Obamacare: The National Road to Where?

In the middle of the 18th century, George Washington was a colonel with the British army, assigned to do something about the competition between the French and the British colonists for the trade with Native Americans.  The exchange of manufactured goods desired by the Indians and the fur pelts they could provide in trade was a very profitable business.  The British could usually offer better trading deals, but the French had been cultivating the friendship of the Indians much longer.  Each saw the other as infringing on its territory, and the Battle of Fort Necessity, in the Laurel Highlands of southwestern Pennsylvania, launched the French & Indian War, a microcosm of the global conflict between the French and British imperial powers, known in Europe as the Seven Years War (1756-1763).

Washington's early experience in the region led him to believe that a good road from the East through the Allegheny Mountains was essential to development of Western lands and expansion of what was to become a new nation.  His vision later became the National Road from Cumberland, Maryland to Wheeling, Virginia.  (That part became West Virginia during the Civil War, and the National Road later carried travelers much farther west.)  Very substantial funding was approved when Thomas Jefferson was president.  Jefferson worried that the project would become a great sinkhole into which money would disappear, imagining that every member of Congress would be trying to secure contracts for friends.  It is unclear whether Jefferson was the first to worry about profligate federal spending on a "pork barrel" project, but what he wrote at the time was to be mirrored in many criticisms of public spending over the next two centuries.

Alexander Hamilton had a vision of a powerful central government that would collect taxes and spend money, helping to expand the United States with federal subsidies for "internal improvements" such as roads and canals and a strong central bank to foster commerce.  This was developed further, in the second quarter of the 19th century, into Henry Clay's "American System."

All along the way, there have been powerful dissenting voices.  Just as Hamilton and Jefferson had opposing views on the merits of a strong central government, there have, ever since, been dramatic differences in political philosophy between those who believe in using the power of the federal government to tax and spend to "provide for the general welfare" (the phrase used in the Constitution's description of the powers of Congress) and those who believe most of these important functions should be carried out by the states or left in private hands.

Hamilton and Jefferson never imagined public financing of the nation's system of health care, likely at least in part because two centuries ago health care had relatively little to offer.  Louis Pasteur, who deserves much credit for development of the germ theory of disease, wasn't born until 1822, and antibiotics would have to wait another century to begin to cure our ills.  In the run-up to the enactment of Obamacare, some students of history pointed to a 1798 law providing for public funding of hospitals to care for sick and disabled sailors, paid for through a tax on private marine merchants.

Whether one can - or should - extrapolate from a system of health care for veterans to a national health service (like the one in Britain) that takes care of everyone is very much an open question.  For each veteran of our armed services who praises the VA health care system and relies upon it exclusively, it is easy to find another who is glad to have access to the private system and sees it as vastly superior in quality.

Obamacare does not create a National Health Service.

But there are many among both its proponents and its enemies who see it as the first steps down that National Road.



Some, including your faithful essayist, see it as a move - welcome, but insufficient - toward universal coverage.  As you know if you are a regular reader, I regard our status as the only nation in the industrialized West to fail to provide universal coverage for, and universal access to, health care to be a national disgrace.

The new law requires everyone to have health insurance.  This is to be accomplished through a hodgepodge of mechanisms, from mandated purchasing (with subsidies for the needy) through health insurance exchanges to expansion of the publicly funded Medicaid system for the more severely needy.  But the enforcement mechanism for the mandate is weak, the subsidies are likely to prove inadequate, and the states have been told by the Supreme Court that Congress cannot make them expand Medicaid. So patients, doctors, and hospitals are waiting, none too optimistically, to see how this all plays out.

I may be among the least optimistic.  I believe the number of uninsured, now standing at about 50 million, will drop by no more than half in the next decade unless we do much more to change the way health care is financed in this country.

