Agreement and division--the American Health Care Act and what we all want

It's been hard to be a concerned American citizen lately. We are facing huge problems which will become larger in our lifetimes, including the need to take care of our increasing global population and the medical complexity of taking care of people who are becoming older and sicker. There is global climate change, which is hard for all but the most stalwart of partisans to ignore. There is an increasing gap between rich and poor in our nation and in many others, which places the rich and powerful at odds with the much more numerous and therefore potentially powerful poor.

To help guide us through these challenges we have a government so deeply divided on democrat/republican party lines that it is mostly unable to do anything creative at all. And we all pay them lots of money to be dysfunctional.

I have been following the activities surrounding repealing and replacing the Affordable Care Act. The ACA (Obamacare) was passed without a single republican "yes" vote in the senate. The American Health Care Act (AHCA = Trumpcare), if it passes, will do so without a single democrat voting for it. It has been difficult to write because it has to please all republicans, including those who feel that healthcare should just take care of itself using the free market and who would happily get rid of any federal subsidies. There does not appear to have been any attempt to make the bill palatable to democrats or even relatively conservative healthcare organizations such as the AMA. The most recent iteration abolishes taxes on investment income which is effectively a tax cut for the rich, takes away all federal money from providers of abortions, even if the vast majority of what they do prevents abortions and so may de-fund Planned Parenthood. It offers block grants for Medicaid instead of paying a percentage of Medicaid costs. This leaves states to either pay more for the program or make cuts to services if medical prices go up faster than the consumer price index (which medical costs have done historically.) It reduces subsidies to pay for insurance for many people who are poor which means that many of them will stop paying for health insurance which they will be unable to afford.

The AHCA, as it was written, also would have provided some subsidies for insurance companies which have lost money under the ACA and many of which have either withdrawn from exchanges or increased their rates. In Idaho, I read in our local newspaper, insurance costs are set to increase by 22% this year, which will be very painful for many people. The insurance companies were hit hard since passage of the ACA, because a republican dominated congress did not appropriate the money promised to the insurance companies in case of shortfalls. People buying health insurance through the exchanges may already be priced out of paying for health insurance, even if nothing is done to "repeal and replace" the ACA. Not only will this leave more people uninsured but rising health insurance costs affect all businesses that are required to buy insurance for their workers, which will either impact their employees' paychecks or even cause the businesses to fail.

The ACA, our present health care system, is like a house whose roof is leaking, and has been leaking awhile. Instead of fixing the roof in the first place we are now wrangling about how to build a new and crappier house. If we don't either fix the roof (which is vanishingly unlikely in a republican held legislature) or build the new crappy house, we will all be shivering in the corners pretty soon.

But there has been a bright spot in my thoughts about the future. I have been reading Srdja Popovic's book Blueprint for Revolution. He was a member of the group Otpor! which was partly responsible for mobilizing the people of Bosnia to oust their dictator Slobodan Milosevic. He talks about some of the ways that people can work together to get big things done. The most important step is to find out what issues virtually everyone agrees about and to move on those. Also to maintain a sense of fun and positivity, because that is what feeds people and helps them stay active.

Our communication via the internet, with a new addiction among some of us to reading what we think is "the news" has been both good and bad. One thing that comes of it is that the economy of the internet, which is driven by ads which are equivalent to real money and resources, pushes conflict. There are natural conflicts, but increasingly we are pulled in by more petty conflicts. People who basically agree, share a political party and a vast number of values, enter twitter or facebook wars about smaller points and end up mortal enemies. This is exactly how you can get more clicks on your comment or your news story and not at all how you can unite to make good things happen.

There are many things that a majority of American's agree upon. We want to be paid fairly for our work. We want our children to grow up safe and responsible and useful. We want to breathe clean air and have healthy food to eat. We want adequate health care that doesn't stress us financially. We enjoy beauty. We want to end the divisiveness that creates inefficiency in our government so we can further our shared values.

