pktechgirlbackup: (pktechgirl)
I have had many criticisms of Obamacare. I thought it was a sop to insurance companies and could only control costs by destroying innovation. But even I was not so cynical as to realize it was in fact another attempt to force the poor to subsidize the middle class.

The Obamacare plans, even the gold plans, have very high deductibles. I should be in favor of this, because low deductible plans are just prepaid health care, not insurance. But there's a wide range of health care that's...discretionary. There's my long health slog, of course, but you'd be surprised what becomes discretionary when you can't afford it. Urgent care for a heavily burned finger that will probably heal on its own. An ER visit when you're almost certainly not having another heart attack. A tooth ache.

Obamacare plans make some preventative care free. But otherwise it doesn't cover anything until you reach your deductible, and is pretty expensive until you reach your out of pocket maximum. The insurance doesn't really pay off unless you spend a lot. Who has the money to do that? By definition, the richer you are, the more money you have, the more likely you're going to reach your out of pocket maximum.

I think the poor are still covered in the event of true catastrophe, because you don't have to spend your out of pocket maximum, you just have to incur it, and hopefully the hospital will extend you credit on that after you've been hit by a bus. But the people this law was supposedly trying to help? They can't afford the premiums on the plans where they can afford the out of pocket maximums, even with the subsidies. Which means the subsidies are not going so much to them as to the people in their risk pool with the resources to meet their deductible (whose premiums are being artificially lowered by community rating and the premium ratio cap). Saying they have equal coverage is insulting and a break from reality.

But adults with wealthy parents can stay on their insurance until age 26, which is nice.
pktechgirlbackup: (pktechgirl)
The surprisingly socially aware Cracked has an article on stupid habits you develop being poor. I had two thoughts when I read it: One, that's not about low income, it's about volatile income. Two, that's perfectly describes what I do with whatever you want want to call the combination of energy and focus that allows me to get anything done, ever.

I really, really identified with the feeling that whatever you do, you're going to end up tired (broke) again soon, so you have to spend this energy (money) as soon as you can. There's no concept of prioritizing because that will slow you down, and no concept of saving because it never seems to stay saved. Logically I know that can't be how it works, but my energy levels seem so exogenously determined that it breeds learned helplessness.

This suggests that ADD meds are useful beyond their primary effect of giving me energy. By providing a chemical reassurance there will always be energy, they create an incentive to use it carefully, the same way a guaranteed income could (theoretically) improve quality of life through increasing stability without costing much.

While we're using financial metaphors for health issues, let's talk about debt. I had a huge amount of physical and emotional debt stemming from a lifetime of malnutrition. Depending on how you count I started trying to pay that back 3 years ago (with cortisol and an artillery of vitamins) and started doing so effectively nine months ago (with HCl, and some vitamins). In many ways food/nutrients felt a lot like money and energy, in that my gut believed every morsel could be the last, and it needed to be spent as quickly as possible. This worked better than you would think, because my body listens to Dave Ramsey and its panicked spending took the form of paying down debt. It's not always the optimal thing to do, in health or in money, and I may not always have picked the optimal debt to pay, but it helped some and there was no chance of making myself worse off.

But I think that recently I paid off that debt, and am ready to start investing. The problem is that bodies are like old-timey economies; there's no bank that is happy to accept exactly as much money as you have for arbitrary, unspecified periods of time. There isn't even a mattress to store nutrition under. Either you invest it now, or you let it go. But investing takes commitment: if you get halfway through a project and run out of money/nutrients, you've not only lost everything you put in, but probably more besides. Potentially a lot more. And then once it's built, you have to maintain it. You'd be stupid to build anything unless you knew you'd continue to have the income to support it.

While I was in debt I could get away with throwing vitamins around haphazardly, knowing there was some decrepit organ somewhere that could be propped up with them. Now that I'm out of debt, I have a much more difficult task: convincing my body the nutrients will keep coming forever, or at least until the new structure has paid for itself. This is a very different challenge.

PS. I would like to state for the record that however challenging my medical issues have been, there are lots of people who have it as bad or worse in addition to being poor, and that is a lot harder than what I lived through.
pktechgirlbackup: (pktechgirl)
[reminder: I've been against Obamacare since it was proposed]

I always knew Obama's promise that no one who liked their health insurance would have to change it, that everyone could keep their doctor, was bullshit. It would have been bullshit even if the law didn't expressly forbid some existing forms of insurance, because even if everything was technically legal, Obamacare changed the incentives and people respond to incentives. I knew that what he meant was "we're not instituting the NHS, your choice of doctor will still be between you and your insurance company." Nothing in the law *demanded* providers shrink their networks, but it would be criminally negligent if no one crafting the bill thought of that as a possible thing insurers would do when faced with a demand to provide more care for less money. So yes, Obama either lied or is so profoundly stupid it's amazing we're not giving farm subsidies to water crops with Gatorade.

That said, I think the insistence that Obamacare be a Pareto improvement over the status quo led to a lot of the worst parts of the bill. They reinforced the link between employment and insurance. Let me repeat that: THEY REINFORCED THE LINK BETWEEN INSURANCE AND EMPLOYMENT.

I have just about the shiniest, most employer provided insurance you could have. And I use it. I would definitely suffer financially if the link between employment and insurance was weakened. And I still think it's a travesty they didn't. I can't even use words to describe this, just more My Little Pony gifs

If they had been willing to let some people suffer temporarily, they could have ended up with a much better bill. One that, say, taxed insurance as regular income and thus removed the incentive to pay people in the form of health care, which they then overconsume. Or at least didn't reinforce the link between insurance and employment.