The question remains how we should go about it. Should we have a mix of public and private mechanisms for financing purchase of health care services, such as we have now?  If so, how will we cover everyone, when so many will continue to find private insurance unaffordable?  If we address that problem by subsidizing the purchase of private insurance very generously, how can we avoid enriching the health insurance industry (and its "fat cat" CEOs and stockholders)?  To carry that a step further, is it even possible to expand health insurance to cover everyone without either enriching or eliminating the private health insurance industry?  Either we subsidize the purchase of private health insurance so generously that everyone can afford it (and it becomes even more profitable than it is now), or we fail to do so, in which case we must expand public financing so greatly that everyone who can move into the less-costly public system will do so, and the private health insurance industry will serve only the most affluent.

I do not claim to have the answers to these questions.  I have opinions about what would work, what would be efficient, and what it would take to ensure high quality. But there are powerful interests opposing change, and vast swaths of the general public stand opposed to change, because they are satisfied with what they have in the current system.  If you are not suffering, it is more difficult to see how things could be so much better.

Remember Washington, looking at the precursor to the National Road.  Soldiers, though they might curse it, could march along that road.  Horses could negotiate it, if not without many a stumble and an occasional fall. Wagons could make it through in good weather, though they were likely to get mired down if it had rained recently.  Washington thought it should be wide and smooth.  Think about your road to readily accessible, high-quality health care.  Have you gotten mired down in that muck? Should we not build a road that is wide and smooth?

We should.  And we must.

 

Legalization of Marijuana

Earlier this week voters in Colorado and Washington state approved ballot measures legalizing recreational use of marijuana. While similar proposals have fallen short of approval in California, it is reasonable to surmise that other states will follow, and a trend will emerge.  Supporters are applauding the end of "prohibition," likening this development to the adoption of the 21st Amendment to the United States Constitution in 1933, repealing the 18th Amendment (1920).

As you know if you read my essay "Temperance and the Addict" last June, I have an academic interest in the use of mood-altering substances, and the effects of changing the status of marijuana from illegal to legal will surely be fascinating to observe.

["Medical marijuana," by the way, is a subject to which I haven't paid much attention, because I think the scientific literature on that is more confusing than enlightening, and I have been inclined to agree with those who perceived the movement to legalize the drug for medicinal purposes to be nothing more than a smokescreen (pun intended) for legitimizing recreational use.]

In the practice of emergency medicine I frequently see the consequences of the choices people make about the use and abuse of tobacco and alcohol.  Much has been written comparing marijuana with those two legal drugs.  Even an overview of those comparisons would take a book chapter rather than an essay.  For example, the long-term health effects of tobacco and alcohol are well understood. Marijuana, not so much.

A column ("The End of the War on Marijuana") published at CNN.com caught my eye early this morning.  The writer, Roger Roffman, is a professor emeritus of social work at the University of Washington and a supporter of the legalization measure in that state.  Roffman made two observations that I found especially noteworthy:

Far too many teens think smoking pot is "no big deal," greatly underestimating the risk of being derailed from social, psychological and educational attainment. Far too many adults don't take seriously enough the risk of marijuana dependence that accompanies very frequent use.

Roffman has written books on medicinal marijuana and the treatment of marijuana dependence, and his next book (titled A Marijuana Memoir) is sure to be interesting.  It's my sense that he knows his subject well, and so his observations worry me more than a little.

One of the aspects of substance use that I often think about is direct cost to the consumer.  While the price of a pack of cigarettes varies with state taxes, not to mention choice of brand versus generic or purchase by the pack or carton, I have a pretty good idea what people are spending on tobacco when they tell me how much they smoke.  I cannot help being amazed that some people whose resources are very limited choose to spend thousands of dollars a year on cigarettes.

It was my sense that prices for marijuana are quite variable, and a Web search for information proved that to be correct.  I found a wide range of reported "retail prices," mostly between $200 and $1,000 per ounce.  Knowing next to nothing about smoking the stuff, I did more research to discover that people typically roll joints containing anywhere from one half to one gram each, which means one might get anywhere from 30-60 joints from an ounce.  At $300/ounce, a joint might cost $5 to $10.  This was an eye opener for me.  I had figured marijuana was much more expensive than tobacco per cigarette, but I didn't realize one joint cost as much as a pack of cigarettes.