It is likely that if there were leaders who stood up and insisted on ending divisiveness in government, they would have followers of all kinds who would come out in force. Democrats and republicans, churched and unchurched, black, white and other rainbow colors of  people would be willing to march in the streets or sit down to a picnic together.

In a congress that was not divided along party lines a healthcare bill could be designed that would serve most of our needs. Legislators who populate the fringe would have to convince others of the wisdom of their ideas, but they would not control outcomes as they do now. Bernie Sanders just sent a letter to me and his 50 million other best friends and suggested "Medicare for All" as an option. This will never pass in a divided congress, but might just gain traction if combined with cost saving ideas that would make it palatable to republicans.

In our present political environment I do not know what to do about the AHCA. The progressive organizations who contact me daily by email urge me to write letters and make calls to my congressmen to oppose it. But I don't know that we have any other options at this point than a bill that, if left unchanged, will have long term consequences of reducing health care to vulnerable populations. Left un-fixed, the ACA is going to have some of the same problems, with bloated but cash strapped insurance companies pricing many people out of the market. If the AHCA is terrible, maybe we will get more substantial improvements as people stand up together to insist that they get what they need. Two states (California and Nevada) have already begun the process of assuring their people adequate health care. We need more action like this.

Most of all we need to realize that we are all in this together and that we agree on many more things than we disagree on. The ways in which we disagree are important. Debate, change and consensus making is a valuable use of our energy, but right now we need to also pull together and gently but forcefully insist that our government do the same.

I recognize and respect people who say that Mr. Trump, our frighteningly incompetent president, should not be "normalized" by cooperation. I do not trust that the election which put him in that position represented the wishes of the American people. But deep divisions and lack of cooperation preceded his presidency and brought us to where we all are. It is time that we all, as citizens, begin to visualize what we all want rather than feel complacent in our resistance.

Should a type 2 diabetic monitor blood sugars? Maybe not!

Today in the JAMA (Journal of the American Medical Association) I read that a group out of the University of North Carolina had actually done a randomized study of whether non-insulin treated type 2 diabetics (usually the adult onset ones) achieved better control of their blood sugars if they did a finger stick test of their blood glucose daily. It turns out that they do not. Blood sugars were not improved in a group of patients who monitored their blood sugars once daily compared to patients who did not monitor them at all. Also combining the blood sugar testing with an automatic message from the machine telling them how to interpret that blood sugar did not improve blood sugar control.

Since 75% of patients with type 2 diabetes are estimated to check their blood sugar and there are over 29 million Americans with type 2 diabetes, and blood sugar monitoring is moderately expensive (though better than it used to be), not checking blood sugars could save billions of dollars a year. But that's not all. The energy used to focus on those numbers, by patients, doctors and nurses, could be focused on something that might actually matter, like increasing physical exercise or eating a more healthy diet...

To be absolutely clear, this information does not apply to all diabetics. Insulin dependent diabetics, who usually get their disease as children, and absolutely require insulin to survive, do need to check their sugars. For those patients it's vital to know the blood sugar so that an appropriate amount of insulin can be administered to keep sugars as close to normal as possible. Even type 2 diabetics who use insulin often need to know their blood sugar levels in order to adjust their insulin dosages. Some type 2 diabetics take medication and a regular dose of long acting insulin, and it would be interesting to know if they, too, could forego testing.

Checking blood sugars is not simple, though it is a procedure that most people learn pretty quickly. It involves pricking the finger with a lancet to draw a drop of blood, placing the blood on a paper or plastic strip which is then read by a little machine which displays a number. There are talking machines for patients who are blind, there are machines with fancy functions, expensive machines, cheap machines...You can buy a machine without a prescription at places like Walmart and even buy the test strips over the counter now. It is, however, just one more thing to fit into a busy day and the numbers can make a person feel like a failure if they are high. The monitors require a certain amount of maintenance and sometimes malfunction, leading a person to make unnecessary adjustments or phone calls to health care providers.

