Every time there is a shooting that makes the national news because the number of victims was more than one or two, and especially if it was quite a bit more than that, we are sure to hear proponents of stringent gun control measures calling for a ban on high-capacity magazines. The idea is that being able to fire numerous rounds without having to reload the gun makes a deranged killer even more deadly. And so, if there is a limit of ten rounds per magazine, the killer will be forced to stop and reload more often than if the magazine holds 15 or 17 rounds.
Such a proposal will invariably be labeled a "common-sense" gun control measure. Anyone who opposes it will be accused of somehow being in league with psychopaths and criminals - who, after all, are the only ones who "need" large-capacity magazines, for the purpose of killing as many victims as possible in the shortest possible time. Oh, and the police need them, too, so they won't be "out-gunned" by the lawless.
Twenty-five years ago, when talk of banning "assault weapons" was approaching a fever pitch, a colleague who was an avid pistol shooter told me, in a conversation about gun control, that no one "needs" a semi-automatic rifle.
[For those unfamiliar with the mechanics of firearms, a semi-automatic rifle or pistol fires one bullet with each squeeze of the trigger, and the next round is "automatically" fed from a magazine into the chamber. This is different from a "machine gun," which will fire bullets in rapid succession if the trigger is squeezed and held. The typical machine gun is capable of "selective fire." Squeeze and release the trigger: one round at a time; squeeze and hold: rapid fire of bullet after bullet until the trigger is released. Some weapons offer the option of three-round bursts. In military parlance, an "assault weapon" is one that can be used to lay down a field of fire, which necessitates the mode known as "full auto." So only a machine gun, or selective fire rifle, meets the definition of an assault weapon. Many people use "assault weapon" to describe semi-automatic rifles and pistols, sometimes out of ignorance, sometimes to make them sound as though their only raison d'être is wanton destruction of human life.]
First, let us take note of the fact that owning a selective fire rifle (lawfully) requires a special license that is very expensive, and an awful lot of paperwork. And the firearms themselves are quite pricey. They are very rarely found on the street. Then we can move on to examine the difference between ten- and thirty-round magazines for use in a semi-automatic rifle or ten- and fifteen-round magazines for use in a semi-automatic pistol. The difference is simple. One must reload once or twice, versus not, in order to fire 30 rounds. How much extra time does that take? And does the pause to reload give a person who might try to stop the shooter time to intervene?
With a little practice, the time to reload is extremely brief: perhaps a second or so. And if you think you can tell when the shooter is pressing the release button to eject the magazine, with the right hand, while reaching for a fresh magazine with the left hand, thus identifying the moment when a flying tackle will put a stop to the carnage, consider this: the way most guns are designed, there is quite possibly still a round in the chamber, and the shooter can fire it at you. Bad plan.
So let's move on a little further. How about banning semi-automatic pistols and rifles (except for use by law enforcement, which means they are still being manufactured, and criminals will still get hold of them), and restricting people (the law-abiding, anyway) to revolvers? They typically hold six cartridges (bullet plus gun powder plus a "primer" to ignite the powder in a metallic case) and take much longer to reload than a semi-automatic pistol. Hmmm. Well, they do take longer to reload, but a lot longer? Not necessarily. There is a device called a speed loader that makes the process a lot faster, especially with practice. Ask any police officer who carried a revolver in the days before most agencies switched to semi-auto pistols.
Maybe we should restrict civilians to single-shot firearms that must be reloaded after each round is fired. After all, a responsible and skilled hunter believes in the "one-shot kill." Why do you need a quick follow-up shot? Ask a good hunter whose first shot didn't put the animal down right away about the importance of a follow-up shot. And then there is the matter of using guns for self-defense, but that is another argument altogether, especially when you're talking to people who think a law-abiding citizen who buys a gun for self-defense is much more likely to shoot his spouse in anger, or by mistake, than to use the gun in defense of home and family.
By now you should be able to see that the title revealed where this was going. And that is the problem with the societal debate on gun control. Every time the proponents of gun control measures put forth what they call a "common-sense" measure, the advocates for gun rights immediately see what will follow it, and what will come after that, and so on.