Of course, users don't typically smoke 20 joints per day.  As I browsed the Web, the self-reported patterns I found for regular users were mostly in the range of 1-5 grams per day, with one person claiming 15 grams per day when he had large amounts of money (and could afford to spend large amounts of time completely disconnected from reality).

So the bottom line on the expense for regular users seems to be about the same as for a pack-a-day cigarette smoker at the low end (one joint per day) to much more than that (perhaps $50/day) for heavy users.  I'm guessing the heavier users likely are able to get better prices by going up the supply chain and paying wholesale prices.  Smoke what you want and sell the rest.

We know a lot about the damaging effects of smoking tobacco on health: heart attack, stroke, peripheral arterial disease, COPD, and lung cancer, just to name the most common problems.  We know far less about what regular heavy smoking of marijuana does to the lungs, but I think we are likely to have much more data in the years to come.

We also know a good deal about the harmful effects of alcohol, including disease of the liver and other organs in the digestive system as well as the brain.  In emergency medicine, while we see plenty of that, we see a great deal of trouble caused by acute intoxication, especially motor vehicle crashes.

So I wanted to find out how smoking a reefer might compare with alcohol consumption for getting behind the wheel.  As you might imagine, the data are not abundant (yet), but here is what the National Highway Traffic Safety Administration (NHTSA) says:

Marijuana has been shown to impair performance on driving simulator tasks and on open and closed driving courses for up to approximately 3 hours. Decreased car handling performance, increased reaction times, impaired time and distance estimation, inability to maintain headway, lateral travel, subjective sleepiness, motor incoordination, and impaired sustained vigilance have all been reported. Some drivers may actually be able to improve performance for brief periods by overcompensating for self-perceived impairment. The greater the demands placed on the driver, however, the more critical the likely impairment. Marijuana may particularly impair monotonous and prolonged driving. Decision times to evaluate situations and determine appropriate responses increase. Mixing alcohol and marijuana may dramatically produce effects greater than either drug on its own.

I must admit I find this more than a little scary if legalization makes smoking and driving anywhere near as common as drinking and driving is now.  And drinking and driving would likely be much more common if it were not for fairly strict enforcement of laws against that.  Will we have laws against driving under the influence of marijuana in all the states where recreational use is legalized?  How will such laws be enforced?  There is no recognized field sobriety test or breath test, and the correlation between blood levels and clinical effects is very uncertain.

One news story about the new law in Colorado said the state expected, through the regulation of sale and the imposition of taxes, to bring about $60 million a year into the state treasury, while saving about $75 million in costs to the penal system associated with the criminalization of sale, possession, and use of marijuana. That's a lot of money going to the state's bottom line.

The obvious question: will it be worth it?  The answer: we don't know, because we have no way to calculate the cost of much more widespread use resulting from its effects on health and behavior.  If the record of tobacco and alcohol is even modestly instructive, we may be in for some rude surprises.  As my regular readers know, I think we do an awful lot of things in our society as if we have never heard of the Law of Unintended Consequences.

The Electoral College: Why or Why Not?

Every four years when we go to the polls to vote for a presidential candidate, most of us are dimly aware that we are really voting for presidential electors and that weeks later they will meet as the Electoral College and cast their ballots.  We don't think too much about it, because the Electoral College usually reflects the will of the American people as expressed in the popular vote totals.

But there is always the possibility that the popular vote and the Electoral College vote will go in opposite directions.  Many say that was the case in 2000, when by most accounts Al Gore received more nationwide popular votes than did George W. Bush, who won the Electoral College (after the dispute over Florida's vote was settled by the U.S. Supreme Court).  There are enough doubts about the popular vote totals, including such questions as counting of absentee ballots, that the picture for 2000 is not entirely clear.  Suffice it to say that it was a very close popular vote, and by that measure the winner may well have been Mr. Gore.

But that isn't what determines the winner.  Instead, the popular vote of each state determines the votes of its electors (except Nebraska and Maine, which split their votes if the statewide winner does not also win each congressional district).  And that's why it is possible to win the nationwide popular vote but not the Electoral College vote (or the reverse).