Speaking of employment and insurance and taxes, let's talk about the Cadillac Tax. Rather than, say, tax the cost of the insurance as income, thus weakening the link between employment and insurance, they have this weird excise tax that is higher than the top marginal rate for income tax (although to be fair, not quite the top marginal income tax rate + payroll tax), based on some weird moralism that person A having really amazing insurance is prima facia hurting person B. I had naively assumed that a plan was considered Cadillac because it had a low deductible or co-pay. This turns out to be wrong. It is considered a Cadillac plan if it costs more than a certain amount. Since premiums vary based on demographics, health status, and risk factors like smoking, this is essentially a tax on being high-risk.

Or at least, it should be. Another problem with Obamacare is that it limits the spread between what young people and old people pay, to a ratio far lower than the expected cost for each group. And it bans considering health status entirely. The explicit goal is to have the young and healthy subsidize the old and sick. Government action making one class of people give money to help another is called a tax, except it's going through a private company and is obfuscated by semi-enforcable demands to purchase a product. I hate taxes as much as the next puppy-kicking neocon, but given that we're going to pay them, I would at least like to pay them to the government. Involving a theoretically unlimited number of private companies to collect the tax and distribute the benefits is a gross violation of every reasonable set of principles I can think of.

It's like someone looked around the country and realized that we pay farmersing conglomerates a lot of money to not grow crops, and the return we do get is less and less like real food every year, and trying to fix it by giving the farming conglomerates more money and forcing everyone to pay a portion of their income to their choice of McDonalds, Wendys, or Burger King. And then claiming all the problems are solved because Consumer Choice.

pktechgirlbackup: (pktechgirl)
Another metaprinciple is "equality." What do you do if you have an opportunity to advance one of your principles, but only for some people? For example, the GI Bill that sent WW2 veterans to college. I haven't thoroughly researched it, but my gut feeling is that was a pretty good idea: it rewarded people for risking themselves in the one war no one has moral qualms about, it was short term economically beneficial by mitigating a post-war recession caused by a sudden glut of labor during a simultaneous demand drop, it was long term economically beneficial by raising the education level of the country at a time when we had a shortage of educated workers.

The G.I. Bill as written was race neutral, but it was implemented by people, and people implemented it in a racist way. Black soldiers were guided/nudged/pushed disproportionately into trade schools, sent to worse trade schools for worse trades than their white equivalents, and disproportionately denied aid entirely. Even if aid distribution had been truly proportionate, you had to be admitted to a school in order to attend, and universities admissions were still quite racist. There are some very good HBCUs, but not enough to absorb so many new students.

So the bill will disproportionately help poor white people over black people. It may well widen the wealth gap as measured in dollars. But the poorer you are, the more utility you get out of each dollar, and poor black people have fewer alternatives than poor white people. Trade school isn't Harvard, but it might still be better than nothing. Tressie Cottom says functionally the same thing about grad school. It might have a terrible average payoff and have an even worse payoff for black students, but it still might be the best option for some black people, at a higher rate than it is the best option for white people.

[Please also read this account of a VA bureaucrat trying to talk a black veteran out of attending a 4 year school he was already admitted to. The counselor couldn't legally say no, but he did everything he could to deny the man his rights. Now read Tressie Cottom's post on how dressing "up" enabled her mother to convince government workers to give her benefits she was entitled to but otherwise would have been denied. ]

So if you're president in 1944, what is the moral thing to do? Is helping some worse than helping none? What about minimum wage laws that exclude primarily-black occupations? Great Depression public works programs that will only hire white workers? A universal health care program that leaves care of the absolute poorest to the states, and states with high numbers of poor POCs are refusing to participate?

[Full disclosure: I opposed the Affordable Care Act act at the time for many reasons, but I have to admit I was against universal health care. Now I see a place for it, but maintain my belief that the ACA was one of the absolute worst implementations that could possibly exist.]
pktechgirlbackup: (pktechgirl)
My digestive system and my immune system are at odds, and it is annoying me.

My immune system hates wheat, milk, and eggs. If I eat them, my lymph nodes swell and I feel generally sluggish and icky.

I don't produce enough digestive enzymes. If I don't supplement with HCl and digestive enzymes, eating anything with real nutritional value, like vegetables and meat, makes me feel ill. I can feel it sit in my stomach and rot. In my stomach's ideal world, I live on bagels and pasta, but of course that is not good for anyone, and is especially bad for people with wheat sensitivity.

I'm sick. My digestive system is even more sluggish than usual, to the point that real food makes me feel icky no matter how many pills I take. My stomach could handle small amounts of simple carbs- but my immune response to wheat hasn't gone away. There is nothing I can eat that will make everyone happy right now. The compromise has been marshmallows and dark chocolate, which are are easy calories that are nonetheless gluten free. You can tell my nutritionist is cool because she said that was not an ideal long term solution but a perfectly good way to cope with the situation at hand.
pktechgirlbackup: (pktechgirl)
Doctor switched me from Halcion (which is what the periodontist gave me) to Xanax to keep me from having a meltdown in the dentist's office, because it's the one she's most familiar with. This proved to be a mistake, as Xanax mostly suppressed my mechanisms for coping with fear and pain. It also left me groggy and useless for >12 hours. In contrast, Halcion starts wearing off before I leave the office. Have left a message asking to go back to Halcion. On the plus side, if you tell the hygienist "I'm on too much Xanax for small talk" she will stop asking about your job.

