Brown: Die, But Don’t Try

A couple of weeks ago, California governor Jerry Brown signed a “right to die” bill that gave Californians the right to get lethal drugs if they wish to end their life. I am mildly supportive of this. I think people have the right to their lives but am uncomfortable with doctors being involved in the process.

This week, Brown vetoed a bill that would have let terminal patients petition drug companies to use experimental or unproven medications. In vetoing it, Brown said that the FDA already allows compassionate use. But 24 states have over-ridden that process because the FDA is slow and cumbersome in its compassionate use. It doesn’t do a patient much good to get permission to use a drug is he’s dead by the time the approval is granted.

Wesley Smith says it perfectly:

Good grief: A “right to die,” but no “right to try and live.”

I honestly don’t what Brown is thinking. I’ve liked some of this recent vetoes, including one where he noted that the legislature was criminalizing things that were already illegal. But this one is mystifying.

(In other news, Brown also approved a law banning conceal carry from college campuses. This also makes no sense. Conceal carry holders, especially in California, are the model of what the Left claims they want: carefully vetted registered gun-owners who have a very low rate of criminal activity. I think the veto — and ongoing protests in Texas against conceal-carry on college campuses — reveals that carefully vetted licensed use of weapons is not what the Left really wants. The more this debate drags out, the more I think it’s a part of the Culture War: one side wants an America with a culture of guns; the other wants that culture abolished.)

Update: Orac makes the case against right to try laws. I’m finding his reasoning weak, paternalistic and motivate heavily by his distaste for the Goldwater Institute. But it’s the best reasoning I’ve seen so far.

Vermont Falls

I am Hal’s total lack of surprise:

Vermonters will not be part of a single-payer healthcare system.

Gov. Peter Shumlin had hoped to create the first state-based single-payer system in 2017, but skepticism from both state lawmakers and constituents has halted the idea.

“This is not the right time” for enacting single payer, Shumlin said in a statement.

Shumlin cited the big increases in taxes Vermonters would see that would be required to pay for the plan.

“These are simply not tax rates that I can responsibly support or urge the Legislature to pass,” the governor said. “In my judgment, the potential economic disruption and risks would be too great to small businesses, working families and the state’s economy.”

Federal funds available were also $150 million less than expected, Shumlin added.

Note that Jonathan Gruber was involved in this, just in case you might be wondering what his overall intentions for Obamacare were.

I’m sure this will be blamed on the “greed” of Vermont voters, wanting to keep more of their money. But Megan McArdle called this months ago. The plan was slated to cost $2 billion, requiring Vermont to raise taxes by 75% at least.

Especially when you consider that estimates for this plan’s cost are likely to err on the optimistic side, because, well, people drawing up proposed budgets for their pet ideas tend to be a little optimistic. Yes, yes, there may be fabulous cost savings from using the government’s monopoly buying power to bargain prices down with providers. But Vermont is already the beneficiary of significant monopoly buying power: One insurer has 74 percent of the state’s small-group business. It’s a Blue Cross/Blue Shield, so don’t count on fabulous savings from squeezing out profits. The large group market is even more concentrated, though on a for-profit insurer.

Nor can you get much administrative saving at the provider level, because they still have to deal with out-of-state insurers quite a bit. And the once-vaunted fabulous savings from preventative care have mostly turned out not to exist.

So this is going to be expensive. So expensive that I doubt Vermont is actually going to go forward with it.

Supporters of single-payer healthcare tell us constantly that such a system would be massively more efficient than what we have now. They base this partially on bogus claims that Medicare and Medicaid have low overhead costs. They base this partially, as McArdle points out, on comparisons to a healthcare system that is already, in many states, a monopsony, one that Democrats have fiercely resisted challenging by allowing insurance to be sold across state lines.

But, in the end, it’s mainly wishful thinking. We’re supposed to believe that socialized medicine magically keeps costs down. But the cost curve in the evil capitalist US system has basically matched that of socialized systems for the last twenty years. Most of the explosion of medical costs occurred in the 1970’s and 80’s and is baked into the system we have.

Vermont has now shown that switching to a single-payer system would be expensive and intrusive. Can’t we try anything else before we go there?

To Quarantine Or Not to Quarantine

As you may know, there is a brewing controversy over what to do with healthcare workers returning from the Ebola hot zone in West Africa. After Craig Spencer came down with Ebola, several governors imposed quarantines on returning healthcare workers. Controversy erupted and, I believe, we are down to home quarantine for 21 days.