There are 538 votes in the Electoral College, and a candidate needs a majority (meaning 270) to win.  So, imagine that the vote is 270-268.  Imagine further that the candidate with 270 votes won his states with slim majorities, but the candidate with 268 votes won his states by landslide votes.  Obviously, the "losing" candidate would then have a hefty popular vote majority.  While that sort of thing has never happened, it is quite common for popular vote and electoral vote majorities to be widely disparate.  For example, in 1984, Ronald Reagan won 58.8% of the popular vote and 97.6% of the electoral votes.  In 1968, Richard Nixon defeated Hubert Humphrey by a mere 0.7% in the popular vote, while the electoral vote was 301-191 (with 46 for third-party candidate George Wallace).

If you are a serious numbers cruncher (like the folks at - where else? - MIT), you could do the math and find out that two candidates could achieve an approximate tie in the popular vote, while achieving an exact tie in the electoral vote, or one could win 538-0, or anywhere in between.

This year both the electoral vote and the popular vote could be very close, and they could easily go in opposite directions.  So that tells us the first objection to the Electoral College: why should we have a system in which the nationwide popular vote does not determine the winner?  That's how it is for the United States House and Senate - at least since we adopted the 17th Amendment to the Constitution and decided to elect senators directly instead of through our state legislatures.

The origin of the Electoral College is quite simple.  Like the composition of the Congress, it was based on a compromise between the more populous and less populous states.  Delegates to the Constitutional Convention from the less populous states were afraid that the new Congress would be controlled by representatives from the larger states.  The compromise was that representation in the House would be proportional to population, while in the Senate, all states would be equal, with two senators each.  The Electoral College is a blend, the number of electors being equal to the number of representatives plus the number of senators.  Thus the least populous states (Wyoming, for example), with only one representative in the House, have three electors (because they have two senators, like all states).

Looking at it this way, small (in population) states are "overrepresented" in the Electoral College.  Wyoming has 3 electors; if California, the most populous state, had a number of electors corresponding to population ratio (relative to Wyoming), it would have 199 instead of 55.  Of course that is the extreme spread, and most of the overrepresentation for states with fewer people is not so dramatic.  But this overrepresentation is perceived as a violation of the "one person, one vote" principle and therefore antidemocratic.

The Electoral College has other antidemocratic effects.  Some would say that elections bring the opportunity to connect the candidates with the voters, and that connection is important to the expression of the will of the people.  Ask anyone who has been in Iowa or New Hampshire at the beginning of the primary season about a sense of direct connection.  (For most of us, there is little sense of such connection.  The only time I met a presidential candidate in person, he wasn't even a candidate yet.  It was 1964, at the Democratic National Convention in Atlantic City, and the candidate (for 1968) was Bobby Kennedy.)  But what is the effect of the Electoral College?

Do you think Obama and Romney are spending much time in California or New York, where the polls show Obama with huge leads?  No, they are in "battleground states," where the polling is close.  You want to see these candidates?  Live in a 50-50 state with plenty of electoral votes.  (My personal view is thanks but no thanks, because it really fouls up traffic when they are in town.)  So big states and small states can be equally disadvantaged.  The candidates ignore New York and California, not to mention Texas and Illinois, every bit as much as they ignore Wyoming or the Dakotas.

A recent article on CNN.com noted that people in Hawaii don't vote in presidential elections - at least not as much as people in the other 49 states.  In 2008, voter turnout there was 48.8%, compared to Minnesota, at the top of the heap, with 77.8%.  Say what you will about the "beach bum" mentality some residents of the Aloha State may have, I think the reason is very simple.  It's difficult to find the motivation to vote when it doesn't matter.  Hawaii has few electoral votes, they almost always go to the more liberal of our major parties, and because of the time zone, the race has very often been projected before the polls close there.

How likely are you to vote if you think it really doesn't matter?  I live in Pennsylvania, where the polls are close this year.  But I can tell you it's really tough to find the motivation to vote in the primary, because the races for the presidential nominations have almost always been settled by late spring, when ours is scheduled.  If you need to feel like it matters, are you more likely to vote if you live in Ohio, and you keep hearing about how close the race is and how no Republican has ever won the White House without winning Ohio?  Or New York, where polling shows Obama with a 25-point lead?

