Hi, I'm a Tea-Partier Video

This video is funny and a good reminder of us of the facts. But it also demonstrates the classic problem of the Democrats: focusing on facts. The Democrat gets better toward the end with values-based messaging.

Remember to vote and keep the Democrats in power, so we can keep moving forward on improving the lives of families in our country.

A Few Nudges Might Help

I just finished reading: Nudge: Improving Decisions about Health, Wealth, and Happiness

It was named one of the best books of the year by the Economist. The basic premise is that classical economic thinking is misguided. In classic economic thinking we all make choices by weighing the benefits and risks of each decision. But most humans do not act like economists.

This book shows that in decisions about health, wealth, and other areas, the maxim of "Give as many choices as possible," does not work. Choices are determined by a lot of subconscious factors that we are unaware of. The liberalistic paternalism the authors speak of is a nonpartisan way of designing choice architecture.

I suggest you read it and think about where you could make simple nudges for you, your family, and your community. Every time you hear a policy maker talk about how great their plan is just because it gives citizens lots of choices (i.e. Medicare Drug Benefit, school choice, retirement savings), tell them to read this book.

Benefits of Health Care Reform Coming to You

I just got a letter from my insurance company informing me that:

1. If I have children, I can now keep them on my policy up to age 26.

I don't have children. But, if I did, this would allow me to keep them insured through graduate school or an early career. Should our kids be insured until they can get a job with benefits? Yes!

2. They will discontinue any lifetime caps on coverage.

This means if you get really sick (think cancer) and need lots of treatment, they won't cut off your coverage. Shouldn't you be covered for the whole course of your cancer treatment, instead of just $400,000 worth? Yes!

These are two of the benefits that Americans will benefit from right away.

Abigail Disney: Taxes Make Our Country Great

In this linked story, the granddaughter of Roy Disney, states why she thinks the estate tax is important.

Showdown Over Bush Cuts Revives Estate Tax Fight : NPR

Taxes are not a penalty for working hard. They are a contribution to building a stronger America. From the Story:

"Disney, a filmmaker and philanthropist, spent a lot of time shooting a film in Liberia. [Abigail Disney] says there, unlike the United States, there are no safe roads or schools and therefore no safe investments. And she says those who make money in a secure society like the U.S. also owe the society a debt.

She joined a group of wealthy individuals called United for a Fair Economy in part, she says, because she felt wealth is fundamentally unfair.

Warren Buffett and Robert Rubin are also members of United for a Fair Economy.

Remake The Dietary Guidelines into FOOD Guidelines

In this new editorial, two prominent nutrition researchers, call for changing our Dietary Guidelines drastically.

JAMA -- Dietary Guidelines in the 21st Century--a Time for Food, August 11, 2010, Mozaffarian and Ludwig 304 (6): 681

The current guidelines are based on nutrients: Eat less fat, more fiber, less salt. However, most of the disease we have today can be prevented by eating healthy FOODS (not nutrients). The guidelines shy away from foods, so that a particular food industry does not get offended. Imagine Coca Cola's response to a "Do not drink soda" guideline put out by the government.

But a focus on food is what we need. The food industry has been able to craft fake-healthy foods by including a healthy phrase on the package: "fat-free cookies", "Trans-free chips", "Calcium-enriched Juice." This mislead consumers and may actually promote disease.

As the authors of the editorial state: "the greater the focus on nutrients, the less healthful foods have become".

Their conclusion: "nutrient targets should largely be replaced by food-based targets."

Doing so would bring us back to a way of eating that is based on food, using modern nutrition knowledge.

As Michael Pollan says, "Eat FOOD. Not Too Much. Mostly Plants."

Disclosure: I worked for one of the authors of this article, David Ludwig.

Breastfeeding: Why the health benefits aren't enough to increase rates.

It would be best for the health of our country if all women were given the tools and the environments that supported breastfeeding.

Notice how I framed that message?

This brief on messaging around breast feeding shows why advocates cannot just use the "it's healthier for the baby" argument.