This study does have some caveats. Many of the patients in the group that did not test blood sugars had been testing their blood sugars already, so it is possible that they had already gotten valuable information from testing. The patients were told to check their blood sugars once daily. It could have been than testing more frequently would have given better information and been more effective. For instance, if a patient didn't know that their lunch of yogurt and a ham sandwich lead to a higher blood sugar in the evening than a lunch of soup and salad, he or she might not change their diet appropriately.

Despite these issues, this study does indicate that we can safely allow many of our type 2 diabetics to stop routine monitoring. Previous studies have alluded to this, and many physicians are already backing away from badgering patients with type 2 diabetes to check their blood sugars. Nevertheless is remains common and is a way that a patient might mis-allocate time away from something active and directly beneficial to their health. It is probably time to allow many of our patients to relegate that blood smeared glucose meter to the back of the bathroom cabinet.

Reducing my cardiovascular risks--the ongoing saga

About 5 months ago I embarked on an adventure in healthcare. My healthcare. I decided to take medicine to reduce my cardiovascular risk. I recognize that my cardiovascular risk is pretty low, and when I am much older I may wish for a nice clean cardiac death before I lose my faculties. Having found a plaque in my carotid artery while ultrasounding myself, I decided that perhaps I should enter the ranks of consumers who take drugs to reduce their blood pressure and cholesterol.

Astute readers made various comments, including that perhaps I should first try diet, weight loss, exercise and that I should be aware that someone of my description has a low likelihood of actually benefiting from drug treatment of these things. These were reasonable comments. It turns out that I don't need to lose weight, being at the bottom of the healthy range of body mass index, and that my exercise level is pretty optimal, my diet is as evidence based as I can make it, and although I have a low risk for vascular disease, the ultrasound says I have it anyway.

I made it my mission to find drugs that would lower my risk of stroke and heart attack without sacrificing my health and well being. This has been surprisingly tricky.

No side effects
If I am to take pills for decades on the small chance that they will keep me from having some vile health event, they need to cause me no trouble. That means they can't make me feel bad and they can't cost very much money. They should also be unlikely to kill me.

Lisinopril
I started with lisinopril, an inhibitor of the enzyme that converts angiotensin to its active form. It is an old drug and inexpensive. It can kill me by making my tongue swell up unpredictably, but that is very unlikely. In certain circumstances it can cause kidney failure, but it can also prevent kidney failure. It is usually quite effective in reducing blood pressure. My pharmacy charges just over $1 for a 1 month supply. I found that it wanted to get stuck going down my throat (it's not very slippery) and that at a low dose it didn't do much to lower my blood pressure.

Atorvastatin
Statin drugs reduce cholesterol and reduce vascular disease, though their effects in patients who have not had any cardiovascular events are minimal. Atorvastatin is pretty cheap, less than $10 a month through my pharmacy. It can definitely make my muscles weak and painful, but I haven't noticed that so far. If it does make me weaker, I may never be aware of that, just thinking that I am experiencing normal aging. Since I am hoping to buy vibrant health, that would be a nasty little irony. It almost never kills anyone, other than by causing a slight increase in the incidence of diabetes, which definitely does kill people. My physician told me I had to take it at night, which means that I forget to take it most of the time. The reason that a person should take a statin at night is because it works best during fasting states. But atorvastatin is a long acting statin and can be taken any time of day. Now I will start being more compliant, taking all of my pills at the same time, vaguely with breakfast. After my first month of taking it nearly every day, my cholesterol was lower than it had ever been, well within guidelines. Whether this is a relevant surrogate measure for any sort of health benefit, I'm not sure.