Dentists spent years and years yelling at me about my homecare and saying it would stop hurting if I did it consistently enough for long enough. It never stopped hurting and my teeth never got better. Than I went on the HCl for hypochlorhydria and my oral health immediately got vastly better. This has made me pretty fatalistic towards the concept of flossing. Plus I'm reading another book on Scientology, and "you only feel pain when you do this because you're not doing it good enough" totally sounds like something they would say.

As I was walking to the dentist I realized I needed to give another donation to Modest Needs, but tracking down a dental case didn't feel quite right. When I checked my email afterwords there was a mass mailing saying that Modest Needs had depleted its emergency fun and needed more money. I didn't give them as much as they asked for, but donating to the emergency fund felt right.
pktechgirlbackup: (pktechgirl)
The health care debate has gotten very, very muddled. Most of my reading on the subject is by progressives (writing either for other progressives or for a general audience as an attempt at conversion), or by libertarians for libertarians. There is a pattern I have noticed that I think is worth addressing: progressives tend to see either One Big Healthcare Issue, or lots of issues with the same solution. Libertarians (as personified by me) tend to see hundreds of small issues that are going to need individual solutions. Which is interesting, because it's the reverse of the usual pattern, in which I think everything could be solved by introducing competition and progressives think we need an expert to tailor a solution to the specific problem.

So here are some of the individual problems I see, and short versions of my preferred solutions.

Problem: People can't afford health insurance/health care.

Give them money. To be fair, this is my solution for all problems relating to poverty. It sounds glib, but I'm being sincere. If we want to place a floor on the consumption of adults, we should just do that. If people are not using the money on the things we want them to, we should reevaluate our wishes or their ability to take care of themselves. Alas, this gets considerably more complicated if children are involved.

Problem: Health insurance is too expensive/increasingly expensive.

Insurance profits are reasonable and have not been rising in recent years. What you are seeing is a rise in the price of health care itself.

Problem: Health care is too expensive/increasingly expensive.

This is sometimes called "health care inflation", which is misleading, because much of the increase comes from the introduction of new things to buy. It's like saying we've had smart phone inflation since 2000. You could make the problem go away by not buying new things.

Some of it is that we're consuming more things. I am maybe the only person who liked Obamacare more after she heard about the death panels, because the alternative was everyone deciding for themselves how much of other people's money they wanted to spend on their own health care. Also, it's still not inflation in the technical sense of the word, any more than we experience produce inflation when I double my banana consumption.

However, some of it is genuine inflation , brought on by Baumol's cost disease (short version: if you have two sectors, and one gets more labor efficient, the other one experiences inflation). There are three solutions: pay workers less for the same job (which every politician ever has promised not to do, because health care professionals are sympathetic, have money, and vote), shift work to lower-wage workers (which we are trying, via things like nurse practitioners and physician's assistants. I am in favor of this but think it bears monitoring before we declare it a total success), or invent labor saving devices (which we have actually done some good at, but since in many cases the replacements are themselves expensive, we won't see returns until they go off patent). I am totally in favor of investment, both public and private, in labor saving devices. But we can't do that by wishing really hard, we have to work with the market we have and adjust if it improves later.

Problem: Wait a minute, you skipped over a possible solution. We could just pay less for the new things.

Okay, technically that's true, but it's a one time savings. Profits are what motivate pharmaceutical companies to make new things that let me live longer. I think our patent system actually does an excellent job here, providing some time to make money and then providing the drugs nearly at cost for all eternity (I have no opinion on the proper length of that first period).

Problem: why don't we just cut out the middle man and do it ourselves?

That is a good idea. There are definitely inefficiencies in the current model. But how do we do that? University research isn't directly translatable into usable drugs. There are many possible improvements to this model, and I am fully in favor of government funding for them as pilot projects, but I would like to see them work before we shoot the old model in the back of the head.

Problem: Even if the increase in insurance costs are due to care costs, couldn't we get a one time boost by removing their inefficiencies?

Yeah, maybe. There certainly are inefficiencies introduced by having 40 different billing systems. But considering that the government's systems are the most complicated and time consuming of all, I don't see them fixing it.

Problem: Health insurance is linked to employment.

Yes, this is deeply stupid. There are two causes: one is that the government subsidizes employer-provided insurance by not taxing it as income. This is stupid and they need to stop doing it.

The second is that employment is a way to get around adverse selection and the resulting insurance death spiral. This one is harder to solve. We probably can't fix the information asymmetry, which leaves mandating everyone purchase insurance. There are two problems with this: done by the federal government, it is either unconstitutional or stretches the commerce clause to the point that it can do anything. State governments can do it constitutionally, but still risk what happened in Massachusetts: originally advertised as mandating only catastrophic (i.e. true) insurance, the bill bloated until it mandated all kinds of care (because lobbyists bought the clauses), raising the premiums considerably. (My impression is that the conclusion progressives draw from this is lobbyists and/or money has too much power over politicians. The conclusion I draw is that we should minimize the number of things government can mandate so that there's no point in bribing politicians).