For much of the 20th century, a citizen with a clean record willing to subject himself to an extensive background check, pay a hefty fee, and do lots of paperwork could get a license to own a selective-fire rifle. Then in 1986 it became illegal for a person with such a license to purchase such a weapon manufactured after that year. The supply of eligible firearms thus severely limited, their prices have since skyrocketed (unless you buy them illegally, or re-engineer a semi-auto rifle to fire in full-auto mode, which is both illegal and much more technically difficult than news reports would have you believe).
So it's extremely difficult and expensive to purchase a selective-fire rifle. Beginning in 1994, and for a period of ten years, certain semi-automatic rifles and pistols, and high-capacity magazines, were illegal; that ban expired, but there are frequent calls for its reinstatement. Many proponents of gun control frequently argue for banning all semi-automatic firearms, and gun-rights advocates are quite certain that a complete ban on private ownership of firearms will eventually follow.
This, you see, is the slippery slope.
We've seen it with waiting periods. How about a background check? Just look at the records to make sure the prospective buyer is not a convicted felon. That can be done instantly with modern computer systems. But why not a three-day waiting period anyway, a "cooling-off" period to help avoid tragedy for the temporarily unhinged suicidal or homicidal person? If three days is good, wouldn't seven be even better? How about 30 days? Yes, those exist in some locales.
There may be some "common-sense" gun control measures that few rational gun owners would find truly objectionable. Except for the slippery slope. As long as law-abiding gun owners who believe in their right to keep and bear arms, as a natural right of self-defense protected by the Second Amendment to the U.S. Constitution, believe that every gun control measure enacted will be followed by more and more until their rights are a memory ... as long as that is the case, which will be as long as gun control proponents give frequent and ample evidence that this is their agenda ... we will never achieve anything remotely approaching societal consensus on just what "common sense" would dictate.
Update: July 21, 2012
In the wake of a massacre in a movie theatre in the early hours of 7/20/12 in Aurora, Colorado, New York City Mayor Michael Bloomberg has renewed calls for stricter federal gun control. New York has very strict gun laws, but Mayor Bloomberg believes the reason that the rate of violent crime is rising in NYC while it is falling for the nation as a whole is that the influx of guns from outside the state cannot be controlled without new federal laws. Most (if not all) of that influx is the result of illegal commerce in guns, so exactly how new laws would solve the problem is unclear.
Political pundits are saying Congress and the Obama Administration will go nowhere near this issue in a presidential election year. Republicans are consistently pro-gun-rights, and Democrats fear the National Rifle Association. Many believe Al Gore would have won Tennessee and West Virginia - and the White House, without Florida - in 2000 if not for his strident pro-gun-control policy positions.
Thousands of Americans have become instant experts on the complex issue of gun control and are expressing their views on social networking sites. It is remarkable how many people are sure they have the solution to one of the most consistently vexing problems of modern American society.
In 1968 Bobby Kennedy and Martin Luther King, Jr. were assassinated. The Gun Control Act of 1968 followed. More than four decades later we seem no closer to real answers.
For those interested in a critical examination of the issues and the full spectrum of perspectives, I recommend The Gun Control Debate: You Decide. This is a collection of articles assembled in a cohesive volume by editor Lee Nisbet, Ph.D. in 1991 and updated for the 2001 second edition.
Tuesday, March 27, 2012
Sunday, March 25, 2012
Old Dog, New Tricks: Catching Up with Medical Technology
I spent last week learning the fundamentals of using ultrasound in the bedside evaluation of the patient in the emergency department. The use of this technology expands the three senses I routinely employ when I examine patients.
In the traditional physical examination the doctor looks at the patient, uses a stethoscope to listen to sounds made by the organs, and feels with his or her hands to discover anatomic abnormalities. Ultrasound has the most profound effect on the visual examination, as it permits the physician to look inside the body. No longer dependent on the reflection of visible light from the patient to the examiner's eye, the doctor can "shine" the ultrasound beam into the body from the surface and see (on a monitor) the images produced by the reflection.
When ultrasound is used to examine the heart and blood vessels, it is possible both to see and to hear blood flow. And this technology enables the physician to combine seeing and feeling in ways otherwise impossible. When I see a patient with pain in the upper abdomen on the right side, I may press where I think the gall bladder is to see if that hurts. With ultrasound, I can see the gall bladder when I'm pressing, so I not only know whether the gall bladder looks diseased, I can also tell directly whether it is tender to touch - important because that helps to confirm that it is the diseased gall bladder that is causing the patient's pain. Similarly, when I see a woman with pelvic pain, I can not only see that she has ovarian cysts (which are very common and usually asymptomatic) but can also tell whether they are tender to touch, and thus likely (or not) to be the source of her pain.