Chlorthalidone or Atenolol/Chlorthalidone
A recent meta-analysis showed that chlorthalidone, an old and less frequently used thiazide diuretic, may be more effective than its sister drug, hydrochlorothiazide (HCTZ), in preventing cardiovascular disease. Other studies have shown that it is more potent, milligram for milligram and more long lasting. Unfortunately it is also more expensive than HCTZ by a factor of more than 10. It is, however, cheap when combined with atenolol, a beta blocker. (Why it is more expensive than its newer relative and less expensive in combination with atenolol is another story that has to do with the dysfunctional economics of drug pricing.)  Thiazide diuretics can lower the potassium level and the sodium levels and by that mechanism can kill people, but this can be monitored and is rare in its most severe forms. Beta blockers have been associated with dangerously low heart rates in some people along with weight gain and depression, but this is not common. I tried the combination. I had to get up and pee more often at night but otherwise it was innocuous. It did not lower my blood pressure very much if at all.

Lisinopril/HCTZ
Lisinopril in combination with a thiazide diuretic such as HCTZ or chlorthalidone is much more effective than either drug alone. They make a generic combination pill and it is also very cheap, just about the same price as lisinopril alone. I got a prescription for 90 of these, and after having taken 2 found they controlled my blood pressure very nicely, were easy to swallow and made me itch and burn in my sun-exposed areas of skin. HCTZ is well known to do this. Chlorthalidone can too, since they are similar in structure, but it didn't have that effect on me. Know anyone who needs 88 lisinopril/HCTZ tablets?

Lisinopril/chlorthalidone
No drug manufacturer in the US makes a combination pill of these two, and I'm betting when they do it will be expensive. But I did, after all, try taking lisinopril plus a half of an atenolol/chlorthalidone pill which has caused no side effects other than the annoyance of the lisinopril pill taking its time to navigate my esophagus. Hooray! Maybe. It probably gives me a little tickle in my throat. This is classic for lisinopril and is very subtle indeed for me. I don't cough all the time, but find that as I fall asleep or am otherwise not occupied, I notice the need to cough or have a sip of water to clear the tickle. This is nearly a deal breaker, but I am willing to wait awhile and see if it persists. This combination works well for my blood pressure.

Aspirin
Why not? Aspirin reduces the tendency of platelets to clump and form clots, so it should reduce my risk of strokes. It will also increase my risk of significant bleeding. Aspirin is a non-steroidal anti-inflammatory drug, and even though low doses do not work to quell knee or back pain, they can cause ulcers or heartburn. I had heartburn as a wee medical student but haven't had it for years. As a new aspirin user I have it again. Nothing terrible, but not nothing.

So theoretically I am now on lisinopril, atenolol/chlorthalidone, atorvastatin and aspirin. They pretty cheap, around $10/month for everything. That still is $120 for a year and $1200 for 10 years and likely to go up in price with time. I am a little more miserable than I was on no drugs at all, and I am being bad about both compliance (taking the pills all the time) and followup. My chance of benefiting from these drugs is low. The pills are on probation.

It is important to ask, while contemplating a lifelong commitment to deliberately putting toxic chemicals into my body, if my data is sufficient. My blood pressure runs 140-160/90-94 untreated (though it is quite normal after 20 minutes of meditation.) We know that treating a population of people to bring their blood pressure down below those numbers reduces heart attacks and strokes, but do we know that my blood pressure, in the setting of otherwise good health, is harmful at all to me? I have a carotid plaque: it is not obstructing flow to any extent, but is impressively lumpy and looks like Mt. Fuji on one view. It is calcified, so it has been there awhile. It probably formed before I even had high blood pressure. Did it happen in the physical stress of childbirth? Was it formed in any of the stressful years when bad life events disturbed my otherwise charmed existence? Is it merely a signpost indicating a path not taken, or will it eventually be one of many? In a nutshell, am I just fine the way I am?

So far the experiment with pills has not been a big win. I have definitely gained, however, from the experience of being a patient, though a mighty privileged one. I have learned that side effects are real, even if they aren't on the package insert, and may be in categories like inconvenience, worry and always wondering if I have a side effect. I have learned that effective medication can be pretty inexpensive, but that the dollar cost belies the expense associated with the life disruption that taking pills can have. And that even cheap pills add up over time. I've learned that when effective medication doesn't have the desired effect, it is sometimes because the patient isn't taking the medication, but sometimes because a given pill just doesn't tweak a given person's physiology in a way that works. I've learned that even though I consider myself to be very tolerant and easy going when it comes to physical hardship, if I mentioned all of these concerns to a personal physician I would almost certainly sound like a whiner.