A few thoughts:

First, it’s true that there has been a bit of an over-reaction. So far, we have only had two people infected while in this country and both of them were healthcare workers taking care of a dying man without adequate protection. Naturally, we need to be vigilant. The virus is unlikely to mutate to become airborne but it may mutate to become far more infectious. As Nobel Prize winner Bruce Beutler has noted, we don’t have as much information as we’d like about how infectious this strain is. But, even with those caveats, the policies being advocated in some quarters are unwarranted at this stage.1

Second, the most important thing about fighting Ebola is stomping it out in Africa. If we do not stop Ebola in Africa, it will spread. It will spread to bigger cities. It will spread to other countries. Right now, we only have to worry about people who have actually been in West Africa. If this goes on and blows up to hundreds of thousands of cases or millions, we will have to worry about everyone. A house in our neighborhood is on fire. We’ve had a few cinders land on our roof. But the most important thing is not that we spray water on our roof; it’s that we put out the fire before the whole neighborhood is ablaze.

Anything that discourages healthcare workers from going to West Africa to fight this thing is likely to make things worse. Quarantine sounds like an easy burden to impose. But, in The Hot Zone, Richard Preston describes the psychological trauma that quarantine imposes on workers at USAMRIID. This is not a light burden. And isolating them in hospitals is a good recipe for getting them sick with the opportunistic diseases that infest every hospital in the world.

That having been said, it’s not irrational to be afraid of this disease. It’s not irrational to think that healthcare workers — who are the most at risk and who have close contact with dozens of people very day — should back off until they are clear. We have been very lucky so far that this hasn’t erupted in a school or something. We’ve been very lucky that infected people have sought help immediately. We have been very lucky that this hasn’t mutated to be much more infectious. All it takes is one idiot to wait until he literally drops dead in the street for this to become a serious serious problem. All the reassurances about how we can contain this are going to be cold comfort to someone who gets infected by a returning healthcare worker.

The dilemma is that treating potential victims like pariahs increases the odds of that nightmare scenario. It encourages them to hide their symptoms and to lie. So what do we do?

To me, these problems are interlocked: getting more healthcare workers to West Africa and keeping them from spreading the disease when they return are the same problem. So here is what I would propose:

  • Healthcare workers who go to West Africa should be guaranteed early spots in the line for experimental drugs like ZMAPP. These drugs are difficult to produce and will come online in small quantities (you can read a great summary of this from the aforementioned Preston). The biggest worry healthcare workers have about Ebola is not that they will lose their jobs; it’s that they will die. Promise them that they will get the best possible care. They deserve it.
  • Congress should authorize a fund to give hazard pay to healthcare workers who volunteer to fight Ebola in West Africa. We have to be careful here to not undermine the volunteer organizations that are the frontline for these epidemics. But they are being overwhelmed. They desperately need reinforcements. This fund would also pay for healthcare, life insurance and maintaining their existing jobs. This in addition to the funds needed to provide medical equipment for them to work with.
  • This fund would will also pay volunteers to undergo a three-week home quarantine on their return, during which they will be monitored for symptoms and maintain a log of any contacts.
  • We have laws that protect military reservists from being financially or legally ruined when they are called up to active duty during a war. Extend those laws to healthcare workers who volunteer to fight Ebola or are in quarantine after their return.
  • If we are going to go to war with Ebola, we have to treat it like a war. Doctors and nurses are our soldiers in this war. Pay them, reward them, protect them. Treat them in a manner that is good for public safety but also recognizes the tremendous risks they are taking and the tremendous good they are doing. Whatever else one may think of Craig Spencer or Kaci Hickox, they have risked their lives to try to save people, most of whom are a different nationality and race from them. Let’s recognize that even as we move to secure our public health.


    1. Of course, the same media telling us we are over-reacting were also saying Ebola would never come here in the first place.

    We Don’t Need a Czar and We Don’t Need a Murthy Either

    Having seen their attempts to blame Ebola on Republican budget cuts go up in flames, the Democrats have stumbled upon a new meme: this outbreak is the fault of Republicans because they’ve blocked Obama’s nominee for Surgeon General.

    CNN host Candy Crowley on Sunday challenged Sen. Ted Cruz (R-TX) while asking him how Republican decisions may have negatively impacted the United States’ ability to address Ebola.

    Crowley asked how the sequester hurt funding for the Centers for Disease Control and how the National Rifle Association’s opposition to President Obama’s nominee for surgeon general, Dr. Vivek Murthy, also hurt the American response.

    “We haven’t had a Surgeon General — who is the nation’s leading public health official, at least the voice of it — for a year. Some Democrats and some Republicans had opposed the particular surgeon general the president had nominated. Do you think it would have helped A. If NIH and CDC had had a little more money and B. Had there been a surgeon general to kind of calm what has been the fear of Ebola?” Crowley asked on CNN’s “State of the Union.”

    (Note that Crowley repeats the BS meme that Republicans have gutted NIH/CDC funding.)

    First of all, the claim that we do not have a Surgeon General is bullshit, no matter how often the left repeats it. Boris Lushniak has been acting Surgeon General for the last year. Lushniak spent 16 years at the CDC, including work with their anthrax team. He’s qualified to deal with the the current crisis. In fact, I think he’s more qualified to deal with the current crisis than Obama’s nominee, who was nominated mostly for founding the political advocacy group “Doctors for Obama” (now “Doctors for America”) and his support of advancing gun control as a healthcare issue.