[For those curious about the other two senses, I'll just say there are many things the astute clinician can discern about patients by smell, but nowadays we don't really employ taste. I can only imagine how that would be regarded by a disciplinary review board.]
We now use ultrasound to examine the body quite literally from head to toe. Ultrasound can reveal important findings of injury to and disease of the eye, and it can be used to find fluid in the joint of a toe and facilitate withdrawing some of that fluid through a needle to send to the laboratory and confirm the diagnosis of gout. We may use it to help us see a large vein in the neck as we place an intravenous line there, or we may evaluate blood flow to the brain through the carotid arteries. We can also examine blood flow through the arteries and veins in the arms and legs. There are many things we can find out by employing ultrasound to evaluate organs in the chest, abdomen, and pelvis, from structure and function of the heart, to diseases of the liver and kidneys, to whether a pregnancy is in the uterus (where it belongs) or in one of the Fallopian tubes (where it may rupture and kill a young woman).
Perhaps the most exciting use of ultrasound is in the rapid detection, in an injured patient, of internal bleeding in the chest, abdomen, or pelvis. This can tell us right away that a patient must go directly from the emergency department's trauma bay to the operating room (do not pass go, do not collect $200) because of major bleeding. Rapid decision making is critical in such a situation, because minutes can, quite literally, mean the difference between life and death.
When I was in training in the mid-80s, there was no such thing as the use of bedside ultrasound in the ED. The first paper about the use of ultrasound in emergency medicine was published in 1988. The American College of Emergency Physicians (ACEP) offered its first course dedicated to the subject in 1990. The Society for Academic Emergency Medicine developed a model curriculum for training emergency physicians to use ultrasound and published it in 1994. ACEP's Ultrasound Section has done a great deal of extraordinary work, including the development of ACEP's emergency ultrasound guidelines, first published in 2001 and revised in 2008.
Many emergency departments, including most of the ones where I've practiced over the years, still do not have ultrasound capability, because the ED does not have an ultrasound machine or the doctors aren't trained to use one (or both). But last summer I joined the staff at an academic medical center, and not only must I know how to do this, but I must acquire mastery sufficient to teach the next generation. So I have just taken the first step on the path to that mastery.
The path is long. If you want to be a technologist ("ultrasonographer"), that takes two years. The training program is also two years for echocardiographers, those who use ultrasound strictly for imaging the heart. Of course physicians learning ultrasound have a big initial advantage, because we already know the anatomy and physiology of everything we want to examine. On the other hand, ultrasound is only a relatively small part of our practice, because we don't use it on everybody, and so that greatly lengthens the learning curve.
Forty hours of highly intensive instruction was a good start, though. If you have occasion to see me as a patient, expect me to try to come up with a reason to examine some part of you with ultrasound. But don't worry. It doesn't hurt, it has no known adverse effects, and because I'm learning, there will be no charge. And I might just find something important, or at least be able to tell you the bad thing we worried about is not there. After more than a quarter century in practice, I am doing something that will make me a better doctor. Yes, I am excited.
In the traditional physical examination the doctor looks at the patient, uses a stethoscope to listen to sounds made by the organs, and feels with his or her hands to discover anatomic abnormalities. Ultrasound has the most profound effect on the visual examination, as it permits the physician to look inside the body. No longer dependent on the reflection of visible light from the patient to the examiner's eye, the doctor can "shine" the ultrasound beam into the body from the surface and see (on a monitor) the images produced by the reflection.
When ultrasound is used to examine the heart and blood vessels, it is possible both to see and to hear blood flow. And this technology enables the physician to combine seeing and feeling in ways otherwise impossible. When I see a patient with pain in the upper abdomen on the right side, I may press where I think the gall bladder is to see if that hurts. With ultrasound, I can see the gall bladder when I'm pressing, so I not only know whether the gall bladder looks diseased, I can also tell directly whether it is tender to touch - important because that helps to confirm that it is the diseased gall bladder that is causing the patient's pain. Similarly, when I see a woman with pelvic pain, I can not only see that she has ovarian cysts (which are very common and usually asymptomatic) but can also tell whether they are tender to touch, and thus likely (or not) to be the source of her pain.