Bystander CPR--some interesting statistics

"Annie, Annie, are you OK?"

Many of us learned to resuscitate a person who has collapsed using Annie, the manikin based on a death mask of a young woman who had drowned in the Seine in Paris in the 19th century. Bystander cardiopulmonary resuscitation (CPR) has become increasingly accepted and expected as the years have passed, and we have even begun to make affordable machines to deliver a life-saving shock (defibrillation) to the heart of a person who has collapsed with an otherwise life threatening heart rhythm disturbance.

We lack, though, much good information about how useful the procedure is in saving lives and bringing people back to meaningful existence.

A recent study completed in Denmark looked at the outcomes of bystander performed CPR and defibrillation. Denmark has been quite aggressive in training and encouraging citizens to perform CPR when a person collapses and is found to have no pulse. They have also been scrupulous about keeping records of what happened in each of these cases. Records spanning 2001-2012 show that having bystander CPR helps a person to survive with their brain intact, more than just waiting for an emergency medical technician to arrive with the ambulance.

What is most interesting, though, is the overall outcome of cardiac arrest. In the period of study, 8.3% of patients on whom resuscitation was attempted survived for 30 days. Of these, 10.3% had brain damage or were admitted to nursing homes. As bystander CPR became more common, the percentage of patients surviving cardiac arrest rose, and was over 12% by 2012. Also, compared to no bystander CPR, those who received bystander CPR were much less likely to end up in a nursing home. The group of survivors with the best outcome were those who were treated by bystanders with an automatic defibrillator; only 2% of those survivors had brain damage. Of the patients who survived for 30 days, 9.7% died in the subsequent year, most often of heart disease.

So, to recap, slightly more than 1 in 10 Danes who collapse and receive cardiopulmonary resuscitation survive over 30 days. Of those who survive, about 1 in 10 will have brain damage sufficient to require nursing home care. Since Danes have healthcare statistics pretty similar to Americans, this study may represent us pretty well. Getting cardiopulmonary resuscitation as soon as possible, in most cases this means by a bystander, probably gets the blood flowing to the brain sooner and helps prevent brain damage in survivors. Having a defibrillator available and using it is even better.

It is a powerful thing, being able to bring someone back from death. If we choose to engage in it, we should stay skilled, start right away after a person collapses, be aware of defibrillators in the places we frequent and plan to use them, and understand our limitations. For those of us who don't want the to receive vigorous resuscitation with a significant risk of failure or brain damage, displaying this preference, possibly with a medical alert bracelet or necklace, may be wise.

Don't look hard for thyroid cancer--you will probably find it

Gilbert Welch has written an excellent commentary on the fresh-out-of-the-printer recommendations of the US Preventive Services Task Force (USPSTF) regarding screening for thyroid cancer. Dr. Welch, a professor at Dartmouth University, has spoken out about wasteful and harmful procedures done in the name of prevention. He is a compelling writer, has written several books aimed at people who are not doctors, and has captured the essence of the thyroid cancer screening controversy in this article, published in JAMA today.

Briefly, he applauds the recommendations of the USPSTF which state that there is no evidence that looking for thyroid cancer in people who have no concerning symptoms (symptoms such as a neck lump, difficulty swallowing or hoarseness) helps them. He looks at the population data on thyroid cancer, first evidence out of Finland that suggested that nearly everyone probably has a small thyroid cancer if you look hard enough, and evidence that discovering and treating these tumors does nothing to reduce the rate at which people die of thyroid cancer. Death from thyroid cancer has always been very rare, and thyroid cancers are pretty common.