Note that Obamacare introduced mandatory issue (insurers must insure everyone that asks) and community rating (insurers may not charge more for riskier people) years before mandating purchase (everyone *must* purchase insurance). This is the worst possible thing.

So it's a stupid system, but it will be very hard to transition to something else.

Problem: what was that snarking about "true" insurance?

Insurance means insulating you from rare, extremely costly, unpredictable events, like car accidents and cancer. What gets called insurance today is often just 3rd parties paying for routine care, like vaccines and annual check ups.

Kathleen Sbelius, United States Secretary of Health and Human Services, got this exactly backwards .

Problem: but preventative care lowers the costs for the insurance company, so it still makes sense for them to pay for it.

This is just not true. Very little preventative care lowers the total cost of care over someone's life, because we just keep treating you until you die. Everyone dies of something, and the causes get more interesting and expensive the older you get. Even if the cost was exactly the same, you've been alive for longer and sucked up more money for annual care. The only things proven to actually lower costs are vaccines, dental care, and pre-natal care. You can argue about preventative care being a more cost effective way to raise life span or Quality Adjusted Life Years, but that is a different issue. To the extent that it is true, the gains don't accrue to the insurance company. This doesn't mean preventative care isn't an excellent thing, but excellence and money saving are not synonymous

Problem: The same care costs a lot more when you pay out of pocket than when insurance covers it, and with a lot more uncertainty and anxiety too.

This is a big problem. I don't know how to solve it and am interested in hearing ideas.

This is all very hard to argue at cocktail parties. The other side has some very good visuals and easy to explain solutions. I have a lot of graphs and arguments about highly distributed long term consequences.
pktechgirlbackup: (pktechgirl)
I've talked before about how I hate how modern/Western medicine focuses on treating symptoms rather than root causes, and in particular ignores nutrition beyond some vague food pyramid that is based primarily on who gave the most money to senators on the right subcommittee. So I went a doctor that actually listened to me as a whole person, and focused on nutrition as a fix for them. Initially in pill form, but hoping to transition to real food eventually. Only that never happened. It helped (I have more energy and didn't get sick at all last winter, as opposed to my usual average of "all winter"), but only temporarily. I was taking more and more supplements until I just gave up and stopped all of them. One would work for a while, and a different problem would crop up, and it just felt like symptom whack a mole. I couldn't go 90 minutes without eating without feeling awful, I'm eating mostly hyperpalatable crap and have to bribe myself to get through a meal with protein, which I nevertheless find incredibly stressful. I don't understand why I freak out if food doesn't taste good, why can't I eat for nutrition like everyone else?

Five weeks ago I went to a nutrition-focused psychiatric ANRP about a possible anxiety disorder. She listens to my symptoms, including the supplement whack a mole, and suggests I have low stomach acid (hypochlorhydria). Dr. Internet tells me there's a fancy test for this involving swallowing a pill containing a radio transmitter and some sort of pH meter, which I kind of want to do just to have a tiny science lab in my stomach, but the ANRP just told me to try taking the treatment (pills containing stomach acid, plus pepsin, an acid-activated enzyme for digesting meat) and see if it helps.

Oh. My. G-d.

Now that I know what it's like to *not* feel ill after eating food with protein or fiber, I can recognize that that's what I was experiencing before. I felt deeply ill any time I anything with real nutritional value, but was pushing my awareness of it away because I couldn't deal with it. Or I was sucking down soda because it was the only way my body could ask for more acid. It also explains:
  • Why I could feel like I was starving and disgustingly full at the same time
  • Why I have always felt so food insecure even though I've never been more than a car ride away from all the food I could ever want.
  • Why I've always been such an insanely pick eater, and found trying new foods so stressful.
  • Highly suspect this has something to do with my salt addiction
  • Why I became a vegetarian at age 6 in a house full of meat eaters.
  • The fascinating variety of subclinical hormonal disorders I have and the fact that curing one just leads another one to pop up somewhere else.
  • Why feelings of fullness were more dependent of food temperature than volume or nutritional level.
  • environmental allergies

Clearly I was able to extract some nutrients because I'm not dead, but I'm honestly not sure how. I'm still working out the exact dosages, but I easily take 200 pills in a week, where the bottle says 1 - 2/meal. I needed 180 mg just to eat a pear. I haven't even been counting how many I'm taking with this protein shake I'm drinking right now, but it's more than 1 gram of betaine HCl per gram of protein. ARNP hasn't ruled out a bone fida anxiety disorder yet, but that's only because she hasn't talked to me in three weeks. It is abundantly clearly to me that the actual problem was the psychic load of feeling that I was going to starve, and borderline malnutrition.

There's a few lessons I want to draw from this. One involves an Inception joke about going deeper: I thought I had found the ultimate problem by taking nutritional supplements, but never looked at why I had a deficiency. The second is that gastric bypass can easily induce hypochlorhydria because it cuts out the acid producing section of the stomach, so don't do that. The third is about will power. I, and others, constantly beat me up over my poor eating habits. I felt really ashamed that I had so many problems. And I suppose things might have been slightly better if I'd powered through the nausea and fatigue and blood sugar induced bitchiness and eaten perfectly anyway, but I wasn't doing those things because it would have left me miserable and friendless and quite possibly unemployed. The problem was not lack of will power or moral fortitude, it was a g-ddamn chemical.