[For those curious about the other two senses, I'll just say there are many things the astute clinician can discern about patients by smell, but nowadays we don't really employ taste. I can only imagine how that would be regarded by a disciplinary review board.]
We now use ultrasound to examine the body quite literally from head to toe. Ultrasound can reveal important findings of injury to and disease of the eye, and it can be used to find fluid in the joint of a toe and facilitate withdrawing some of that fluid through a needle to send to the laboratory and confirm the diagnosis of gout. We may use it to help us see a large vein in the neck as we place an intravenous line there, or we may evaluate blood flow to the brain through the carotid arteries. We can also examine blood flow through the arteries and veins in the arms and legs. There are many things we can find out by employing ultrasound to evaluate organs in the chest, abdomen, and pelvis, from structure and function of the heart, to diseases of the liver and kidneys, to whether a pregnancy is in the uterus (where it belongs) or in one of the Fallopian tubes (where it may rupture and kill a young woman).
Perhaps the most exciting use of ultrasound is in the rapid detection, in an injured patient, of internal bleeding in the chest, abdomen, or pelvis. This can tell us right away that a patient must go directly from the emergency department's trauma bay to the operating room (do not pass go, do not collect $200) because of major bleeding. Rapid decision making is critical in such a situation, because minutes can, quite literally, mean the difference between life and death.
When I was in training in the mid-80s, there was no such thing as the use of bedside ultrasound in the ED. The first paper about the use of ultrasound in emergency medicine was published in 1988. The American College of Emergency Physicians (ACEP) offered its first course dedicated to the subject in 1990. The Society for Academic Emergency Medicine developed a model curriculum for training emergency physicians to use ultrasound and published it in 1994. ACEP's Ultrasound Section has done a great deal of extraordinary work, including the development of ACEP's emergency ultrasound guidelines, first published in 2001 and revised in 2008.
Many emergency departments, including most of the ones where I've practiced over the years, still do not have ultrasound capability, because the ED does not have an ultrasound machine or the doctors aren't trained to use one (or both). But last summer I joined the staff at an academic medical center, and not only must I know how to do this, but I must acquire mastery sufficient to teach the next generation. So I have just taken the first step on the path to that mastery.
The path is long. If you want to be a technologist ("ultrasonographer"), that takes two years. The training program is also two years for echocardiographers, those who use ultrasound strictly for imaging the heart. Of course physicians learning ultrasound have a big initial advantage, because we already know the anatomy and physiology of everything we want to examine. On the other hand, ultrasound is only a relatively small part of our practice, because we don't use it on everybody, and so that greatly lengthens the learning curve.
Forty hours of highly intensive instruction was a good start, though. If you have occasion to see me as a patient, expect me to try to come up with a reason to examine some part of you with ultrasound. But don't worry. It doesn't hurt, it has no known adverse effects, and because I'm learning, there will be no charge. And I might just find something important, or at least be able to tell you the bad thing we worried about is not there. After more than a quarter century in practice, I am doing something that will make me a better doctor. Yes, I am excited.
Monday, March 12, 2012
Is Rush Limbaugh a Clear and Present Danger?
The First Amendment to the United States Constitution prohibits Congress from enacting any laws abridging freedom of speech or of the press. As with any other freedom, there is a societal expectation that it will be exercised responsibly. But what does it mean to exercise freedom of speech responsibly? The courts have given us very wide latitude. Perhaps most famous among relevant quotations are these words from Supreme Court Justice Oliver Wendell Holmes, Jr.: "The most stringent protection of free speech would not protect a man falsely shouting fire in a theater and causing a panic." Although the ruling in which Holmes wrote those words in his opinion was later overturned, the principle was not: there is some speech that is sufficiently dangerous that it is not protected.
Although the First Amendment's protection of free speech has been interpreted broadly to cover a wide range of "expression," including the visual arts, the intent of the Framers was to protect political speech, and especially unpopular political speech.