He also discusses how the USPSTF can continue to develop recommendations which are based on evidence but often go against what is commonly done by physicians. The panel is made up of volunteers who are physicians in primary care and epidemiologists, medical professionals who study how disease occurs and can be controlled in populations. This limits conflicts of interest since none of these professionals stands to gain from promoting or discouraging given procedures. Apparently in November of 2016 legislation was introduced to put specialists and representatives from industry on the USPSTF. It did not pass, and should not be allowed to pass if it is introduced again. Screening for thyroid cancer results in many people being diagnosed with thyroid cancer which would never harm them if left untreated, but will result in hefty medical costs which will go to endocrine specialists, surgeons, pharmaceutical manufacturers and radiation providers. It is vital that task force members not be connected to fields which would gain or lose based on their recommendations..

Those of you who have been following this blog may recall the saga of my very own thyroid nodule. Much like many of my fellow humans who have been overdiagnosed with thyroid cancer, my thyroid nodule was discovered by an overzealous doctor. Actually me. I hadn't had a physical exam in awhile and thought maybe I better check myself out to see if there was anything amiss. I discovered a small lump in the right side of my neck. Being skilled in ultrasound, I headed down the very same garden path trod by the ranks of the overdiagnosed and had a scan (by me) of the nodule. It had characteristics that were benign and ones that were suspicious. I chose to follow it along for a year or more, but was alarmed when I heard that even benign appearing thyroid nodules sometimes harbored thyroid cancer. I was lucky at this point, however, when my thyroid biopsy (which hurt a lot and was very expensive) did not show cancer.

With the present guidelines, I would have spared myself multiple repeated ultrasound scans (all free in my case, because I did them myself) and the fear that persisted over the time that I followed the nodule as well as thousands of dollars and a very sore neck. Had thyroid cancer been discovered, and data suggest that it is probably there somewhere, I would have also had surgery, radiation and regular followup for recurrence, putting me at risk for complications and costing many tens of thousands of dollars, to say nothing of work lost, anxiety, pain and inconvenience. The new recommendations of the USPSTF will likely draw criticism. Those recommendations appear to me to be well considered and right on target.

Do read Dr. Welch's commentary. He is an excellent writer. Also be aware of the great resource we still have in the USPSTF which can say true things that might be unpopular with other powerful interests.

How reduced regulation by the FDA will save money--except not

There is enthusiasm in politics about reducing regulation to stimulate creativity and economic growth. Maybe. But reduction in oversight of medication and medical devices by the Food and Drug Administration (FDA) will probably lead to a proliferation of expensive potions and gadgets that don't actually help.

This week, the New England Journal of Medicine published an article detailing the near miss associated with an injectable monoclonal antibody for Alzheimer's disease. (Spoiler alert: it doesn't work.)

Authors Chana Sacks, Jerry Avorn and Aaron Kesselheim detail the saga of Solanezumab, a drug that attacks the protein in the brain that is associated with Alzheimer's dementia. A monoclonal antibody is a molecule that binds to a specific target allowing the immune system to clear it from the body. Solanezumab binds to amyloid beta protein which is increased in the brains of patients with Alzheimer's disease. Although it may help clear amyloid protein from patients' brains, it did not help patients' brains to work better. It wasn't clear that the drug was worthless until all of the studies that the FDA required were completed. In fact, before the final, costly and rather time consuming trial, it looked like it might help patients with mild dementia. But it really doesn't help.

Because so many people have mild dementia and are desperate for a way to delay or reverse it, this could have been a very sought after drug. We don't know what it would have cost, but we can guess that it might have been similar to other monoclonal antibody drugs on the market, ranging from $14,000 to nearly $30,000 per year. There are several million people in the US who have mild dementia, so the cost to Medicare, private insurance companies and individual patients would have been in the many billions of dollars each year.

Drugs can be very good at changing blood tests or pathology slides without being good at all at changing patients' health.

