Jonah Goldberg, conservative columnist, wrote yesterday how government intervention into American medicine would be no panacea.  He cited that while Australia had 3 years’ longevity on average more than Americans, Denmark had only a year and a half.  Then he took issue with the average.  At my age, an extra three years looks good.

Goldberg compared Summit County, CO with Pine Ridge, SD, showing about a 20 year difference in life expectancy, commenting that lifestyles have a lot more to do with the discrepancy than having insurance.  Of course, lifestyles affect longevity.  Native Americans have a high rate of unemployment, diabetes, and alcohol/other drug abuse, but their medical care is not as good as mainstream America.  Yes, they have the Indian Health Service, which I have been a part of, not Mr. Goldberg, and I can attest on reservations the IHS is not staffed nearly as well as it is in, say, Anchorage or Phoenix.  The anecdote fit Mr. Goldberg’s case, however, so it stayed.

He then went on to say a study by a member of the Hoover Institution (on War, Revolution, and Peace, the full name of which he did not mention, and I think is relevant) said while America was ranked 19th of 29 in life expectancy, if we “removed fatal car crashes and murders” we would rank first.

Wow.  If we didn’t count cancer, we’d blow away the field.  This reminded me of a cardiac surgeon I once spoke to, back when my hospital had one of the highest cardiac surgery death rates in the country, ostensibly because we did sicker patients.  Why we operated on them when others didn’t was never explained.  Anyway, one day a surgeon told me most of his fatal outcomes were “non coronary.”  I was speechless, because to me, as a neurologist, the patient had an operation and the patient died.  Period. Very end. Don’t dress up a pig.  Given that the Republican leadership has steadfastly refused to fund studies by the CDC to help us learn from and deal with firearm violence, I hardly think murders should be removed from the count, especially since we rank 99th in the world by rate per million, a third more than Uzbekistan, and four times that of Australia, which did do something about firearms, and eleven times that of Japan.  Imagine, Uzbekistan has a lower murder rate than the US.

Then Mr. Goldberg trod where he had no business treading.  He quoted the Medicaid study in Oregon, where several years ago, extra money allowed more people access to Medicaid via a lottery, which made an ideal study group (comparison of like groups with only presence or absence of insurance as a variable).  Mr. Goldberg stated that with the exception of depression, having health insurance produced no significant improvement in health.  Many of the outcome variables tracked, such as treatment of hypertension, diabetes, PAP smears, colonoscopies, and smoking cessation treatment will require years to determine whether access to affordable medical care will in fact make a difference in longevity.  Mr. Goldberg would do well to show some patience; health care doesn’t file quarterly earnings statements. People who haven’t been able to afford a doctor aren’t going to suddenly feel great when they finally can.  Still, increased health related quality of life and happiness was measurable, and that increased significantly along with a decrease in depression scores.  People sleep better at night when they know they can see a doctor without becoming bankrupt should they fall ill.

Depression is not a minor disease.  A major depressive disorder afflicts up to 25% of all women during their lifetime and 10-15% of men.  I treated thousands of people with depression during my medical career.  The disorder has protean manifestations; it is not a matter of someone’s  being down in the dumps.  Depression is a cause of appetite disorders and subsequent obesity or severe weight loss.  It affects energy level and productivity.  It may present as chronic pain.  Sleep disturbances are present in most depressed people; lack of good sleep is a major health problem today. The immune system is affected. Depression is a major cause of significant memory disorder, often masquerading as dementia; indeed, my father’s depression looked like dementia, and my mother’s dementia presented as depression. Moods are affected, and depression is a significant cause of sexual dysfunction.  These six: S-A-E-Me-Mo-Sex were written on my medical records in the upper right hand corner as soon as I saw a person with many somatic complaints that didn’t fit neatly into a neurological container.  In the ‘80s, I risked patient anger when I diagnosed depression.  People assumed I thought they were crazy, rather than having a chemical disturbance in their brain that was potentially treatable.  Today, we know better, but suicide by firearm is more common than murder by firearm, and depression remains a major cause of the former.

Goldberg concluded by stating that while the Affordable Care Act was correlated with the decline in America’s life expectancy in 2016, he said that some people were helped, quickly adding that there was no evidence that government run medical care did any good.  Mind you, Goldberg wasn’t blaming the ACA, although he didn’t refer to it by that term, which I find annoying.

Mr. Goldberg didn’t mention that the number of bankruptcies fell in half from 1.5 million to under 780,000 from 2010 to 2016, long after the bankruptcy law was tightened.  Some wrote: “bankruptcies disappeared ‘overnight’ with the advent of the ACA.”

I think it is entirely fair to have a reasonable debate on the role of government in medical care.  Let us, however, have a debate based on all the facts, not cherry picked ones. I resent Goldberg’s using his anecdotes then claiming the ACA was anecdotally helpful.  That is galling.  The ACA probably prevented 4 million bankruptcies so far, bringing peace of mind to millions.  Market based care, “choice,” the word used when it doesn’t involve a woman, and lifestyle changes are not the answer.  People need to be able to access basic medical care without financial hardship.  We need to catch illnesses early, and we need to screen for medical conditions, like cancer and yes, depression.

It’s time for the Congressional Budget Office to put a price tag on peace of mind, not declaring bankruptcy, and the long range value of early screening for disease.  Until then, I state that a good night’s sleep without worry about medical care is worth $100/night.  I’m open to negotiation, but it must have a dollar value.  We’re in America.

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