Recently Rush Limbaugh directed his intemperate vitriol against the Obama Administration's decision to deny a religious exception for insurance coverage of prescription contraceptives (a topic on which I wrote earlier this month). But Limbaugh did not limit his attacks to the president or officials in his Administration. Rather, he included a Georgetown University law student who had testified before Congress, advocating such insurance coverage. She explained that the cost of prescription birth control is not inconsiderable. She was talking about hormonal contraception, but Limbaugh took the amount she estimated and applied it instead to one of the cheaper methods (condoms), calculating how often one must have sex to spend that much on birth control. Having done the faulty arithmetic, Limbaugh derided the law student as a "slut."
[It would, I think, have made just as much sense to do that arithmetic, assume the law student was in a monogamous relationship, and consider her intimate partner: "Wow. Lucky guy! Tired, but lucky." But I digress.]
While one who testifies before Congress makes herself into something of a public figure, there is certainly no expectation that she will then be subject to vile verbal attacks from those who disagree with her opinions. There was public outrage about Limbaugh's remarks, and a campaign quickly got underway to apply pressure to commercial sponsors of his radio show to withdraw their advertising support.
That is how it should be, I think. You don't like what Limbaugh says or how he says it? Convince those who support his program through advertising that being thus associated with him is not in their best interests. Commercial sponsors are very sensitive to what they believe are the public images of celebrities with whom they have relationships. Witness the reaction to the sexual promiscuity of Tiger Woods or the cannabis indulgences of Michael Phelps.
CNN has provided some perspective on this issue. Their Web site ran a piece by Marc Randazza, a First Amendment attorney from Nevada, explaining the continued importance of protecting politically unpopular speech. There is no question that much of what Limbaugh has to say is politically unpopular with those who are not among his loyal radio audience. Randazza is the editor of his own blog, The Legal Satyricon, which posted his thoughtful essay. But it also posted (as did CNN) a piece by Jane Fonda, Robin Morgan, and Gloria Steinem, co-founders of the Women's Media Center, who say the FCC should boot Rush off the air. They warn of the consequences of "society tolerating toxic, hate-inciting speech." They exhort their readers to complain to the FCC about Limbaugh, the idea being that the FCC would respond by taking action to remove Limbaugh from the broadcast radio spectrum.
How exactly the FCC could do that without plainly violating the First Amendment is unclear. The FCC can fine stations that have programming that violates its standards of decency. It might be amusing to see whether the ACLU is willing to defend Limbaugh should FCC declare his show in violation of those standards. But the FCC could do that. And, if it did, that would silence Limbaugh once and for all. Just like it did Howard Stern. Oh, wait. Stern just moved to satellite radio. Could Rush do that?
And that brings me back to the opening question, because Rush Limbaugh cannot be silenced unless he is dangerous - by First Amendment standards. Justice Holmes wrote that "the question in every case is whether the words used are used in such circumstances and are of such a nature as to create a clear and present danger that they will bring about the substantive evils that Congress has a right to prevent."
In the spirit of full disclosure, I should acknowledge that I listen to Rush, because I am interested in a broad spectrum of opinion, which necessarily includes extremes. In the same spirit, I must acknowledge that I often become sufficiently exasperated with him to change the station. And that is a freedom we all have. I will continue to exercise that freedom, and I will defend Rush Limbaugh's freedom to go on expressing his opinions on the public airwaves, no matter how offensive or stupid they may be.
Although the First Amendment's protection of free speech has been interpreted broadly to cover a wide range of "expression," including the visual arts, the intent of the Framers was to protect political speech, and especially unpopular political speech.
Recently Rush Limbaugh directed his intemperate vitriol against the Obama Administration's decision to deny a religious exception for insurance coverage of prescription contraceptives (a topic on which I wrote earlier this month). But Limbaugh did not limit his attacks to the president or officials in his Administration. Rather, he included a Georgetown University law student who had testified before Congress, advocating such insurance coverage. She explained that the cost of prescription birth control is not inconsiderable. She was talking about hormonal contraception, but Limbaugh took the amount she estimated and applied it instead to one of the cheaper methods (condoms), calculating how often one must have sex to spend that much on birth control. Having done the faulty arithmetic, Limbaugh derided the law student as a "slut."
[It would, I think, have made just as much sense to do that arithmetic, assume the law student was in a monogamous relationship, and consider her intimate partner: "Wow. Lucky guy! Tired, but lucky." But I digress.]