I will digress a bit here, on the subject of expensive monoclonal antibody drugs that don't actually do much to help people. Evolocumab (Repatha) was approved by the FDA recently as an injectable drug to reduce cholesterol. This it does incredibly well. Read about it here. It has finally undergone testing to see if it really does any good by reducing cholesterol so dramatically and the results were hailed as a victory. The study enrolled patients with heart disease who were already on medication that had reduced their cholesterol. In this group, evolocumab actually does reduce the incidence of strokes, heart attacks, heart surgery or stents, hospitalizations for unstable angina and cardiovascular death, but only just a little bit. At the cost of over $14,000 per year for the injections, it saves only a few patients receiving the drug from these events at a cost of nearly $1 million per event avoided every year. If you only look at death or death from heart disease, there is no difference between patients who take the injections and ones who do not. Since the initial studies done for approval of this drug only looked at safety and the drug's ability to reduce cholesterol, it wasn't clear until after it was in clinical use that it didn't actually work that well for the outcomes we care about.

There are other drugs in other classes that looked like great ideas and weren't, and they either cost the taxpayer loads of money as we finally figured this out, or died in clinical trials. Drugs that increased the strength of the heart to treat heart failure often fell in this category, and, if they had been adopted in standard clinical practice, there would have been needless deaths in addition to needless costs. There are other drugs that appeared safe and were eventually taken off of the market when monitoring by the FDA showed significant side effects. The FDA monitors and approves (or doesn't) not only drugs, but also medical devices, food, cosmetics, veterinary products and machines which emit radiation. Its budget is $4.7 billion, of which not quite half is paid by the companies it monitors.

We should not ask the FDA to reduce its oversight of medication. What would be more helpful would be to increase funding for their efforts so they can do a better job and even complete an approval process more quickly when it's indicated. Perhaps an FDA with more funding and more teeth, not less, might have been able to be firmer with the makers of evolocumab, requiring it to show more efficacy before it was rolled out to physicians and patients eager to try something new to reduce the risk of heart attacks. The FDA's work on solenazumab, the Alzheimer's cure that wasn't, more than paid their cost to the taxpayer.

Medicaid and the national debt--why should we shell out so much money for healthcare for the poor?

Medicaid, the program that provides funding for adults, seniors (along with Medicare), children and people who are blind or disabled who can't pay for their own healthcare, is expensive. It is painfully expensive. The program, along with CHIP (the Children's Health Insurance Program), marketplace subsidies and Medicare is responsible for 25% of the federal budget. Total Medicaid costs in 2016 were around $532 billion per the Kaiser Family Foundation. States fund up to half of the cost of Medicaid, and in my state, Idaho, our share of Medicaid and related payments makes up about 21% of the state budget.

Medicaid is a safety net that allows people who can't afford private insurance or to pay out of pocket to get healthcare. It pays for doctors' fees, preventive care services, hospital care, mental health care, the majority of women's costs for pregnancy and childbirth and costs for the impoverished elderly who are in nursing homes. It pays for emergency room visits. It pays the costs of care for people who are uninsured and become sick and their healthcare debt makes them so poor that they are then eligible for Medicaid. With small exceptions, all medical bills for those insured under the program are paid by Medicaid, with none of those nasty co-pays left over. It often pays less than other insurance companies for the same services so some providers will refuse to accept Medicaid insurance, but the full spectrum of care is available to patients including such things as organ transplants. Medicaid has different names in different states: Oregon Health Plan in Oregon, Badger Care in Wisconsin, MediCal in California for instance. It has been expanded in  32 states under the Affordable Care Act to cover people making up to 138% of the federal poverty line.

Presently the federal government pays a percentage of the medical bills of the Medicaid insured patients and the states pay the remainder, usually a smaller amount. Medicaid block grants, which have been proposed by Republican lawmakers, would still pay the majority of Medicaid costs, but would pay a fixed amount, rather than a percentage, and that amount would increase at a rate slower than the predicted increase in healthcare costs. Thus the federal government's share of the bill for Medicaid would gradually shrink. This proposed change is temporarily on hold due to snags in Republican's efforts to produce and pass a healthcare bill to replace the Affordable Care Act. I and many other people have shared opinions about block grants over the last month. The bottom line is that they would likely shift costs from federal to state governments without making a major impact on overall costs.