The fourth is that I can eat 12 Wendy's Chicken Nuggets without needing a single pill, and I think this tells you a lot about the food content in fast food.
pktechgirlbackup: (Default)
As I mentioned in my review of The Abyss, I am horribly affected by pets being hurt, killed, or threatened in stories. Cat deaths are especially bad (see: Battle Royale, Rifter's Trilogy, and The Filth, all of which are about truly awful socities), but I got emotional watching the fish deaths in A Fish Called Wanda too. It's not so much a trigger as a place completely without armor.

I think part of what bothers me is that 1. pets are our responsibility and the trust us and 2. we (I) can't explain what is happening to the pets, which Peter Watts covered better than I ever could in this eulogy for his cat Banana:
He tried to run, you see. Something happened, inside; something broke, and he felt it but he had no way to parse it except that somehow there was a mortal threat and he wasn’t equipped to tell the difference between the things that kill you from the outside and those that kill you from within. All he knew was that his life was in danger, and he reacted the only way he knew how: he tried to run away.
. The fact that something I pledged to love and protect is suffering and I know what the stress chemicals are doing to it but I can't fix it- may even be causing it- tears me up every time.

I was discussing health care and end of life care with a friend today, and realized that this is really present in my feelings on dementia as well. One day you're an entity (or caring for an entity) that can think and plan and rationalize short term pain for long term benefit, and then you're not. And you're left with something that looks like a person but is missing one of the hallmarks of humanness, who is just aware enough to know they're missing something but not what or how to get it. I would be less afraid of Alzheimer's if it didn't make you so mean. Losing your mind is terrible, but senility led to Down's syndrome like behavior, it would bother me less, because you're happy and, while there's some burden of care on your loved ones, they're receiving love and kindness in return. Alzheimers, most other forms of old age senility and dementia, and most forms of mental retardation leave you just aware enough to get angry and hurt the people who love you the most. And I don't see why anyone wants to maintain that, much less force others to do so.
pktechgirlbackup: (Default)
Just watched Orgasm, Inc, a documentary on the creation of the diagnosis Female Sexual Dysfunction and the search for treatment (verdict: decent, but not spectacular). My short thoughts:

  • If 80-something percent of people who can have the diagnosis do have the diagnosis at some point in their lives, it is probably worth reevaluating the concept of what merits the dysfunction label.
  • There was a woman who had new wires put into her spine in order to correct the deficiency of being unable to orgasm from penetration. Goddamnit doctors, you should not be so bad at this.

My longer thought involves the (long term) use of testosterone to treat FSD. Testosterone is a critical chemical in many biological pathways. Using it to treat one very localized problem seems like using a sledgehammer on a fly. On the other hand, testosterone seems like an excellent treatment for low testosterone levels, for which low libido is definitely a symptom. Because of the way medical patents work, there's no financial incentive for a drug company to investigate what a normal testosterone range is, and what symptoms indicate a person would benefit from more testosterone even if their numbers look normal. This seems like an excellent thing for the government to invest in.
pktechgirlbackup: (Default)
One of the accusations frequently lobbied against organizations like the Pink Ribbon Foundation is that their corporate ties lead them to focus on cure over prevention- in the worst case, partnering with companies and even specific products that contain carcinogens. I kind of feel the same way about government and public health. I've talked before about how ridiculous it is to cover organ transplants for 80 year olds but not dental care for children, but I think it goes even deeper than that. The US government not only allows but subsidizes meat raised on a diet of grain and antibiotics, to the detriment of our health.

I don't think medical companies (or farmers) are evil for wanting to make money. It's what they do, and a lot of good comes out of it. And I don't think people who fight for cures for the specific disease they have, as opposed to general prevention, are evil either. It's human nature to overweight things that affect you.* But left unchecked, these things lead to a highly reactionary approach. Preventing the tragedy of the commons is an excellent use of governmental authority and I'd like to see us get good at that before we start trying to do stuff like decide exactly how much tamoxifen we're willing to buy for an individual 75 year old.

You know, I started this trying to explain that I wanted something else in place of what we're doing, but the more I think about it, the more I realize that this misallocation of energy really is what keeps me from getting behind Obamacare in particular and socialized medicine in general. It's like putting a crown on a tooth needs a root canal: technically some helpful in the short term, but it will need to be torn out before you can fix the real problem. I need to devote more thought to this, but it's entirely possible that if we mastered the fundamentals of not poisoning ourselves, I would not only be okay with socialized medicine, but championing it.

*See: me and dental care.
pktechgirlbackup: (Default)
My dental surgery was originally scheduled 5 weeks in advance. The pain got worse, they gave me antibiotics. The pain still got worse. It felt like biting tinfoil, which meant whatever it was was interacting directly with the nerve. This would make me nervous if I didn't already have a broken oral nerve. The periodontist agreed to work outside her usual hours to fit me in in a week (three weeks earlier than scheduled). The pain did get better, but it came in waves and I decided I didn't want to reschedule again, so I didn't tell them. The surgery was today.

In many ways, it was the best possible outcome. 30 seconds after cutting (just long enough to clear out the pus), she found aberrations big enough to cause the problem, but no bigger. There was a sliver of broken tooth, presumably left over from my wisdom teeth removal (which was over four years ago), and a lesion that is assumed to be a bacterial cyst unless the biopsy says otherwise.* The lesion was within a few millimeters of the nerve, but not touching it. This is good, because if it was on the nerve my choices would have been nerve damage or never clear the infection.