While one who testifies before Congress makes herself into something of a public figure, there is certainly no expectation that she will then be subject to vile verbal attacks from those who disagree with her opinions. There was public outrage about Limbaugh's remarks, and a campaign quickly got underway to apply pressure to commercial sponsors of his radio show to withdraw their advertising support.
That is how it should be, I think. You don't like what Limbaugh says or how he says it? Convince those who support his program through advertising that being thus associated with him is not in their best interests. Commercial sponsors are very sensitive to what they believe are the public images of celebrities with whom they have relationships. Witness the reaction to the sexual promiscuity of Tiger Woods or the cannabis indulgences of Michael Phelps.
CNN has provided some perspective on this issue. Their Web site ran a piece by Marc Randazza, a First Amendment attorney from Nevada, explaining the continued importance of protecting politically unpopular speech. There is no question that much of what Limbaugh has to say is politically unpopular with those who are not among his loyal radio audience. Randazza is the editor of his own blog, The Legal Satyricon, which posted his thoughtful essay. But it also posted (as did CNN) a piece by Jane Fonda, Robin Morgan, and Gloria Steinem, co-founders of the Women's Media Center, who say the FCC should boot Rush off the air. They warn of the consequences of "society tolerating toxic, hate-inciting speech." They exhort their readers to complain to the FCC about Limbaugh, the idea being that the FCC would respond by taking action to remove Limbaugh from the broadcast radio spectrum.
How exactly the FCC could do that without plainly violating the First Amendment is unclear. The FCC can fine stations that have programming that violates its standards of decency. It might be amusing to see whether the ACLU is willing to defend Limbaugh should FCC declare his show in violation of those standards. But the FCC could do that. And, if it did, that would silence Limbaugh once and for all. Just like it did Howard Stern. Oh, wait. Stern just moved to satellite radio. Could Rush do that?
And that brings me back to the opening question, because Rush Limbaugh cannot be silenced unless he is dangerous - by First Amendment standards. Justice Holmes wrote that "the question in every case is whether the words used are used in such circumstances and are of such a nature as to create a clear and present danger that they will bring about the substantive evils that Congress has a right to prevent."
In the spirit of full disclosure, I should acknowledge that I listen to Rush, because I am interested in a broad spectrum of opinion, which necessarily includes extremes. In the same spirit, I must acknowledge that I often become sufficiently exasperated with him to change the station. And that is a freedom we all have. I will continue to exercise that freedom, and I will defend Rush Limbaugh's freedom to go on expressing his opinions on the public airwaves, no matter how offensive or stupid they may be.
Sunday, March 4, 2012
Covering Contraceptives
The recent discussions of health insurance coverage for contraceptives have prompted me to take a look at a question I hadn't thought about in years. I have been vaguely aware that some paid prescription plans covered contraceptives and others did not. Recently the Obama Administration attracted attention by declining to allow exemptions, for reasons of religious objection, to the requirement in the Affordable Care Act that FDA-approved contraceptives be covered by health insurance policies without cost sharing.
At first I was intrigued by the subject because it appeared to raise an issue of constitutional law. Was refusing to allow a religious exemption a violation of First Amendment protections of religious liberty? First Amendment jurisprudence is both fascinating and daunting because there is so much case law. You cannot simply read the text and have a complete understanding of religious liberty in the United States. The plain language is very brief and very simple: "Congress shall make no law respecting an establishment of religion, or the free exercise thereof...." This simple text has been the subject of interpretation in many federal court cases over the past two centuries, a review of which is, I can safely say, far beyond the scope of an essay for this blog. Suffice it to say that "the free exercise" of religion is at the core of quite a few such cases.
A young law student attends a Jesuit university, and the health insurance provided by that university does not cover contraceptives. Many other universities not only cover prescription contraceptives but provide them to students at subsidized prices. Is this a matter of the free exercise of religion? I suppose the Jesuits think it is. I find myself inclined to agree with them, but then I am also sympathetic to the argument that employers will opt for coverage that does not include contraception for purely economic reasons (in other words, they're cheap) while claiming religious objection (maybe the company's owners are Catholics who assert their belief in Church doctrine). I am having trouble making up my mind about this, which is, I think, a good thing, given the complexity of the issue. But it would surprise me not at all if the Supreme Court were to say this provision of the Affordable Care Act is on the wrong side of the First Amendment.