If the Electoral College discourages people who don't live in "battleground states" from going to the polls, that is a bad thing.  If abolishing it would have the opposite effect, maybe that's worth some serious consideration.

Remember, that would require a constitutional amendment.  After passing both houses of Congress, it would have to be ratified by 38 state legislatures.  Won't 13 or more of the least populous states vote against it to preserve their overrepresentation?  Yep.  It's a long shot.  

Alas, Poor Newsweek

Next year Newsweek magazine will celebrate the 80th anniversary of its founding.  Earlier this month it was announced that the print edition will not reach that anniversary.  The magazine is going digital-only and will be called Newsweek Global.

Over the years I have subscribed, at various times, to the three traditional print news weeklies: Time, Newsweek, and US News & World Report.  As I reflect upon how long it has been since I received a print copy of any of the three of them, I realize it shouldn't surprise me in the least that Newsweek is succumbing to a changing market.  In the magazine business it is referred to as a "challenging" situation for print advertising.  Challenging, indeed.

It is difficult to make money on print advertising when print circulation is declining. Furthermore, it is easy for advertisers to tell whether online readers actually pay attention to the ads, because they click on them. No click means the ad was ignored.  You just can't tell, with a print ad, whether the reader even noticed.

[It is interesting, then, that in some lines of publishing - medical journals being an example - advertisers still want print ads in print journals, even though they know more and more readers are reading the journals electronically.  I'm still trying to figure that out, and I suspect they are, too.]

I cannot help wondering what the long-term future of news publications holds. There are so many sources of news and opinion online that are free (once you have Internet access and a device that allows you to connect and read).  People will surely expect it to be free, and if you want to charge for it, you will have to offer something of value readers cannot get elsewhere.  Otherwise they'll be thinking, hey, if your competitors can make it on ad revenues alone, why can't you?

When the New York Times started charging for online content, I started looking elsewhere for high-quality news reporting.  I thought, gee, if The Washington Post is still free, why should I pay for the Times?  It's not like their journalism is clearly superior.  They may be called the "newspaper of record," but they are also the newspaper of Jason Blair.  Woodward and Bernstein wrote for the Post.

By nature I am conservative, a creature of habit who prefers the traditional and opposes change that seems to have no impetus beyond a desire for change. However, as much as I am a creature of habit, even my habits change.  And sometimes they have help from unexpected sources.

I used to read a local newspaper.  Then we got a new carrier.  He refused to put the paper in the delivery box.  It was too much trouble.  Emails to the home delivery department of the paper resulted in his putting the paper in the box for a week or so, and then he'd go back to tossing it in the driveway.  The problem was inclement weather, in which a plastic wrapper was inadequate to the task of keeping the paper from becoming an unreadable, sodden mass by the time I got home.  A long series of emails, each followed by an all too transient change in delivery and then a return to bad behavior, led to the end of my print subscription.

I now read local news - when I want to subject myself to bad reporting and worse writing - online, without paying for a subscription.

Two years ago Newsweek merged with The Daily Beast, a news and opinion Web site.  Selected content from the new Newsweek Global will be made available via The Daily Beast.
Full subscription to Newsweek Global will be paid.  It will be interesting to see whether people will be willing to pay the extra money for that.  Maybe I'll start reading The Daily Beast to see what is being done under the editorial leadership of Tina Brown.

So far I haven't done that, largely because it never occurred to me that something with that name could be taken seriously.

I know one shouldn't judge a book by its cover, but how can one not judge a publication when its creators give it a name like that?

The target readership for Newsweek Global will be "a highly mobile, opinion-leading audience who want to learn about world events in a sophisticated context."  I'm not sure how highly mobile I am, because I've been living in the same township for 27 years.  I like being an opinion leader, however.  (Except when the drug companies want my help with marketing.  Then I just tell them they won't like my opinons.)  I desperately want to learn all I can about world events, and I long for sophistication.  So I may just have to check this out.  Except for that one nagging drawback: they'll expect me to pay for it.  Hmmm.  Maybe they'll have an introductory offer that will be too good to pass up.