Advocacy rests on framing, as I've argued before. We need to frame breast feeding with the Berkeley Media Studies formula:

Environmental Cue + Value + Policy= Desired Message

We need to focus on values. Health of the baby is one, but so are ingenuity, and equity. We need to focus on providing these types of environments to support the health of women and children.

Protect Bikers and Save the World @lacbc @laist

A real battle is going on at the World's Oldest Bike race. Lance is out of contention. Contador and Schleck are going at it on the mountains of France. There is still hope for American Levi Leipheimer. Team Radioshack is leading the team contest.

But a much bigger bicycle battle is going on in the streets of our cities. One of my best friends (and a great family doctor) was hit while riding in a bike lane last week. He's ok, but needed some surgery. One of my sister's friends was hit while riding in New York City a few months ago. Also injured. A renowned researcher and one of the Deans of my Medical School was hit a few years ago, and is recovering from partial paralysis. Now the Mayor of LA was hit by a taxi, while riding his bike.

Now I don't want to scare anyone. Biking's health benefits outweigh it's risks. I think more of us need to get out on our bikes. More biking can save the world. How? Here's my top 10:

10. More Biking= more activity= healthier people.

9. More biking= less vehicular traffic. Less pollution and global warming.

8. Biking gets people to interact as they travel. You can't talk to the person in the car next to you, but you can converse with a fellow biker.

7. Biking makes you happy. Ask my sister.

6. Imagine the boost to our economy if everyone went and bought a bike.

5. Fun activity for child-parent bonding.

4. You can bike to beautiful places and see nature.

3. It gives super cool legs.

2. You can wear cool bike clothes.

1. It is super fun.

We need to make our communities safer to biking. Here are some ways we can do this, courtesy of the Bike League:

1. Adopt a target level of bicycle use (e.g. percent of trips) and safety to be achieved within a specific timeframe, and improve data collection necessary to monitor progress.

2. Provide safe and convenient bicycle access to all parts of the community through a signed network of on- and off-street facilities, low-speed streets, and secure parking. Local cyclists should be involved in identifying maintenance needs and ongoing improvements.

3. Establish information programs to promote bicycling for all purposes, and to communicate the many benefits of bicycling to residents and businesses (e.g. with bicycle maps, public relations campaigns, neighborhood rides, a ride with the Mayor)

4. Make the City a model employer by encouraging bicycle use among its employees (e.g. by providing parking, showers and lockers, and establishing a city bicycle fleet).

5. Ensure all city policies, plans, codes, and programs are updated and implemented to take advantage of every opportunity to create a more bicycle-friendly community. Staff in all departments should be offered training to better enable them to complete this task.

6. Educate all road users to share the road and interact safely. Road design and education programs should combine to increase the confidence of bicyclists.

7. Enforce traffic laws to improve the safety and comfort of all road users, with a particular focus on behaviors and attitudes that cause motor vehicle/bicycle crashes.

8. Develop special programs to encourage bicycle use in communities where significant segments of the population do not drive (e.g. through Safe Routes to Schools programs) and where short trips are most common.

9. Promote intermodal travel between public transport and bicycles, e.g. by putting bike racks on buses, improving parking at transit, and improving access to rail and public transport vehicles.

10. Establish a citywide, multi-disciplinary committee for nonmotorized mobility to submit to the Mayor/Council a regular evaluation and action plan for completing the items in this Charter.

Let's do it in LA and around the country! We should all aim to be like the #1 Bike friendly city in America, Davis, CA! Start us out by donating to Los Angeles County Bicycling Coalition.

Obama Understands the Importance of Primary Care

Based on these remarks, it is clear to me that President Obama has a vision for changing our healthcare system to improve primary care:

President Obama Calls for Better Payment System for Primary Care Physicians -- AAFP News Now -- American Academy of Family Physicians

"It used to be that most of us had a family doctor," said Obama. "You would consult with that family doctor. They knew your history. They knew your family. They knew your children. They helped deliver babies."