Then I began to wonder about the economics of health insurance coverage for contraception. When I try to make sense of something complicated, I often resort to analogy. My employer offers vision care insurance as a stand-alone policy. That makes it very easy for the employee to evaluate its worth for the individual or the family. How much does the coverage cost? How much do we spend on vision care? Let's see: eye exams, glasses, contact lenses. It's not hard to do the arithmetic and come up with an estimate of whether the premiums are worth it.
Then I stopped and thought about it. Vision care insurance is not really insurance at all. Insurance is a way of pooling risk to protect against large losses that the individual cannot readily afford. So I have insurance on my car, because owning and operating a car presents some risks that I cannot readily afford, including expensive collision repairs, replacing the vehicle in the event of a serious crash or theft, or - and this is the really large risk - being held liable for personal injury to another person harmed in a crash.
Routine vision care provided by my optometrist isn't like that at all. I can certainly afford it. But my employer subsidizes the premium cost (which is why it's called a "benefit"), and my share of the premium is a good deal relative to the amount by which it reduces my out-of-pocket expenditures.
So what about contraception? Would I pay for coverage? Of course not. I don't use it. And even if I did, I'm not sure it would be a good deal. That's because it would probably be priced to offset the cost of the most expensive options, while my preference might be for something much cheaper. The expensive options are some of the higher-priced birth control pills, which can run $3 a day. But there are also BCPs that cost about one dollar a day, and other methods may be much cheaper. The long-term cost of an intrauterine device (IUD) is much less. An old-fashioned method, not very popular nowadays, the diaphragm, is highly effective when used properly, carries none of the risks associated with hormonal contraception, and is very cheap.
But coverage for birth control is not sold separately. It is included - or not - in health insurance policies that are primarily intended to protect us from high-dollar risks. Anyone who has ever had to receive inpatient care in a hospital or any kind of surgery or high-tech testing knows about that.
So I'm trying to make an economic case for including contraceptive coverage in health insurance. I can see the utility in including it for poor women on Medicaid, because the price may be an obstacle for them if they have to pay out of pocket. (Yes, I know, even the most expensive BCPs are cheaper than the pack-a-day cigarette habit many of them have, but they are addicted to nicotine, so they are not going to stop smoking to save the money to buy BCPs, even though a woman should not smoke and take the pill because of the risk of stroke and blood clots in the lungs).
But for women who can afford contraceptives, even if it means choosing one of the less expensive options, what is the economic argument for covering it through health insurance? All that does is drive up the cost, because the prescription plan administrator has overhead to cover and a profit to make. Not only that, but when a subscriber's out-of-pocket cost is just a co-pay, the high prices of some BCPs don't produce sticker shock, and that makes it easier for the manufacturers to charge much higher prices than they otherwise would. All in all, this seems a bad deal.
I suppose some will make the argument that unless contraception is provided "free" - see the words "without cost sharing" at the end of the first paragraph - some women will go without, which will increase the number of unwanted pregnancies. That, in turn, will increase either the number of abortions or the number of unwanted children, both unfortunate consequences. I imagine there are some public health researchers who have gathered empiric data and can tell us whether this intuitive assumption is correct. I imagine they can also provide an economic analysis comparing the cost of making contraception "free" with the cost burden of unwanted children growing up in families relying on government assistance for subsistence.
All of that makes my head hurt, because it brings us around to the subject of personal responsibility (or lack thereof) and the poor life choices so many people insist on making. Too bad there is no way to fix that. It's also too bad that, one way or another, we all wind up paying for it.
At first I was intrigued by the subject because it appeared to raise an issue of constitutional law. Was refusing to allow a religious exemption a violation of First Amendment protections of religious liberty? First Amendment jurisprudence is both fascinating and daunting because there is so much case law. You cannot simply read the text and have a complete understanding of religious liberty in the United States. The plain language is very brief and very simple: "Congress shall make no law respecting an establishment of religion, or the free exercise thereof...." This simple text has been the subject of interpretation in many federal court cases over the past two centuries, a review of which is, I can safely say, far beyond the scope of an essay for this blog. Suffice it to say that "the free exercise" of religion is at the core of quite a few such cases.
