Suppose there were: (1) a widely held but false perception that gays had lower productivity and higher healthcare costs than straights; (2) false literature that companies with gay conversion programs outperformed the stock market; and (3) a mandate that companies disclose to shareholders the percentage of gays they employ.
Obviously, many corporate CEOs would stop hiring gays, de facto require gay conversion among current employees, and fire gays who failed the program, in order to maximize stock price and hence their own net worth.
Preposterous? Of course, but if Johnson & Johnson (J&J), Vitality Group and a few pharmaceutical companies get their way, this exact same scenario will befall overweight employees. Indeed, two-thirds of this dystopian scenario is already in place:
“Where in the Affordable Care Act (ACA) does it mandate that every health insurance policy must include a free annual checkup?”
I posed this question to Al Lewis and Vik Khanna in the comments of their recent post entitled: The High Cost of Free Checkups, where they argue against the Affordable Care Act (ACA) provision that requires “free checkups for everyone.” They cite a recent New York Times Op-ed authored by ACA co-architect, Dr. Ezekiel Emanuel, that essentially debunks the link between annual checkups and overall health outcomes. For Lewis and Khanna the solution is simple, we need to “remove the ACA provision that makes annual checkups automatically immune from deductibles and copays.” But for me there’s an enormous problem with their argument: The ACA doesn’t actually have any such provision.
After raising the issue in the comments section of the post, Mr. Lewis responded informing me that: “It’s definitely there” and “You’ll have to find it on your own, though — I unfortunately have to get back to my day job.” What Mr. Lewis doesn’t consider with his quick dismissal, is that I have already looked. I’ve combed through the law and other policy guidance, rules and regs; searching for any mention of this required annual wellness exam, physical, visit, or any other linguistic derivative. It doesn’t exist.
So what gives? Lewis and Khanna aren’t the only ones who’ve mentioned this “free” Obamacare benefit. Even when researching this piece I had to engage in a lengthy discussion with a friend who is a healthcare policy advisor, unexpectedly defending my position. This claim has to be coming from somewhere, surely people smarter than me have gotten it right?
An iconoclast must not only have abundant common sense but the gift of the gab to state the obvious. Simply stating won’t do. You must rub it in.
My favorite iconoclasts are Peter Skrabanek and Thomas Szasz. Skrabanek was a general practitioner who authored Death of Humane Medicine and Rise of Coercive Healthism. Szasz, a psychiatrist, who volunteered that he entered psychiatry to unveil its pseudoscience, is the Voldermort of psychiatry – he who must not be named (may be Voldermort is the Szasz of muggles). He wrote several books including “Myth of Mental Illness.”
Neither believed in nominative subtlety. The title of their books gave it away. Both Szasz and Skrabanek had a point. The point was simple. Be careful. Don’t allow the medical profession to medicalize the broad coastline of normality – the dog ears of the bell-shaped curve.
Skrabanek was a socialist, Szasz a libertarian. Neither was against medical care for the sick and poor. Skrabanek was urbane, Szasz went for the jugular. Both were prescient. They predicted modernism’s medical epidemic: overdiagnosis.
I’m a pseudo iconoclast. I look for real ones. I recognize them a mile off. They are straight shooters. They are humane but do not wear sentimentality on their sleeves. So it was not hard to spot Vikram Khanna, the author of Your Personal Affordable Care Act. Khanna is an ‘in the trenches’ foot soldier who has worked on the wards, worked with insurers and worked as a regulator. He has a mission, like Skrabanek who he worships. To fight healthism.
“Gentlemen. Great post. Like you, I am disappointed that researchers of the caliber of Kate Baicker and David Cutler do not respond to the mounting debate about their paper. They should defend or disown their work rather than hope that the debate goes away.
In my mind, their paper is a product typical of high-end academic research. Two brilliant professors spot a gap in the evidence on a hot policy topic and decide to go after it. But the actual work gets done by a graduate student in his cubicle without windows or guidance, and then hastily published.
Then the problem arises that the paper becomes hugely influential and people start having a closer look. For our paper on the PepsiCo program, we reviewed in detail the seven publications that Baicker and colleagues called “high quality evidence”. We found that five of those analyzed programs that operated over 20 years ago and most of them had severe methodologic flaws. (John P. Caloyeras, Hangsheng Liu, Ellen Exum, Megan Broderick and Soeren Mattke. Managing Manifest Diseases, But Not Health Risks, Saved PepsiCo Money Over Seven Years. Health Affairs, 33, no.1 (2014):124-131)
Unfortunately, many defenders of the industry continue to take the Baicker paper at face value, while closely scrutinizing or ignoring more nuanced and scientifically sound findings.
There are certainly many points of contention and areas for continued discussion on this topic. It turns out that Lewis et al. and I agree on many things, and there are other areas where we see things differently.Continue reading…
I am a public health professional, educated at the vaunted Johns Hopkins University Bloomberg School of Hygiene and Public Health. I like guns, and I believe the Second Amendment clearly secures the rights of individuals to own firearms.
You read that correctly. I am a public health professional.
And I like guns.
This make me a heretic in American public health, where embracing firearms and the rights of gun owners is a gross violation of orthodoxy.