Now we often have a mishmash of consultants dealing with each organ in a patients body, instead of having someone deal with the whole person:

"Now in these big medical systems, so often, what happens is that you're shuttled around from (sub)specialist to (sub)specialist," said Obama. "Oftentimes, people don't have a primary care physician that they're comfortable with, so they don't get regular checkups. They don't get regular consultations. Preventable diseases end up being missed, and you don't have the kind of coordination that's necessary between all these different specialists."

Then he agrees with my JAMA editorial from early this year:

"Right now you've got a situation where if a primary care physicians says to a patient, 'You know what, you need to lose some weight because you're at risk of diabetes, and I've got a good exercise program that makes sense, and here's a dietitian that you should talk to,' sometimes Medicare may not reimburse that consultation," Obama said.

But, he noted, Medicare will pay $30,000 for a foot amputation that results from the ensuing diabetes.

Let's fix this. One first step is to get Dr. Don Berwick confirmed as director of Medicare and Medicaid Services. We need an innovative thinker to help transform our system into a modern health system, that focuses on primary care, prevention, and everyone having a personal physician.

Bring back Home Economics: JAMA Editorial

I gave a talk two weeks ago, where I spoke about the origins of the college I went to, the College of Human Ecology at Cornell. It was originally started as the school of home economics. Its leader was Martha Van Rensaleer, a visionary female. The goal of the college was to teach women the skills they needed to be effective in the home in NY farms.

Martha Van Rensaleer went on to become a advocate for women and children's health and wellbeing. In 1930 she helped form the National Children's Charter which said:

"“For every child health protection from birth through adolescence, including: …the insuring of pure food, pure milk, and pure water.”

I think we can help guarantee this to our children by teaching them home economics skills, as this editorial states. We can also continue the great work of Martha Van Rensaleer, by teaching people nutrition through state cooperative extensions, such as the same Cornell Cooperative Extension that MVR was a leader of in the 1900s. The country's agricultural schools can be the birthplace of educators in nutrition and innovative farmers. They successfully improved nutrition in the early part of last century. They could do the same in this century.

Food Politics � Here’s a thought: bring back Home Ec

Mr.Evil Creates Fake Charities to Fight Public Interest Groups like MADD, CSPI, and the Humane Society

Anyone who is familiar with nutrition advocacy will know the group, "Center for Consumer Freedom." It is an industry front group (started by Phillip Morris) that fights against food policies that could help us become a healthier nation. It just so happens that the man behind this, Mr. Berman, creates these fake charities to fight a bunch of organizations, from the Humane Society to MADD. He makes a fortune off these fake charities. This articles exposes it all.

Investigative Report: Richard Berman : The Humane Society of the United States

I found the quote from his son most damning:

"'My father is a despicable man. My father is a sort of human molester. An exploiter. A scoundrel. He props up fast food/soda/factory farming/childhood obesity and diabetes/drunk driving/secondhand smoke. He attacks animal lovers, ecologists, civil action attorneys, scientists, dieticians, doctors, and teachers. His clients include everyone from the makers of Agent Orange to the Tanning Salon Owners of America. …'"

Colbert's Salt Shaker

While this video clip is very funny, Michael Jacobson points out that it is a tragedy that some many people die each year from too much salt intake. Now we can debate whether the number is 150,000, as the health organizations state, or if it is much smaller. However, the question is: Why do we need this much salt?

FDA Salt Regulation - Lori Roman & Michael Jacobson | May 3, 2010 - Elizabeth Warren | ColbertNation.com

Two vignettes may help. A few years ago I worked at the Duke Diet and Fitness Center. I was not paid, but I got to eat all my meals at the center. Their kitchen cooks without salt. All the food tasted good to me, so I did not even notice there was no salt in it. It was not until I left the center and started eating typical American food again that I realized how salty everything was. The bottom line is that if the FDA required companies to slowly roll back the amount of salt in foods, we would probably hardly notice. (Except for the Salt Institute, who would probably notice, which is why they are so against this.)