But the real question that arises, as we consider reducing payment for Medicaid, is why we should pay for it at all. That question underlies the question of how to fund it or whether to increase or decrease the resources we put into it. Why should those of us who are taxpayers, especially wealthy and therefore hefty taxpayers, put such a lot of money into a program that pays for the healthcare of people who, by their status as patients qualifying for Medicaid benefits, pay little or nothing in taxes?

This is an awkward and uncomfortable question to ask. My first response, as a person who believes in the inherent worth and dignity of every human, is possibly misguided. That answer, based on a kind heart alone, is that we pay for healthcare for the poorest and most vulnerable because it is the right thing to do and it would be terrible for people to die or suffer from treatable or preventable diseases because they don't have the money to pay for care.

But, according to The Economist, many of the other countries in the developed world came to take on the responsibility of universal healthcare because it was extremely inconvenient to have many of one's citizens sick, especially when they were necessary to staff a war somewhere. To take this further, the best argument (or at least the most robust one, from a political standpoint) for providing healthcare to the poor is that a healthy population makes for a more successful country. People who aren't disabled by chronic diseases or the sequelae of epidemics tend to be better workers, invent more things and require fewer subsidies.

But how can we tolerate, in all good conscience, the staggeringly large national debt that is necessary to fund a program like Medicaid? Our federal deficit last year was $572 billion, almost the same number as our spending on Medicaid. If we just cut Medicaid completely, we would be nearly deficit free. Aside from the fact that eliminating Medicaid won't even begin to be a possibility, and that it is a terrible idea for all sorts of reasons, it is financially stupid. Our debt, alarming as it may be, can be looked at as using borrowed resources to create a healthy and productive country. Paying interest on that debt is the cost of maintaining programs, such as Medicaid, that make us more productive. Debt is a good bargain if we get more in productivity than we pay out in interest.

The most important question, then, is not how to reduce the costs of Medicaid but how to get good value for our money. Medicaid, in order to give good value, needs help. It has excellent aspects. It provides healthcare for many children. That is clearly a good investment. Children, when healthy, grow up to do great things. It cares for poor families who have children, which is clearly a good investment, because healthy families are more likely to raise children who are healthy, creative and self sufficient. It pays for nursing home stays for the elderly after they can no longer afford to pay for themselves. Right now that is vitally important because families and friends who would be required to care for them at home can be freed up to do all of the things that they were intending to do, including jobs and education. Designing ways to allow the old and disabled to be at home rather than in institutions would be better, and that is a direction that Medicaid is trying to take. Caring for people with developmental disabilities or disabilities relating to injury or illness is important because this is specialized work, and not everybody, including their families, necessarily does it well. This is a valid role for Medicaid (though plagued, like much of healthcare, with preventable waste.)

Medicaid's real weakness is that it pays and keeps on paying for the diseases of self abuse and is not designed to make the necessary social impact to prevent the misery that leads to the problems of drug abuse, interpersonal violence, alcoholism and morbid obesity. The endless circle of getting sick or injured because of poor life choices in impossible situations, being patched back together at astoundingly high cost and then returning to the same situation to repeat the process is demoralizing for all involved. From an economic standpoint, it is also Medicaid money wasted. Solving this problem involves creating healthy communities. It needs to happen despite the fact that the people who need this help have close to no political clout. We must continue to treat these people when they come in sick and in need because it should not be the job of caregivers or payers to decide who is virtuous enough to receive care. But Medicaid does not function in a vacuum, and cannot give good value if it is not supported by other well designed social programs, designed to prevent their illnesses. Until we are able to focus reform efforts on the social problems that create some of our sickest and most hopeless patients, a substantial portion of public healthcare spending will not be a good investment.