Thursday, November 10, 2011

Steve Forbes's Prostate vs Mehmet Oz's Heart

Last week two articles highlighted America's split over health-care policy. One likened the U.S. Preventive Services Task Force* to a "death panel" and argued that we need more free enterprise in our health-care system. The other lamented the tens of millions of Americans who do not have adequate health care and argued that our inability to come up with "a health care reform law that we can all live with" is "a failure of basic morality."

The first article, "The Department of Health and Human Services' Death Panel" (Forbes magazine, 21 November 2011), is by Steve Forbes, a publisher and businessman whose net worth is estimated at $430 million.

The second article, "Enough Is Enough" (Time Ideas, 31 October 2011) is by Mehmet Oz, a cardiothoracic surgeon and media personality whose net worth is estimated at $7 million.

I'm pretty sure both writers are part of the 1%. Both were graduated from Ivy League universities: Mr Forbes with a history major from Princeton, Dr Oz with an undergraduate degree from Harvard, an MD from the University of Pennsylvania Medical School, and an MBA from the Wharton School of Business. Both are Boomers: Mr Forbes was born in 1947, Dr Oz in 1960. But despite the similarities, their views on health care couldn't be further apart.

Steve Forbes is irate with what he calls a "committee of 'experts' [scare quotes in original] appointed by the Department of Health & Human Services," because "this group recently declared that men should not be routinely screened for prostate cancer." See, Mr Forbes recently had a routine exam which led to removal of his prostate, and he is convinced - medical research be damned - that routine prostate exams save lots of lives. What is more, he is sure that the HHS research is all about "rationing and saving money," and that "what we need in health care is more free enterprise, not Soviet-style controls." He does not explain why he is opposed to the government's saving money, or why he thinks free enterprise would be less interested than the government in doing so.

Let's say Mr Forbes is right, the researchers are mistaken, and all men should get regular prostate exams. I am wondering how free enterprise will encourage that, given the ever-increasing number of uninsured Americans. Mr Forbes has endorsed Rick Perry for president; both men believe that health care is best handled by the private sector. It's not working so well in Governor Perry's Texas, however, according to a September 8, 2011, article in the L.A. Times. Insurance premiums are up - "when compared with incomes, insurance in Texas is less affordable than in every state but Mississippi" - as is infant mortality. "More than a quarter of Texans lack health insurance, the highest rate in the nation." Texas has some of the best hospitals in America for the rich and the well-insured, but "nearly a third of the state's children did not receive an annual physical and a teeth cleaning in 2007, placing Texas 40th in a state ranking by [the nonprofit Commonwealth Fund]." I don't imagine Texas, despite its governor's faith in private enterprise, will be offering free prostate exams any time soon.

Looked at another way, how would a federally managed health-care system prevent men from getting regular prostate exams if they really want them? A PSA test can cost as little as $45. If insurance companies, those pillars of private enterprise, stop subsidizing such tests on the grounds that the federal government says they have no proven value, will it be such a hardship for men to pay for their own tests? The poor might not be able to afford them, of course, but they're mostly uninsured and aren't getting them anyway - unless they are enrolled in some government program like Medicare or Medicaid. Yet Mr Forbes doesn't seem worried that those very programs may be cut back by politicians who favor a free-enterprise-based health-care system. His logical contradictions make the head spin.

Mehmet Oz, by contrast, doesn't serve up any ideology in his article. If he cares whether our health-care system is based on free enterprise, a single-payer system, or some combination of government and private business, he doesn't say. His article was sparked, not by a personal health crisis, but by what he saw when he volunteered at the "CareNow Free Clinic in the Los Angeles Sports Arena, where more than 700 doctors, nurses and health professionals had turned out to serve the local community."

During this four-day event, according to the CareNow website, "1,000 patients per day [were provided] with medical, dental and vision care they would not otherwise have received. A total of 7,200 procedures were performed, from dental fillings and root canals to medical exams and podiatry; from eye exams and prescription glasses to mammograms, Pap smears, immunizations and other services. Everything was offered at no cost to the patient."

Dr Oz, who has also volunteered at free clinics in Arkansas, North Carolina, and Texas, saw a "tide of disease and despair" in Los Angeles. A young mother whose children were insured by the state but who had no insurance herself. A young man with untreated, out-of-control diabetes who had no idea how to treat it. A woman who had lost her job and her insurance two years before, and was "too ashamed to seek help for a mass she felt in her right breast. Now the tumor had replaced her entire breast and blasted through the skin." Dr Oz writes:
At what point, I wondered that day and still wonder now, will we finally say enough? ...  I don’t underestimate the complexities of implementing a health care reform law that we can all live with. As with most entitlement programs since the Great Depression, we will have to perfect health care reform over time, just as Social Security, Medicare, veterans’ benefits and others were.

But we’re not perfecting the law; we’re fighting over it. Politicians dither and people die. Lawyers argue the merits of this or that technical point, and more blameless Americans grow sick and slip away.
Which is the real "death panel" - a government agency concluding that routine PSA screenings save few lives, or a health-care system that, favoring industry profits over human needs, leaves 50.7 million Americans uninsured?
*The USPSTF, according to their website, is
an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists). [It] conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."


Anonymous said...

Maybe capturing more of the 30% of the health dollar that is consumed by the insurance companies is a better place to start. Maybe a single payer system is a more important change. If you are a person with fast growing CA of the prostate that was found by testing you would be less likely to applaud testing restriction recommendation. It may be that screening great numbers of men isn't cost effective but I can certainly understand being thankful it was used when aggressive CA is found. When you are the exception you are very glad you've been diagnosed earlier rather than later. The group that decided the test recommendation may or may not have had all the information they needed for a correct conclusion. I notice no urologists are listed in the group that recommended the position. Having testing be off a recommended list, some people will go undiagnosed and die early. You can't tell which person that will be. I am totally sympathetic to finding prostate CA. Steve Forbes isn't a physician. His argument has a personal reason. For him, it could have been an earlier death sentence. In the art of medicine maybe more free enterprise isn't bad. How to encompass more Americans in affordable health care is the most important thing. Cost cutting at the edges with PSA tests will not solve the large problem Dr. Oz is commenting about.

LaVonne Neff said...

Anonymous, you bring up good points. In trying "to encompass more Americans in affordable health care," there are lots of approaches to consider. And yes, some people will die early if they are not tested. That's probably why my husband has decided to go ahead with the tests in spite of the recommendations. The fact that no urologists were on the review panel, though, may not be important, since urologists were definitely involved in the research they were reviewing. I'd recommend that everyone interested in this topic read the 2008 recommendations and the 2011 update. They are not as draconian as some people think. You can find links to them and other papers here:

LaVonne Neff said...

Oops, the link got cut off. Let me try again.