I don't have good data on this and the doctor was patently uninterested in playing what-if with me, but it certainly seems plausible that the three weeks between the new date and the old would have been enough to grow the cyst all the way to the nerve. I already have nerve damage on one side and it's awful, I don't know what I'd do about both. it's entirely possible the reason this got so bad was that I'm so good at not hearing pain from my mouth that I didn't notice it. I know I didn't report it to the dentist at first because I was too fucking stressed out to deal with it, I just wanted to do the right thing and get my teeth cleaned and I'd deal with the chronic stuff later. If I hadn't gone in for the intensive cleanings, who knows when this would have been caught? So there's two paths that lead to nerve damage.

I think this got treated faster in America than it would have in any other country. As I understand it (and good data is woefully hard to find), countries with national health care operate on a pretty strict queue system, and doctors have no incentive to work extra hours. I assume you can jump the queue if you can prove you have a more serious problem, but because the cyst was soft tissue it didn't show up on an x-ray; the only metric we had was my pain. While my periodontist believed me enough to reschedule the surgery, it was clear that seeing the size of the cyst** caused her to retroactively give my complaints a lot more credence. A queue that can be jumped by claiming more pain won't do it's job, so in an NHS world I probably would have been stuck with my original number, which undoubtedly would have been longer than the 8 weeks between my dentist popping the first (smaller, exterior) cyst and now. Socialized medicine could easily have caused me permanent nerve damage.***

On the other hand, I only got seen and operated on that quickly because I have money. Lots of money. Enough money to see my dentist 16 times a year, to take the first available periodontist appointment without worrying about paying for it, to take the first available surgery slot without worrying about paying for it. More subtly, having and growing up with money makes it easier to have the entitled attitude that led me to tell the periodontist this couldn't wait. When I told (not asked) my boss I needed to move the surgery earlier, but this was better timing for the company anyway, he said "well, it really doesn't matter how the timing affects us, if you need it now you need it now." This exactly the sort of care you can make yourself believe doesn't need to be treated right away, giving the infection time to spread. People die of this.

I prefer a market-based health care system not because our system is working particularly well, but because I believe it has to capability to improve in a way the NHS does not. This ability to change comes at a terrible price, and no matter how much money I donate to dental charities, I'm not the one paying it.

*Me: so is there anything the biopsy could reveal I should be worried about?
doctor: no.
Me: Then why are we doing it?
Doctor: something something best practice

I assume that there is a small but present chance this is something awful, like cancer, and she doesn't want to have to talk to me about it until we have actual data. Which I'm sympathetic to, but I'm also pissed that I was being asked to decide whether this was worth my money and the cost of a false positive while I was under a quarter milligram of a benzoate, massive amounts of whatever local anesthetic they gave me (which does make me feel mentally weird), and the stress of surgery. This was a predictable outcome of the procedure and they should have asked me ahead of time.

**Biggest she'd ever removed. She had to leave behind a plug so the gum tissue wouldn't collapse in on itself, any bigger and it would have required a graft.

***Possible relevant and even more frightening: antibiotics would not have fixed this. My cyst was that huge despite me finishing a course of amoxicillan a week prior.
pktechgirlbackup: (Default)
A while ago I was filling out a new patient form for a doctor's office, and saw an "other" option for both gender and sexual identity, and a "polyamorous" option for relationship status. As it happens I don't need any of those boxes, but I still felt better for seeing them on the form. At first I thought it was because if the doctor considered these sometimes heavily stigmatized states of being to simply be information she needed to know to do her job, then there was reason to believe she wouldn't judge me for my non-standard interests. It made it easier to talk freely without fear of judgement.

But now I think maybe there is more than that. I was watching For The Bible Tells Me So, a documentary on use of the Bible to justify hatred of homosexuality. And it occurred to me that they never say "I hate men having butt sex" or "I hate two men being in love" or "I hate women getting off without a penis involved", or anything specific. The talk about abominations, and perversity, and sickness. Which is a good strategy on their part, because there is nothing homosexuals specifically do that could possibly justify that amount of hatred and fear. But it makes me think that some of what was so comforting about that intake form was the willingness to explicitly name things that many people would not acknowledge.

People, including people who pride themselves on being open minded and accepting, including me, sometimes complain about the extra time it takes to not use "woman" and "vagina haver" as shorthand for each other, to not assume an anonymous internet is a woman because they mention having a husband, to not say "mom and dad" when you mean "parents" and not say "your parent" when you mean "grown up who is mostly responsible for your raising." It makes sentences much longer, ruins comedic timing, and it's a lot of effort for such a small portion of the population. But taking the time to draw these distinctions helps more than trans women and men, gay men, and children being raised by their gay grandfathers. By talking explicitly about things often left implicit due to discomfort, they help everyone whose life is even a little nonstandard feel more accepted and less afraid. And that is worth doing.
pktechgirlbackup: (pktechgirl)
Headline: Merck halts shipments of key cancer drug to Greece

Me: You mean Greece is no longer buying the drug because it can't afford it?

Source article: " German pharmaceuticals firm Merck KGaA is no longer delivering cancer drug Erbitux to Greek hospitals, a spokesman said on Saturday, the latest sign of how an economic and budget crisis is hurting frontline public services."

Me: ... so is Greece in debt to Merck KGaA and they're refusing to ship more until the account is settled? Are they willing to sell for cash but not credit? Is that a change? Has Greece declared it won't pay more than $x and Merck judged that to be insufficient? If they'll ship to pharmacies but not hospitals, what's the difference between them? Is there a supply shortage? If no, what are they doing with the excess pills and/or capacity?