I will still have to find something else to read in the barbershop.  Popular Mechanics, anyone?

Check the Earthquake Forecast

Last week I wrote about the decision by the Italian supreme court validating the claim of a plaintiff who said his cell phone caused him to develop a brain tumor. The science was, shall we say, sketchy.

But now another Italian court has rendered a decision that cannot be called anything but stunningly irrational.

On March 31, 2009, Italy's National Commission for Prediction and Prevention of Major Risks met to consider the significance of a series of minor tremors (an earthquake "swarm") in central Italy's Abruzzo region.  Enzo Boschi, president of the National Institute of Geophysics and Volcanology, was asked if the swarm was a portent of a major quake in the immediate future.  Boschi said it was possible but unlikely.  The city of L'Aquila was struck by an earthquake six days later: magnitude 6.3, causing the collapse of tens of thousands of buildings, leaving more than 67,000 homeless and 308 dead.

The international consensus among geophysicists and seismologists is that the current state of scientific knowledge does not permit the prediction of earthquakes with any sort of precision or accuracy.  Thus we read about the likelihood that a particular region will likely suffer a major quake some time in the next century.  This is not exactly the sort of information on which you can base any short-term decisions, such as whether to evacuate a city, although you might choose not to live in a quake-prone region, just as many decide against living along parts of the Atlantic coast frequented by tropical storms and hurricanes.

I live in southwestern Pennsylvania, where we don't get much in the way of natural disasters.  Earthquakes and tornados are rare, and we get only remnants of hurricanes.  But I've been in a few car crashes on icy roads, which folks who live in hurricane and earthquake zones generally don't have to worry about.  So nothing is perfect.  We all make our choices.

But now seven members of the Commission have been convicted of manslaughter for failing to predict the major quake and issue a warning.  Their sentence - likely to be appealed - is six years in prison.

This truly defies reason.  In June 2010 an open letter was sent to the Italian president from the American Association for the Advancement of Science, which is the world's largest general scientific society and publisher of the internationally renowned and prestigious journal Science.  The letter, urging the dismissal of charges against the Italian commissioners, said:

Years of research, much of it conducted by distinguished seismologists in your own country, have demonstrated that there is no accepted scientific method for earthquake prediction that can be reliably used to warn citizens of an impending disaster. To expect more of science at this time is unreasonable. It is manifestly unfair for scientists to be criminally charged for failing to act on information that the international scientific community would consider inadequate as a basis for issuing a warning.

In a disturbing similarity to the kinds of things that happen in American civil courts, there was emotional testimony from witnesses who had lost loved ones in the quake - the sort of testimony that should have been considered irrelevant and highly prejudicial, and therefore excluded.

It is very difficult to imagine how competent jurisprudence could have failed to rely on the best scientific evidence and reach the conclusion that, tragic though the outcome surely was, no standard of criminal (or civil) negligence could possibly exist under which the Commission should be held responsible.

We have so much more to learn about earthquakes and other natural disasters. Perhaps some day scientists will be able to tell us when and where an earthquake will strike, much as we now get fairly accurate warnings about hurricanes, giving authorities days to order evacuations and spare many lives.

In Japanese mythology, the Namazu (鯰) is a giant catfish who lives in the mud under the island nation and causes earthquakes.  He is generally restrained by the god Kashima, but when Kashima becomes complacent and lets his guard down, the catfish thrashes about, and earthquakes result.

In modern science, Namazu has been replaced by plate tectonic theory.  But it seems the Italian legal authorities think their seismologists must be Kashima.

Cell Phones and Brain Tumors

Are cell phones harmful to your health?  From personal experience I can say yes.

Over 20 years ago, when a cell phone had the size, shape, and heft of a brick, holding my phone for frequent, lengthy calls, the phone against the right side of my head, my right elbow flexed to a very acute angle, gave me a nasty case of lateral epicondylitis (often called tennis elbow).