As a society, our focus on guns and not gun users derives from the shock of mass killings, such as those in Newtown, CT, Aurora, CO, Virginia Tech, and Norway, which has some of the strictest gun control laws on the planet. Mass killings, however tragic, get distorted by saturation media hysterics and 24-hour political grandstanding. What gun opponents refuse to discuss is the precipitous fall in violent crime and deaths by firearms over the past 20 years, and how it coincides with an equally dramatic increase of guns in circulation in the US.
While that isn’t cause and effect, the association is certainly curious.
In 2013, the Institute of Medicine, at the behest of the Centers for Disease Control, produced a report on firearms violence that has been ignored by the mainstream media. The upshot: defensive use of firearms occurs much more frequently than is recognized, “can be an important crime deterrent,” and unauthorized possession (read: by someone other than the lawful owner) of a firearm is a crucial driver of firearms violence.
That report went away for political reasons. Translation. Nobody wanted to talk about it because it raised more questions than it answered.
Two weeks ago, Vik wrote a column for the The Health Care Blog on the now infamous meat-and-cheese study done by a team of researchers led by folks from USC. You can read the column, and the hilarious comments, here. I sent the column to one of the researchers, using the messaging available at LinkedIn. Here is that researcher’s response in its entirety:
I feel no need to get into a debate with someone who doesn’t understand basic statistics, how research is conducted, and has written a statement that is blatantly wrong. It does worry me that you are propagating yourself as an “expert” when you can’t seem to critically evaluate or understand a study. I know that this study is not perfect, hardly any are, especially in epidemiology, but the points you bring up in your blog are completely misconstrued and show very poor understanding of research methodology.
If you had actually read and understood the paper you would see that we controlled for waist circumstance [sic] and BMI. Also, this isn’t some random population of fat, low educated, American smokers, it is a nationally representative sample–unfortunately this is what the American population looks like. Finally, the idea that you think our supplemental tables house the real results illustrates your lack of understanding about statistics or how mortality models are run.
That being said, if you come up with a legitimate critique, I would be happy to engage in a friendly debate. When you attack something, I would suggest you make sure you understand it first, otherwise it is hard to legitimize anything else you say. I find it ironic that most of the push back from this paper has been from the general public who don’t have experience doing these types of studies, while for the most part, the scientific community (at least from people at R1 universities) has been fairly receptive.
We are glad to offer this legitimate critique, beginning with what we find in the very first sentence of the Results discussion that is not in the paper itself, but in the supplementary materials: “Using Cox Proportional Hazard Models, we found no association between protein consumption and either all-cause, CVD, or cancer mortality (Table S2).” Table S1 makes the point even more clearly: all-cause mortality in the low protein group was 42.9%. All-cause mortality in the high protein group was 42.9%, meaning that there is ZERO impact on overall mortality from protein variation at the extremes.
Consider that for the last year or so, we have been treated a deluge of entreaties to reduce our salt intake, with the American Heart Association going so far as to claim that daily sodium intake should not exceed 1,500 mg. This puts it at odds with the Institute of Medicine, and now European researchers whose data indicates that the healthy range for sodium intake appears to be much higher.
Our conversation about sodium, much like advice about purportedly evil saturated fats and supposedly beneficial polyunsaturated fats, exemplifies a national obsession with believing eating more or less of a one or a small number of nutrients is the path to nutritional nirvana.
A few weeks back, an international team of scientists did their level best to feed this sensationalistic beast by producing what’s become known since then as the meat-and-cheese study, because it damned consumption of animal proteins.
Al’s son once complained to Al’s Aunt Tillie about an overbearing supervisor. Aunt Tillie suggested that he try to work under a different supervisor. Tillie was one of those people – and we all know them – who could be counted on to inadvertently provide punchlines when needed. Conversely, Al is one of those people – and we all know them – who can’t resist setting up those punchlines. So I lamented that this suggestion may not work because, “Aunt Tillie, it’s a sobering fact that 50% of all supervisors are below average.”
Tillie replied, “I blame our educational system for that.”
Likewise, we may need to blame our educational system for Keas’ new poll on workplace stress. To begin with, the lead paragraph from Keas — which like many other companies is “the market leader” in wellness – “reveals” that “4 in 10 employees experience above-average stress.”
SAN FRANCISCO, CA – (Apr 2, 2014) – Keas (www.keas.com), the market leader in employer health and engagement programs, today released new survey data, revealing four in ten employees experience above average levels of job-related stress. Keas is bringing attention to these findings to kick off Stress Awareness Month, and is also providing additional insight and tips to bring greater awareness to the role of stress in the workplace and its impact on employee health.
Wouldn’t that mean some other employees – mathematically, also 6 in 10 – must be experiencing average or below-average levels of stress? It would seem like mathematically that would have to be the case. However, the Keas poll also “reveals” that while some employees are average in stress, no employee is below-average – a true paradox. Hence Keas’ selfless reasons for publishing this poll: All employees being either average or above average in the stress department means we have a major stress epidemic on our hands. This perhaps explains why Keas is “bringing attention to these findings.”
In a further paradox, Keas also uses the words “average” and “normal” as synonyms, even though they are often antonyms: All of us want our children to be normal but who amongst us wants their children to be average?