A young law student attends a Jesuit university, and the health insurance provided by that university does not cover contraceptives. Many other universities not only cover prescription contraceptives but provide them to students at subsidized prices. Is this a matter of the free exercise of religion? I suppose the Jesuits think it is. I find myself inclined to agree with them, but then I am also sympathetic to the argument that employers will opt for coverage that does not include contraception for purely economic reasons (in other words, they're cheap) while claiming religious objection (maybe the company's owners are Catholics who assert their belief in Church doctrine). I am having trouble making up my mind about this, which is, I think, a good thing, given the complexity of the issue. But it would surprise me not at all if the Supreme Court were to say this provision of the Affordable Care Act is on the wrong side of the First Amendment.
Then I began to wonder about the economics of health insurance coverage for contraception. When I try to make sense of something complicated, I often resort to analogy. My employer offers vision care insurance as a stand-alone policy. That makes it very easy for the employee to evaluate its worth for the individual or the family. How much does the coverage cost? How much do we spend on vision care? Let's see: eye exams, glasses, contact lenses. It's not hard to do the arithmetic and come up with an estimate of whether the premiums are worth it.
Then I stopped and thought about it. Vision care insurance is not really insurance at all. Insurance is a way of pooling risk to protect against large losses that the individual cannot readily afford. So I have insurance on my car, because owning and operating a car presents some risks that I cannot readily afford, including expensive collision repairs, replacing the vehicle in the event of a serious crash or theft, or - and this is the really large risk - being held liable for personal injury to another person harmed in a crash.
Routine vision care provided by my optometrist isn't like that at all. I can certainly afford it. But my employer subsidizes the premium cost (which is why it's called a "benefit"), and my share of the premium is a good deal relative to the amount by which it reduces my out-of-pocket expenditures.
So what about contraception? Would I pay for coverage? Of course not. I don't use it. And even if I did, I'm not sure it would be a good deal. That's because it would probably be priced to offset the cost of the most expensive options, while my preference might be for something much cheaper. The expensive options are some of the higher-priced birth control pills, which can run $3 a day. But there are also BCPs that cost about one dollar a day, and other methods may be much cheaper. The long-term cost of an intrauterine device (IUD) is much less. An old-fashioned method, not very popular nowadays, the diaphragm, is highly effective when used properly, carries none of the risks associated with hormonal contraception, and is very cheap.
But coverage for birth control is not sold separately. It is included - or not - in health insurance policies that are primarily intended to protect us from high-dollar risks. Anyone who has ever had to receive inpatient care in a hospital or any kind of surgery or high-tech testing knows about that.
So I'm trying to make an economic case for including contraceptive coverage in health insurance. I can see the utility in including it for poor women on Medicaid, because the price may be an obstacle for them if they have to pay out of pocket. (Yes, I know, even the most expensive BCPs are cheaper than the pack-a-day cigarette habit many of them have, but they are addicted to nicotine, so they are not going to stop smoking to save the money to buy BCPs, even though a woman should not smoke and take the pill because of the risk of stroke and blood clots in the lungs).
But for women who can afford contraceptives, even if it means choosing one of the less expensive options, what is the economic argument for covering it through health insurance? All that does is drive up the cost, because the prescription plan administrator has overhead to cover and a profit to make. Not only that, but when a subscriber's out-of-pocket cost is just a co-pay, the high prices of some BCPs don't produce sticker shock, and that makes it easier for the manufacturers to charge much higher prices than they otherwise would. All in all, this seems a bad deal.
I suppose some will make the argument that unless contraception is provided "free" - see the words "without cost sharing" at the end of the first paragraph - some women will go without, which will increase the number of unwanted pregnancies. That, in turn, will increase either the number of abortions or the number of unwanted children, both unfortunate consequences. I imagine there are some public health researchers who have gathered empiric data and can tell us whether this intuitive assumption is correct. I imagine they can also provide an economic analysis comparing the cost of making contraception "free" with the cost burden of unwanted children growing up in families relying on government assistance for subsistence.
All of that makes my head hurt, because it brings us around to the subject of personal responsibility (or lack thereof) and the poor life choices so many people insist on making. Too bad there is no way to fix that. It's also too bad that, one way or another, we all wind up paying for it.
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