Such conditions don't make headlines, but brain tumors do.  You may have read about the recent decision from SCORI.  (I made up that acronym.  The Supreme Court of the United States is often called SCOTUS for short, so why not do the same for the Supreme Court of Repubblica Italiana?  OK, OK, for those of you who are fussy about accuracy, the Italians actually call it Corte Suprema di Cassazione.)
Anyway, the Italian court ruled that a businessman who said he held a cell phone to his left ear, with his left hand, often while taking notes with his right hand, six hours a day for twelve years, had a valid claim when he said this caused him to develop a benign tumor of one of his cranial nerves.  Testifying on behalf of the plaintiff were a neurosurgeon and an oncologist who specializes in environmental factors contributing to cancer.

Dr. Marco Coppola,
Speaker of the ACEP Council

Never having made a study of the Italian system of jurisprudence, I have no idea what the standards of evidence are.
I also have no way of knowing what the expert witnesses said.
Even if I could get transcripts of their trial testimony, I would have to get someone to translate them for me.
(Marco, would you help me with that?)

What I do know, however, is that Italian courts must work a lot like ours do, because the overwhelming weight of the evidence in the published scientific literature fails to support a causal link between cell phone use and development of brain tumors.

To be fair, it is entirely within the realm of possibility that the amount of use described by the plaintiff in this case caused his tumor.  The scientific evidence does suggest that extremely heavy use might be a problem.  But if the standard of evidence were "clear and convincing," that wouldn't make his case.  Even with a "preponderance of the evidence" standard, it should have fallen well short.  So I am forced to conclude that in handling civil torts of this nature, the Italian courts operate the way ours do: maybe it was their fault, so we'll give you lots of their (or their insurance company's) money.

My own review of the literature found more than a dozen studies of varying design and variable quality in methods and statistical analysis.  Nearly all failed to find a link (let alone causation) between cell phone use and brain tumors.  Note that I said "nearly all."  There was one well-done Swedish epidemiologic study that showed a link to the development of a certain type of benign tumor (similar to the one afflicting the plaintiff in the Italian case) for people who were very heavy users of cell phones for more than a decade.  Again, this is an association, which doesn't prove causation.  But I suspect this is the study on which the Corte Suprema di Cassazione relied.

I found it interesting that, in an interview with the British tabloid The Sun, the oncologist said, "The court decision is extremely important.  It finally officially recognizes the link.  It will open not a road but a motorway to legal actions by victims.  We're considering a class action."  What this quotation tells us is that the witness was serving not as an impartial expert on the relevant scientific evidence but as an advocate for the plaintiff.  Such behavior on the part of experts, which is all too common in U.S. courts too, does not aid the search for truth or advance the interests of justice.  Those among my readers who know enough about the American legal system to have become appropriately cynical are now smirking at the notion that truth and justice play any role at all.

The more I observe use of cell phones and smartphones nowadays, the more convinced I am that all these concerns about brain tumors are rapidly becoming passé.  First, many users do more texting than calling.  A recent study showed three times as many texts as voice calls for the average user, and the proportions favor texting even more heavily among younger users.  Second, hands-free calling is becoming more common all the time.  In some states only hands-free use is legal while driving a car.  There was a time, not that long ago, when a person using wireless, hands-free (bluetooth) technology would be perceived by others as likely schizophrenic, apparently having an animated conversation with himself. But bluetooth is now so common that no one even notices such behavior.  All this hands-free use means the phone is nowhere near the head.

But for those who like to worry about adverse effects of technology on our health, go right ahead and keep worrying. You now have "texting thumb" to obsess about.  Not as frightening as a brain tumor, perhaps.  And you could solve the problem by using an Android phone with a Swype keyboard.  But then you'll have to find something else to fret over.

I am happy to oblige.  Phones cause far more trouble when people use them while driving.  In order of risk, texting > handheld calling > hands-free calling.  And how many people have you seen texting while walking? They shouldn't be trying to cross streets when they're texting.  This is like a blind person crossing the street with neither a guide dog nor the heightened sense of hearing that the blind possess.  We like to multi-task, but we should remember that some tasks are just not meant for "multi" - unless you like to live dangerously.