So clearly, my first reaction is to assume that Merck KGaA, and drug companies in general, do things for reasons. And to implicitly assign blame for the people who will die for lack of the drug to the Greek government, not the corporation who manufacturers it. This is not the universal reaction. The nicest suggestion in the BoingBoing comments was patent infringement. The worst was throat slitting for the board of directors.

We don't have the drug without the research to produce it. Merck did the research (or bought whoever did). Merck did the research in anticipation of profits. We could temporarily boost everyone's utility by selling all drugs at cost, but as the system stands now, there would be no new drugs, because there would be no incentive to make them. This system has flaws, and those flaws kill people, and there are quite possibly better systems out there. But until we actually have such a system in place, dismantling the current one will cause more death than leaving it alone.

On abortion

Nov. 1st, 2012 10:11 pm
pktechgirlbackup: (Default)
This is the story of a woman carrying a fetus that was self-evidently non-viable, but still had a heartbeat. The heartbeat is used as the definition of life for the purpose of Chicago laws. Right now, this means that she had to listen to a doctor explain what abortion was and sign consent forms 24 hours in advance, and that her insurance carrying wouldn't cover it. If abortion was banned, or only allowed for dead fetuses, or only in cases of imminent deadly threat to the mother,* she would have had to carry a dying fetus inside her until she spontaneously miscarried or went into labor. This could have left her infertile, or killed her. If it did none of those things, she would still have to carry around a reminder of the child she wasn't going to have, fake happiness for strangers or share an intensely personal story, and suffer the usual risks of pregnancy.

Individual pro-lifers may not want this to happen, but the laws they advocate predictably lead to this result. They can either admit that this is an acceptable cost to them, or they can advocate for something else.
pktechgirlbackup: (Default)
At the end of a 4 visit, $1200 dollar deep teeth cleaning sequence, we discovered I have a deep gum infection. My dentist is sending me to a specialist, who she predicts will want to do minor surgery to clean out whatever the source of the infection is. And while I'm deeply unhappy about this for many reasons, I am still secure in my ability to pay for it, and that is a gift.

The thing is, I believe in the concept of exchange, and that relationships that are out of balance cause problems. My relationship with my dentist is totally square: I gave her money, she gave me use of equipment and her employee's time. But my relationship with dentistry-as-a-concept is deeply out of balance. It is offering me the potential for a longer, less painful life. I am offering nothing in return.

The only way I can think of to fix this is donating to a dental charity, so someone else can benefit from the same level of care I get. I don't know why I think that benefits dentistry-as-a-concept in a way alleviating my own suffering does not, but I do. I looked around, and while there are dedicated dental charities, and free clinics that do dental work, none of them are big enough to be on charity navigator.

At first, I rejected modest needs because none of the dental cases were the maximum impact kind- i.e. otherwise healthy young adult or child suffers from a single, uncomplicated issue that requires a one time grant to fix. They were all elderly, or disabled, or very sick. Funding their dental care has a substantially smaller snowball effect than removing someone's last big problem. But I think I was wrong about that, and was in some ways falling into the trap I discussed yesterday. The value of dental care is most obvious when nothing else is going wrong, but that doesn't lessen its value to people with many problems.

As it happens, the first case on modest need's website was for partial dentures, and needed only $35 to complete.
pktechgirlbackup: (Default)

I am lucky to have always had access to frequent top notch dental care. I give dentistry a hard time for handling my trigeminal neuralgia so poorly, but the truth is that without electric toothbrushes and 4x/year cleanings by very good hygienists, I would be in constant oral pain until I died at 40. It's one area I just lost the genetic lottery in.

My dentist talked me into a cleaning with local anesthetic. I kind of thought this was bullshit: we weren't hitting the limits of my pain tolerance, we were hitting the limit of the hygienist's ability to listen to my pain. Which then lowered my pain tolerance because she would stop working and make me reassure her that I was fine, which broke up my attempts to process and not notice that someone was repeatedly stabbing me in the gums. But I agreed, and it turned out to have been a really good idea. Judging just by the amount of blood, She really got in there. Sober, I couldn't have sat still if i wanted too. Numbed out on lidocane, it was basically the world's worst manicure. I'm not having fun, but it is nice to have an hour where nothing is expected of me. I am really lucky to be able to get both the cleaning and the anesthesia without having to sacrifice in other areas.

Money probably does this in a lot of other places too. Even if a rich person and a poor person are suffering nominally the same thing, money lets you escape some of the consequences. Everyone has to go to the DMV, but it's a lot easier when you have flextime. Anyone can use the unemployment office's online system, assuming they have the money for a computer. And so on.

Suppose I could afford the cleaning but not the anesthesia. After the last anesthesia-free cleaning, I was useless for an entire day. I was just too pained and too pissed off at the dental office to accomplish anything. After the anesthesia cleaning, I felt fine. I still took the day off because I already told work I was going to do it and I had a lot of anxiety going in to the appointment, but it wasn't necessary.* I don't enjoy losing a day's pay, but I can afford to do so. Presumably I wouldn't have done that if I absolutely needed the money. But cope is a limited resource, and if I hadn't been able to get it back by staying home and watching Once Upon A Time, I would have found some other way. Alcohol. Abdication of parental duty. Putting off other necessary work. You pay for it somehow.

