Universal Health Care - a Personal Perspective

The latest figure I've seen for the USA is that about 11% of Americans don't have health insurance. Tens of millions more have coverage with premiums, co-pays, and deductibles that either wreak havoc on the family budget or make them effectively uninsured, because they never seek medical care unless they are quite certain they have something very serious. I'm not one of those. (I do tend to seek medical attention only if I think I have something very serious, but that's unrelated to health insurance; it's just the way I am.) I'm one of the very fortunate ones. I have excellent health insurance through my wife's employment, and her job (knock on wood) seems to be very stable.

A few years ago I developed an unusual heart condition, the evaluation and treatment of which has been costly.

Today I needed to gather up statements of what I paid in calendar 2019, to submit for reimbursement from a health savings account (HSA) - that device that enables us to pay for our out-of-pocket expenses with untaxed dollars, at least to the extent that we are able to forecast them. (It's like the old TV show "The Price is Right," in that you want to get as close as possible without going over your expenses, because if you don't use it, you lose it.)

After some time-consuming and irksome phone calls, I was able to get the information I needed online, as I hadn't saved all those tree-killing paper statements.

I believe we have a family deductible of "only" $1,000 a year, so I knew I would cover the amount that we put in the HSA, which was less than that.

I looked at the charges billed for all of the medical evaluation and treatment I received in calendar 2019.

I did not have major surgery. (Most of us know how expensive that is just from the information we get from stories in the news.)

Yet my total charges for the year were just shy of $450,000.

Without health insurance, I would be bankrupt or dead (or both, in that order, I suppose).

My cardiac condition is not the kind you get because of advanced age or unfortunate lifestyle choices (smoking, dietary over-indulgence, being sedentary). We so often think of America's health problems as being self-inflicted, and many of them are, to some degree. Not this one. Nope, nobody's fault. Just bad luck.

If this bad luck had been coupled with the kind of bad luck that afflicts thirty-some million Americans - being uninsured - my life would be a financial calamity, to put it very mildly.

What is the moral of this story?

Every American who lacks health insurance is just one unlucky roll of the dice from financial disaster. It is completely unacceptable that people facing dire threats to their health must simultaneously spend time with lawyers navigating bankruptcy proceedings.

I happen to like doctors better than lawyers, but that's just me. Nevertheless, I think people who are seriously ill or injured should focus on their health - not on the fact that everything they've worked for their whole lives is now gone.

COVID-19: What's the Big Deal?

The proteins on the surface look like a crown, as in coronation

As is true for influenza, illness caused by COVID-19 can range from very mild to severe.  So why are we more worried about it than we are about seasonal flu?

The answer lies in part of the original name - before COVID-19 was adopted.  It was called "novel" coronavirus. Novel doesn't mean the virus likes to read fiction, any more than the "corona" part of the name means it's connected to Corona beer.

Novel means new. Not new in the big scheme of things. New to humans, after making the leap from an animal species.

How can that cause so much trouble?

It means that it is new to our immune systems.

Let's say we take a group of 100 people who are well, put them in a room, and then add a person with seasonal influenza. That person can spread the flu virus to the others in the room. But not so easily. Each time a person who comes into contact - of the sort that lends itself to transmission - with the infected "index case," either of two things can happen. The new contact gets infected, and experiences illness.

Alternatively, if the new contact has some immunity, through vaccination against, or previous infection with, the same or closely related flu strains, the new contact will most likely not get sick, and will not be a source of contagion that - like the index case - threatens everyone else in the room.

The presence of immunity among people in the room means person-to-person spread will be limited. Thus, what epidemiologists call the "attack rate" will be reduced. (This is what epidemiologists sometimes call "herd immunity.")

Now, take the same group of 100 well people and add a person sick (even very mildly) with COVID-19. Nobody else in the room has any immunity, because this is a "novel" virus. So person-to-person transmission happens much more readily, and thus the "attack rate" will be much higher.

So we can see that even if COVID-19 is no worse than seasonal flu in the average person, the "novel" attribute enables it to spread quickly to a large number of people. And that really matters, because a certain percentage of people who get infected will die. That is called the "case fatality" rate. No matter what the case fatality rate is, the more people who get infected, the more will die.

Right now we aren't really sure how the case fatality rate compares with seasonal influenza. We just don't have enough population data yet, and that makes it a moving target.

But there is reason to be concerned that it will be significantly higher than for seasonal flu. Again, this is because of the "novel" attribute.

It is believed that one of the reasons the Spanish Flu of a century ago, a novel strain, killed so many people - and especially so many young and previously healthy people - has to do with the immune response. If you have been exposed to other viruses that are similar, you will have a little bit of immunity. This helps in two ways. First, your immune system is at least a little "primed" to respond. Second, some of the immune system's response will be to produce partially-matching antibodies that can act as "blocking" antibodies that lessen the intensity of the overall immune response. And this is actually a good thing.

Why? Because a good bit of the effect of the virus on your body - especially on the respiratory tract - is the result not so much of the virus itself but the inflammatory aspects of the immune response. The "blocking antibody" effect can lessen the severity of the inflammation. You don't get that when you're infected by a novel virus. Since young, healthy people typically have the most intense immune response to any infectious agent, the lack of a "blocking antibody" effect means they can get very sick very quickly. Paradoxically, then, their risk of becoming seriously ill or dying may not be that much lower than it is for the elderly and infirm.

What does all this mean? If we start to see evidence of rapid "community spread" - and there is reason to think we will - the attack rate will be high, the number of cases will be high, and the number of deaths will be high.

So pay attention to all the advice you're getting from reliable sources on how to limit contagion.

For my entire career I have been telling patients and families who ask me how to avoid spreading an infectious disease from the "index case" in the family: "Lots of hand washing." This applies to everything from "pinkeye" to the common cold to influenza. And now to COVID-19.

Wash your hands!