The Emergency Department as Health Insurance

It was bad enough when George W. Bush told us the poor have access to health care because they can just go to the ER.  We had come to expect W to say dumb things.  But Mitt Romney?  I expected better.  Yes, I know, I piled on when the Brits called him a "wazzock" for ill-considered remarks he made last summer in connection with the Olympics.  And, in fairness, he didn't say the ED is a substitute for health insurance.  He merely pointed out that the poor are not dropping dead of heart attacks in the streets for want of health insurance, because our EMS colleagues pick them up and take them to hospitals, where they receive care.  But, for those with little depth of understanding of the consequences of being uninsured, Romney's remark reinforces a very foolish notion.

Earlier this month I addressed the Council of the American College of Emergency Physicians.  My subject was the problem of the uninsured.  Here is an excerpt of that address.

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Today I want to talk to you about a woman I met in August.  I’ll call her Nancy.  Nancy came to see me in the emergency department.  She was coughing up blood.  I took a quick look at her records.  Fifty-seven years old.  Diagnosed in July with lung cancer.  

Wait a minute.  That was July of 2011.  Not a month ago, but thirteen months ago.  She must be going somewhere else for her cancer care.

“Where?” I asked her.

“Nowhere.  I lost my job and my health insurance.”

I asked about COBRA, or the possibility that she might have become eligible for Medicaid or Medicare.  She looked at me blankly.  Everyone else she knew who had lost health insurance simply went without health care.  She assumed that was her lot.  She focused on finding a new job.  She was still working on that.

I ordered a CAT scan of the chest and compared it with the old one.  I explained the difference to her.  She told me she had a grandson who was about to start twelfth grade.  She looked into my eyes, through her tears, and said, “I’m not going to get to see him graduate, am I?”

ACEP has long had a policy position advocating universal coverage.  So have several other medical professional organizations: the AMA, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Surgeons among them.

Harry Truman sought universal coverage.  We made some progress in the 1960s with Medicare and Medicaid.  But we have fifty million uninsured.  And even with the passage of the Affordable Care Act, we stand to make only modest inroads.  Those newly covered under Medicaid are supposed to have equal access, but that is true only if you accept an Orwellian vision in which some are more equal than others.

Why can’t we get there?  Because most Americans have health insurance.  In the abstract they support universal coverage, just as we do.  But when you get down to particulars, they don’t want any changes that will affect what they have. And they balk at the prospect of higher taxes, even when they are told that access to longitudinal primary care for those with chronic diseases can save money.

The public must understand that the uninsured are everyone’s problem.  This is partly a matter of social justice.  It is also a matter of providing health care to all in the most cost-efficient way possible.

It is not enough to adopt this as an advocacy position if doing so does not influence the national debate. There are 850,000 licensed physicians in the United States.  If we all tell the public in a loud, clear, united voice that the status quo is unacceptable, we can transform public opinion.

Why should ACEP take the lead on this?

Emergency physicians provide more uncompensated care than doctors across all specialties by a factor of ten.  We can stand up and say this.  We can say we do this because we have always believed it is our ethical duty.  We wear this as a badge of honor.

But when the wealthiest nation in the history of the world has fifty million uninsured, that is a badge of shame.

We must take the lead in carrying this message to the public, and we must get all of our colleagues across all specialties to join us.

How do I know this is what we must do?

I know what Nancy’s grandson would say.  Shout it from the rooftops - and the studios of CNN.  Go tell it on the mountain - and the pages of the Wall Street Journal.  With strong physician leadership,  America can solve this problem. 

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So, Romney is right.  If you're having a heart attack, you don't have to sit at home and wait to die because you have no health insurance.  You can call 9-1-1, and you will be taken to a hospital ED and receive excellent health care.

But you might never have gotten to that point if you'd had health insurance and primary care to manage your high blood pressure, high cholesterol, or diabetes. Sometimes an ounce of prevention is worth ... well, you know what it's worth. And so does Mitt Romney.  We all do.  So why are we being penny wise and pound foolish?