The other reason the food industries add so much salt is this: Last weekend I ordered some black bean soup from Panera Bread. After I finished, I was really thirsty. I looked on the nutrition info and saw that the half portion of soup had 960mg of Sodium! Now I was so thirsty and had such a salt taste in my mouth, that I needed something sweet. I ordered a smoothie (an extra 260 calories), which cured my problem. My point is that the food and restaurant industries know that by adding more salt they promote people to buy more drinks and other food. (Every try to eat just one salty chip? Ever successful?)

We do not need this much salt in our food system. A reduction would benefit the health of our families, and would prevent many of the strokes and heart attacks of our loved ones.

Conflict of Interest Statement: In 2005,I worked at CSPI on a petition to the FDA to limit the amount of salt in foods.

Meat as Source of Antibiotic Resistance

In a Congressional hearing on Wednesday, Drs. Freiden and Fauci, from the CDC and NIH, reported that 90,000 Americans die each year due to resistant bacteria. A large amount of debate in the session concerned whether antibiotic use in agriculture contributed to this problem. (Antibiotics are mostly used in agriculture to promote growth in healthy animals, and not to treat infections.) The Doctors said they could not cite particular evidence from the US that linked the use to human sickness. (One of the Republicans asked specifically for US research, implying that research for Europe is not valid.) It is a shame that they did not directly cite the Institute of Medicine Report:

Microbial Threats to Health: Emergence, Detection, and Response

which shows that antibiotic resistant bacteria were found in multiple foods in the supermarket. The report concluded that the resistance does transmit foods ingested by humans. It is virtually impossible to see if a specific person's bacteria is linked to an animal getting an antibiotic. But, it appears that since the ban of antibiotics in Europe, antibiotic resistance has decreased, which is definitely a good thing.

It appears although multiple scientific groups are advocating the ban of antibiotics, Congressional action will be hampered by the lobbyists from Big Farma and Big Pharma. the best thing you can do to act personally is not eat mean/poultry that contains antibiotics. It is safe to assume, that unless mean is labeled in this way, it has antibiotics. So eat antibiotic-free foods, and you may save the life of your child, mother, or other loved one, including yourself.

Insurance companies hold billions in fast food stock

This new study shows that companies supposed to be supporting health are invested in some of the most unhealthy companies. While I doubt the insurance executives were thinking, "Let's invest in fast food so we can get more people sick," it does bring up a potential conflict of interest. Now that insurance companies will not be able to deny people insurance, they may start thinking more about health. Hopefully this will prompt them to invest in companies that promote health for American families.

Study: Insurance companies hold billions in fast food stock - CNN.com

(p.s. Great to see Cambridge Health Alliance, where I trained, putting out great studies!)

Exodus, Collectivism, and the USA

A Passover plea: Don't tread on E Pluribus Unum - On Faith at washingtonpost.com:

"With Passover on the horizon, Americans can look to the Jewish founding narrative -- the Exodus story -- for perspectives on freedom and nation building. Interestingly, the Exodus from Egypt is framed not in terms of the individual's right to freedom from oppression (though that is certainly implicit) but rather in terms of the freedom to work together to build a society of equity, of justice, and of collective social responsibility."

The Brain Needs to Travel

I just got back from traveling to Mexico, and then to New York City. I happened to read a few good quotes while traveling.

One was from Chabon's Adventures of Kavalier and Clay. It made me think of travel as a temporary escape:

"The shaping of a golem, to him, was a gesture of hope, offered against hope, in a time of desperation....It was the voicing of a vain wish, when you got down to it, to escape. To slip, like the Escapist, free of the entangling chain of reality and the straitjacket of physical laws....[They] always cited "escapism" among the litany of injurious consequences of their reading, and dwelled on the pernicious effects, on young minds, of satisfying the desire to escape. As if there could be any more noble or necessary service in life."

Then I read an article by Jonah Lehrer, "Definitive Incontrovertible Proof: Why Travel Makes you Smarter" from the San Francisco Panorama. He uses some experimental examples and some thought to show why traveling is so important:

"Such cultural contrasts mean that seasoned travelers are alive to ambiguity, more willing to realize that there are different (and equally valid) ways of interpreting the world."