So I have two points here. First, if you have the money, totally use it to drug yourself during teeth cleanings, even if you have to pay for it out of pocket. I refused for a long time out of some sort of misguided puritanism, plus I was insulted that my dentist kept implying I needed it. Now? I would ask for narcotics if I didn't find them horribly unpleasant. Let modern medicine do one of very few things it's actually good at. Also, don't let your dentist try to talk you into an hour and a half if your back starts complaining half an hour in and the anesthetic lasts an hour. Just come back another day.

Second, it's good to consider what else you're able to buy yourself out of. You don't have to stop doing it, because suffering is not zero sum, but it's good to be aware

*Which is good, because the hour we spent was enough to do exactly one quandrant of my mouth, and I need at least three more of the same, and possibly another cycle after that, at which point I *might* be able to go down to every three months, although it'll take eight appointments because we'll have to do top and bottom separately.
pktechgirlbackup: (Default)
I found a very good book on stretching. I started using it on Sunday- and really, "using" is an exaggeration, I've only done a handful of the stretches two or three reps per day, and read the introductory chapter where he explains some of his philosophy and how he discovered it- and by today I was noticeably more relaxed. At least, I think that's what this is. I don't know if I've ever had a muscle be relaxed without the aid of exhaustion, alcohol, or endorphins. I will be talking more about this book, but I'd like to maybe finish it and apply in consistently first, so it will wait. Today's news is that I started taking magnesium again. I've used magnesium before and it helped my flexibility and flexibility-related health problems tremendously. I've been meaning to start taking it again for weeks or possibly even months. I have some sitting on my desk at work. And yet, I never got around to taking it until the problem was already being solved.

There's a well known study in which a group of pink collar workers were given identical information about the health benefits of exercise. The treatment was then given additional information about how and why their jobs (hotel cleaners) counted as exercise. Both groups were tracked on various health and weight related measurements at the start of the study and again 30 days later. Despite neither group receiving any differences in intervention, nor reporting any changes in routine, the treatment group was noticeably improved. Not hugely, and any one number could be dismissed as statistically but not medically significant, except there was no statistically significant change in the control group, and every single measurement improved in the treatment group. Weight, BF%, waist to hip ratio, systolic and dystolic blood pressure. I think using weight to track health is iffy, which is why it's good that the most significant improvements were in systolic blood pressure. A 10 point drop over 30 days is not trivial.

The authors call this the placebo effect. This bugs me because it implies telling the maids they were exercising was a lie, when it was in fact true, and truer than the traditional definition exercise, which is formed around people who have money and sit all day. On the other hand, it's perfectly in line with my definition of the placebo effect, which is basically "human brains are powerful and respond to expectations in ways we don't fully understand". This study was only a month long. It would be very interesting to know if the effects were cumulative over time; even if peace of mind is only good for one 10 point drop in BP, that may allow you to exercise a little bit more, which will build muscle that protects your joints, which lets you work a few more years in less pain...

If it's true that emphasizing the good that people are already doing leads to measurably better indicators, what does shaming them do? It's entirely possible that the ,anti-fat PSAs are ineffective not just because shame never motivates anyone for more than 10 minutes, but because they induce stress that hurts people's health. They may, literally, be killing people. Children. If the fact that these were giving ammo to the already well stocked childhood emotional torture brigade was not enough, the evidence indicates that these campaigns are failing at the only thing they're supposed to achieve. And they're doing it with government money. This has to stop.
pktechgirlbackup: (Default)
Everything I know about the new potential prophylactic HIV cocktail I learned from this Savage Love Podcast. I'm very willing to believe that Dan Savage (or his doctor co-host) did not deliver a full and accurate reporting of the research. But my thoughts on the topic are so general I'm prepared to plunge in without learning more.

The reported efficacy is 40-60%, with perfect use. Let's pretend everyone uses it perfectly: that's still not high enough to produce herd immunity. Herd immunity is when you've manipulated the environment (through preventatives or treatment or simply sufficient numbers of the susceptible people) such that the average infected person infects fewer than one person. The disease can't propagate at that point. From a public health standard, it's herd immunity or nothing: anything else is nice for the individual but irrelevant.

But everyone won't use it perfectly. People don't take drugs perfectly even when they're immediately helpful. A preventative drug with nasty like effects (which this is) is going to have severe compliance problems.

Some people are arguing we shouldn't release the drug because it will give people a false sense of security and decrease condom use. I don't care. Adults get to make their own choices even when they're stupid. What concerns me is that intermittent use of preventatives against an entity that can evolve is the perfect way to evolve resistance. You couldn't design a better way to create drug-resistant AIDS if you wanted to.

I think the FDA has no business telling people what drugs they can or cannot take and does a lot of harm in trying. But that's for things affecting individuals. Antibiotics and antivirals are public goods, and degrading their efficacy for a small chance at dodging HIV is exactly the sort of thing government should prevent.
pktechgirlbackup: (Default)
I can't find it now, but previously I harshly criticized doctors office asking pro forma "are you being abused?" questions, for being insulting to those who weren't abused and ineffective for those who were. I have to take that back. Because abuse- sexual or physical- isn't just about the physical act, it's all the mental gymnastics you're put through and go through to make it seem normal. And any reminder that it's not normal is potentially useful.


pktechgirlbackup: (Default)

May 2014

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