    (Of course, Murthy’s lack of qualifications is probably seen as a qualification. Obama named an Ebola czar this weekend: a career Democratic political operative. Vox immediately defended the choice, saying we need a manager, not a doctor. Because, you know, if you have a rare and dangerous tropical disease, what you really want is a manager. Personally, I don’t think we need another czar for anything, certainly not for Ebola. Handling this is the job of CDC. Or maybe we should put these guys in charge.)

    Second, I’m not sure what the Surgeon General is supposed to do here. The main thing we need is for the public to be aware of the danger and what to do if they might have Ebola. And we need hospitals to have better isolation procedures. I guess the Surgeon General could help with a public information campaign. But I don’t see that this would desperately need the particular skills of Murthy.

    That having been said, the Republicans should let the Murthy nomination move forward. I’m tired of this filibustering, especially for a fairly unimportant position. Murthy may or may not be an anti-gun nut, but he’s Obama’s anti-gun nut so let Obama own up to whatever foolishness he says or does.

    Blaming Republicans Again

    I know you thought that the current Ebola outbreak was the result of dysfunctional countries with horrendous health care systems. Or maybe you thought it was the fault of organizations like the WHO to respond quickly enough. Or maybe you think it’s no one’s fault and that disease outbreaks are going to happen.

    But you’re wrong. The current Ebola outbreak is the fault of …. Republicans:

    “Republican Cuts Kill” is the message coming from The Agenda Project, a 501(c)4 organization that is placing ads in various battleground states. According to an email signed by the group’s founder Erica Payne and titled “If you die, blame them,” the group is starting a

    a multi-pronged blitzkrieg attack that lays blame for the Ebola crisis exactly where it belongs– at the feet of the Republican lawmakers. Like rabid dogs in a butcher shop, Republicans have indiscriminately shredded everything in their path, including critical programs that could have dealt with the Ebola crisis before it reached our country.

    The supposed proximate cause is “deep draconian cuts” in the budgets of the NIH and the CDC which hindered their disease response. Never mind that the US still spends a total of $8 billion on global health. Never mind that the CDC and NIH have nearly $40 billion in funding between them. Never mind that cuts to CDC/NIH and specifically cuts for disease control were included in the budget proposal of Barack Obama who, last time I checked, was not a Republican. Never mind that according to Daily Kos’s own graph, the steep budget cuts in PHEP started in 2006, when the Democrats controlled Congress. Never mind that the Republican increased CDC funding over the President’s budget.

    Conservatives, dammit!

    This was partially stimulated by the head of the NIH saying that we would have an Ebola vaccine if not for budget cuts. Numerous people have responded by finding silliness in the NIH budget — such as $666,000 grant to find out why people like watching Seinfeld reruns — that they did have money for. I’m a bit loathe to play that game because often projects that sound stupid aren’t or are, at least, massively misrepresented.

    But I will take issue with the NIH’s claim that we’d have an Ebola vaccine if it weren’t for budget cuts (a claim they are slowly backing away from). Vaccine research is hard. We’ve been spoiled because most of the vaccines we’re used to — like measles — are cheap, effective and have minimal side effects. Such vaccines have wiped out smallpox and brought polio to the brink of extinction. But not all vaccines are that easy. We’ve been working on an AIDS vaccine for thirty years. Enormous effort has gone into finding a vaccine for malaria — which kills hundreds of thousands of people a year — with no success. Even some of the vaccines we do have are hideously expensive, come with significant side effects or have limited effectiveness. NIH might have an Ebola vaccine if they had more money. They might also have nothing.

    I’m a big fan of science funding, obviously. I like NIH to be well-funded. Public health is one of the few things we can all agree government should invest in. And I think basic science funding falls under Adam Smith’s description of something “which it can never be for the interest of any individual, or small number of individuals, to erect and maintain” but that benefits the public generally. But Ebola is not the reason to fund the NIH. They should be funded because of the outstanding research they do on everything else, especially the chronic common diseases that affect all of us. I especially want them to be working on antibiotic-resistant diseases, which, to my mind, pose the greatest healthcare menace for the 21st century. They should research Ebola as well. With a $30 billion budget, there’s plenty to go around. But Ebola research is only a tiny fraction of what they do. And I’d prefer they not try to pretend otherwise.

    As for the CDC, a bit less money on public health issues and a bit more money on infectious disease would be a good idea. And that, my friends, is squarely on the President and the man he appointed to head that agency.

    As a general rule, however, I would prefer that we keep Ebola and politics apart. This isn’t an excuse to grind your favorite political axe, be it immigration, budget cuts or single-payer healthcare. This is a time to calmly but decisively react to a potential health crisis. The main effort should be stomp this out in West Africa before it really does rage out of control. Because if this blows up to hundreds of thousands of people, if this spreads to South Africa or India or China, we will have a global epidemic on our hands.