documented here, here, here, and here.

So, as insurance companies charge more and make more, you pay more. I’m not really seeing the role of government in that sentence except as a barrier to keep the insurance companies from raising premiums too quickly. Prior to the ACA (“Obamacare”) health insurance companies were entitled to made as much profit as they could. The ACA capped that amount to 20% effective January 1, 2011. Other developed countries deliver their health care far more efficiently than the United States and have much lower administrative costs.

It is true that many people do have to pay much more out of pocket for health care than they used to. This is primarily due to the increasing popularity of high deductible health care plans that are associated with healthcare savings accounts (HSAs). But, again, making people more accountable for their health care spending decisions, while not a terrible idea, isn’t really a particularly Democratic solution, nor does it sound like a part of the Affordable Care Act! It does have a decidedly Republican ring to it and, lo and behold, the HSAs were legislated by President George W. Bush in 2003.

So, what have we learned?

  1. health care insurance costs were going up at least 10% every year during the last Republican administration
  2. health care insurance costs have gone up much less since the passage of the Affordable Care Act
  3. a large majority are paying more “out of pocket” money for health care
  4. health insurance companies are making more profit than ever before

Three finals thoughts on the Affordable Care Act.

First, we should all be immediately suspect when someone blames something on “Obamacare”. It’s an easy scapegoat because so very few people actually know what the legislation does. I’ve found the best response to be “what, in particular, is there about the Affordable Care Act that you find offensive?”. I have yet to find a single person who claims to “hate Obamacare” that can elucidate a single part of the legislation that they don’t like. Most, in fact, like most of the changes that have been made, if you ask directly.

Second, for those who are interested but don’t want to read the entire legislation, which is daunting, I’d strongly recommend Inside National Health Reform by John E. McDonough. Entertaining, readable, and will give you great insight into the Affordable Care Act and how it was passed.

Lastly, for those who never knew or have forgotten, most of the key aspects of the Affordable Care Act are nicely summarized here. Might be worth 2 minutes to scroll through. Hell, it might just change your mind.

General Health Healthcare Politics Nutrition

So what’s holding YOU back?

I had an interesting discussion with one of my kids last night. This is the son that is most definitely not a plant based eater. He said that it was going to take a lot more than health benefits to get a lot of people to consider changing their diet from standard American diet (SAD) to a whole food plant based (WFPB) diet. He thought that things like cost and convenience were very important. As I’ve already posted on Twitter and Facebook this morning, an epidemiological study in Spain reports that those who spend more on their food generally have a healthier diet and weight. But this is not new information. A 2012 article in the American Journal of Preventive Medicine described “Obesogenic Neighborhoods” and make a clear link between zip code and obesity that was at least as prevalent as genetics. In follow up work, a 2015 article in the same journal was the kind of study that doctors and researchers love. The researchers looked at people who moved into poorer socioeconomic neighborhoods and found that people gained weight after doing so.

But I digress. Rather than cover the science, I thought today I would share more personal information. Here’s why I follow a WFPB diet.

  1. Health. No secret here, WFPB diet is the healthiest diet we know. While there may be some who “feel” that other diets have health benefits, there is little scientific data to support long term health for any pattern of eating other than WFPB. This is particularly true for those who suffer the “diseases of affluence” like cancer, obesity, hypertension, diabetes, vascular disease and all of the non-disease symptoms that are diet related (like abdominal pain and constipation).
  2. The Planet. There are not a lot of ways individuals can actually make a difference, but this is one. If you won’t do it for yourself, do it for your planet. If you are such a brainwashed dolt as to believe that Climate Change isn’t real, well, go somewhere else and put your head back in the sand. Don’t worry, it will all be fine, just like Fox News said it would be (or, open your eyes and your mind and do a little research, it’s not hard to find). Everyone else knows that emissions from cars is bad for the environment. It turns out, cows are worse. The impact of methane emissions from livestock is worse than the impact of car emissions. A couple of “factoids” taken from The Purple Carrot website:
    • each burger you don’t eat saves the impact equivalent of 320 miles of driving
    • If everyone in the USA ate not meat or cheese for one day a week for a year (52 times a year) we would save the impact of 91 billion miles of driving
    • Eating WFPB for four days a week is the carbon-savings equivalent of three months with no car for a family of four
    • It takes 1,811 more gallons of water to produce a pound of beef vs. a pound of vegetables.
  3. Because I’m mad about being deceived. Yes, this the “let’s stick it to the man” part of me that is likely a product of being raised in the 1960’s. But this has seen a huge resurgence with millennials in response to “Big Tobacco” and it’s pretty clear that “Big Food” doesn’t want to go the way of Tobacco. The Physicians Committee for Responsible Medicine (PCRM) has been at the forefront of trying to hold the government and “Big Food” responsible. They successfully sued the USDA and in October of 2000, the court ruled that the USDA violated federal law by withholding documents and hiding financial conflicts of interest. In 2011 PCRM again sued the USDA over the 2010 dietary guidelines and “food pyramid” the did not give good guidance to Americans on diet choices. In response, the USDA switched to the “Healthy Plate” model that they still use. PCRM has also petitioned the FTC, USDA, and national dairy organization to stop false and misleading ads about the health benefits of milk consumption, which led directly to a cessation of that promotion. Apparently the Center for Consumer Freedom objects to all of this activity by PCRM and led to this “report“. However, the Center for Consumer Freedom is “The Center for Consumer Freedom (CCF), formerly the Guest Choice Network, is an American non-profit entity founded by Richard Berman that lobbies on behalf of the fast food, meat, alcohol and tobacco industries.” This whole nutrition thing stinks of greed and profit through purposeful deception and ignorance. I’m grateful that I have the time, energy and education and interest to pursue this and I truly understand that most of you do not. All the more reason why it should not be so difficult to get the truth.

So, that’s it. It’s why I am a WFPB eater. How about you?