"...this increased creativity [as a result of traveling] appears to be a side-effects of difference: we need to change cultures, to experience the disorienting diversity of human traditions. The same details that make foreign travel so confusing-- Do I tip the waiter? Where is this train taking me?--turn out to have a lasting impact, making us more creative because we're less insular. We're reminded of what we don't know, which is nearly everything..."

"We travel because we need to, because distance and difference are the secret tonic of creativity. When we get home, home is still the same. But something in our mind has been changed, and that changes everything."

I'm going to plan my next trip....

(more quotes are on my quotes page- see link at top of blog)

Health Reform Benefits Our Families #hcr

I'm so excited that we got health reform past. I think this will be overall good for the American people. I would prefer a public option or an expansion of Medicare, but I think this law is a start.

Here are some of the benefits:

- Health insurance providers cannot deny any child coverage because of a pre-existing condition
- Insurance companies can no longer drop someone when he or she becomes ill
- Young adults can stay on their parents' health insurance plan up to their 27th birthday
- Health Insurers must now reveal how much money is spent on overhead
- New health insurance plans must cover checkups and other preventative care without co-pays
- New measures will be implemented to help eliminate health insurance waste, fraud, and abuse
- Small businesses (fewer than 50 employees) will get tax credits covering up to 50% of premiums
- Seniors on Medicare will get a rebate to fill the "donut hole" in their drug coverage
- Insurers will be required to put more premiums dollars toward actual health care services, not administration, advertising, or profits
- Insurance premium increases will be have to be reviewed and justified
- Lifetime caps on the amount of insurance a person can have will be banned
- A temporary high-risk pool will be set up to cover adults with pre-existing conditions

Health Reform (#hcr) by Our Values

Obama is giving great talks and pumping up the crowds on health care reform. Yesterday in Pennsylvania he was introduced by a woman who had diabetes, whose insurance company kept raising her rates. Obama continued with this theme, talking about PEOPLE, INSURANCE COMPANY DENIALS, AND WHY WE BELIEVE EVERYONE SHOULD BE INSURED.

That's why I was surprised by the new White House website: Health Reform by the Numbers: 1,115 | The White House. They are devoting a website to focus on the numbers of health care: how much insurance cost, how many people we will drop. This is exactly the WRONG strategy. As I've posted before, people do not respond to numbers. They respond to value arguments. We need to keep talking about the Americans who cannot receive care in our current system, and why we believe they should.

Values win over numbers. Thank you again, George Lakoff.

Drug Trials Should Not be done by companies

In this article, Dr. Krumholz, talks about the recent diabetes drug issues. He advocates for all drug data (after a drug is approved) to be in the public domain. This way, academic researchers can look at the data and see if there are lots of adverse effects, instead of relying on drug company documents.

Drug Companies Disappoint Me Again - Forbes.com

I would go a step further. As I've said before, I think all drug trials should be done by FDA-designated academic centers. First a drug company puts the drug through Phase 1 and Phase 2 trials. (These are early trials that figure out the dosing and initial safety.) Then the FDA takes over. The drug company pays the FDA to do the Phase 3 trial (the major part of the trial that tests if the drug works). The FDA contracts an academic researcher to do the trial and publish the results. The FDA uses that data to determine whether the drug gets approved. (I also would have the drug tested against a drug that works, instead of a placebo.)

This process still allows the drug company to do the initial development. It just protects the research from too much industry bias in the development. The drug company then still gets to make the profits after the drug is approved.

We need to separate the research from the industry, after a certain point. Without this, we will continue to have more drug recalls.

Improve Prevention by Paying for What's Important

In this commentary Dr. Bazemore and I discuss 3 ways in which health reform could improve the delivery of preventive care. We need to align preventive care with the USPSTF recommendations, and start paying for preventive coordination. The current health reform bill offers some ways to do this, but we need to experiment with more ways, so that older Americans can prevent disease and live a more fulfilling life.

JAMA -- Improving the Delivery of Preventive Services to Medicare Beneficiaries, December 23/30, 2009, Lesser and Bazemore 302 (24): 2699

We Have 60!

While this bill isn't perfect, it will do a lot of good things to help a lot of people struggling with lack of health insurance. Here are the highlights of what should pass this week. What's not included in this summary is that the nonpartisan Congressional Budget Office states that the bill will reduce the deficit by $132 billion over 10 years.

Manager’s Amendment to the Patient Protection and Affordable Care Act

Providing More Competition & Affordable Choices for Americans

The Manager’s Amendment to the Patient Protection and Affordable Care Act builds upon the strong bill we already have. It demands greater accountability from health insurance companies while creating more choice and competition for consumers. It implements new programs to further rein in health costs and makes health insurance policies more affordable; and it improves access to quality, affordable health care for children and vulnerable populations.

Tougher Accountability Policies for Health Insurance Companies

• Stronger medical loss ratios. Health insurers will be required to spend more of their premium revenues on clinical services and quality activities, with less going to administrative costs and profits – or else pay rebates to policyholders. These stricter limits will continue even after the Exchanges begin in 2011, and apply to all plans, including grandfathered plans.
• Accountability for excessive rate increases. A health insurer’s participation in the Exchanges will depend on its performance. Insurers that jack up their premiums before the Exchanges begin will be excluded – a powerful incentive to keep premiums affordable.
• Immediate ban on pre-existing condition exclusions for children. Health insurers will be immediately prohibited from excluding coverage of pre-existing conditions for children.
• Patient protections. Health insurers will have to abide by a set of patient protections that, for example, protect choice of doctors and ensure access to emergency care.
• Ensuring access to needed care. The use of annual limits on benefits will be tightly restricted to ensure access to needed care immediately, and will be prohibited completely beginning in 2014.
• Guaranteed opportunity to appeal coverage denials. All health insurers will be required to implement an internal appeals process for coverage denials, and states will ensure the availability of an external appeals process that is independent and holds insurance companies accountable.

Stronger Policies to Make Health Care Affordable

• Innovation. Medicare will be able to test new models and, if successful, implement them via a stronger Innovation Center, Independent Payment Advisory Board, and other authorities.
• Transparency. New requirements will ensure that insurers and health care providers report on their performance, empowering patients to make the best possible decisions.
• Small businesses. A package of improvements include starting the health insurance tax credit in 2010, expanding eligibility for the credit, and improving the purchasing power of small businesses.

More Health Insurance Choices

• Multi-state option. Health insurance carriers will offer plans under the supervision of the Office of Personnel Management, the same entity that oversees health plans for Members of Congress. At least one plan must be non-profit, and the plans will be available nationwide. This will promote competition and choice.
• Free choice vouchers. Workers who qualify for an affordability exemption to the individual responsibility policy but do not qualify for tax credits can take their employer contribution and join an exchange plan.

Improved Access to Quality Health Care for Seniors, Children, and Vulnerable Populations

• Quality of care in Medicare. Seniors will benefit when additional health care providers are reimbursed by Medicare for the quality of care they deliver, not the quantity of services they provide.
• Children’s health. Support will be extended for the Children’s Health Insurance Program and the adoption tax credit. Foster care children aging out of Medicaid will be able to retain its comprehensive coverage.
• Community Health Centers. A substantial investment in Community Health Centers will provide funding to expand access to health care in communities where it is most needed
• Rural and underserved communities. Access will be expanded through funding for rural health care providers and training programs for physician and other types of health care providers.
• Vulnerable populations. A range of new programs will tackle diseases such as cancer, diabetes, and children’s congenital heart disease, will improve the Indian Health System, and will provide support for pregnant teens and victims of domestic violence.

Identifying Alternatives to Litigation

• Testing new models. States will be eligible for grants to test alternatives to civil tort litigation that emphasize patient safety, disclosure of health care errors, and early resolution of disputes, with a provision for patients to opt-out of these alternatives at any time. Alternatives will be evaluated to determine their effectiveness.