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One thing this article misses are medical procedures that improve the quality of life, but have no bearing on life expectancy.
For example, if you knock out your front row of teeth, not only do you look weird to people (a pirate), but also you can no longer easily bite into a hamburger, and your speech is impacted. You will have trouble pronouncing words that contain 'v', 'th', or 'f'.
Getting implants is not going to increase your life expectancy, unless you live in a society devoid of knives (our external teeth). But the increase in quality of life is often worth it.
That being said, in the US dentists seem to take way too many X-rays. They take X-rays before the doctor even sees you. Then the doctor tells you what you could have told them.
Source: personal experience.
This is why we need medical payments to be capitated, not fee for service. The way medical care currently works has horrible incentives. Medical providers have an incredible informational advantage so patients just do whatever their doctor tells them. Since doctors get paid for doing things they routinely tell people to do things that are proven to have little efficacy. Medical providers should instead be paid per patient they cover. Especially now that hospitals are so consolidated it's relatively easy to tell if health outcomes are better or worse than average over the group of patients they cover. By punishing providers for achieving bad outcomes and sharing the savings they obtain by cutting waste we can drastically reduce healthcare costs.
Medicare and Kaiser permanente are leading the charge with this style of insurance and have already shown it to be cost effective while not reducing the quality of outcomes.
This is tricky to implement as it introduces other perverse incentives: namely that health care providers stop treating very sick people. You see this in some cases with surgeons already that have a very high success rate. They'll only opt for surgery if it's a relatively minor need, but if it's complicated or there are potentially complicating issues they'll pass.
Outcomes for very sick people being worse is taken into account so providers aren't punished if their success rate is lower for those patients. We have all the data we need to know what the outcomes should be for a provider over the course of a year. Anyway, providers have to precommit to their pool of patients, so it's not like they can just pick the lucky ones.
Capitation is admittedly a much more complicated way to administer health care, but fixing the incentives is absolutely worth the pain we may face in the short term. Which we might not considering how well these programs have been shown to work.
you're not fixing the distortive incentives with this scheme, just transforming them. 'capitation' incentivizes hoarding of patients, most obviously by incentivizing the minimization of treatment times and associated costs but also through outright fraud (by falsifying records, etc.). so you're essentially trying to maximize patient outcomes by capping costs, which is a terrible proxy metric all around.
to actually improve healthcare, we'd need to _increase_ spending per person (by an order of magnitude or more, using more team-based medical care rather than 1-on-1), for not only direct care costs, but also research and development. what we absolutely need none of is deadweight losses, like profit-maximizing medical administration, big pharma, and the whole medical insurance industry. medical 'insurance' has become a complete misnomer, as it no longer serves to mitigate the distasterous effects of low probability, high impact events, but as a socialization of routine medical care, which is not _insurance_ at all.
Huh, I didn't expect to come across something I have such direct knowledge of.
I used to work with this data directly - I worked with MACPAC to prepare reports for the CBO on the efficacy of pay-per-performance programs, especially as it pertained to the possibility of switching Medicaid from a fee-for-service model to a pay-for-performance model. (6-9 years ago)
I just wanted to chime in on this one quote:
> We have all the data we need to know what the outcomes should be for a provider over the course of a year.
The data here is exceedingly low quality, especially for Medicaid. Medicare is in a better state due to being centrally administered. We do *not* have all the data we need to make pay-for-performance more than an extremely rudimentary approach. Is that rudimentary approach still better than fee-for-service? Maybe - that's a complicated question I let the public health PHDs write very long reports on.
The healthcare industry is gradually shifting from a fee-for-service model to a value-based-care model. This will take a long and we'll probably always have a hybrid model with varying levels of financial risk spread across insurers, providers, patients, and government.
As an incremental step forward bundled payments are a good approach. For common interventions like a hip replacement the insurer gives the provider a single lump sum for everything instead of having separate line items for surgery, anesthesia, medical device, antibiotics, hospital stay, physical therapy, etc.
(OP here)
This essay set may superficially appear to be another repetitive salvo in the interminable US healthcare political conflict, but I recommend reading a bit deeper. I think the perspective these essays offer (that, at the margin, medical spending doesn't affect people's wellspan much, at least not in the US) is both quite important and underrepresented in most discussions of healthcare.
I mean, why would we expect it too? Spending is about profits accumulating somewhere, so why would that have anything to do with optimizing healthspan? Note, I'm vehemently critical of the modern medical establishment, and a health loon myself (by necessity, was hit with a though illness early on in my life).
medicare for all. done.
A lot of $ is spent on medicine because medicine works. Alternatives such as diet, exercise either are spotty in efficacy or do not work. Medicine offers a quick fix and in some cases the only fix. Someone who has cancer will need to be treated with medicine, not diet.
Diet and exercise will work much better to prevent obesity than any medicine on market. It is just that long-term adherence to these things is very much determined by culture and will be much harder for Americans compared to Japanese, for example.
There are new discoveries in diabetes medicines recently but again, you will do much better by not getting diabetes in the first place.
The same goes for smoking which can cause, for example, lung cancer. Roughly speaking, once you get diagnosed with lung cancer you only have 40% chance living more than 1 year. Costly novel medicines often prolong the life by few months only.
We really need better health economy education for everyone.
I mean, it's not complicated, when we allowed the tobacco industry to manipulate people for profits while hiding the disastrous health consequence of their products, people got ill in larger numbers
It's the same for the processed food industry. It's time will come, soon, too, as healthcare systems everywhere are failing because of it.
all the nutrition info is on the labels yet people knowingly overeat. different type of problem.
I don't think people think much beyond calories wrt to overeating. I know my mentality was once "calories can come from anywhere, can always take a multivitamin to cover deficiencies", which I now find, to put it gently, silly.
Not "diet and exercise", just diet. Exercise doesn't contribute more than ~10% to weight loss (it helps for many other things but not that) - and if you're having trouble with the diet then it makes it more difficult because you get hungry, which sometimes cancels the entire thing out.
Well, the idea is probably not to gain weight in the first place. Once you gain weight it is very hard to lose it. Many people manage naturally to keep perfect BMI by eating healthy diet and having enough exercise or by just moving around. Exercise will have more health benefits than just keeping your body weight low.
IME exercise (combined with appropriate diet, mind you), actually reduces food intake for me. Or at least, makes it so I eat less net calories after removing the expenditure. But otherwise agreed, diet is the foundation.
this is such a strange comment for me, and I beg people not to reflexively downvote and instead join in for a discussion, but I'm part / have been part of communities where people ROUTINELY achieve remission from disease the medical establishment deems incurable
I can go in further details if people ask, but lifestyle intervention has DRAMATIC results for many people, myself included, and results not provided by drugs or any commonly available medical intervention
Let me give you an example, RE: cancer and diet, look up "Andrew Scarborough brain cancer" and you'll find a detailed account of someone treating incurable brain cancer with diet and lifestyle; and this is someone working in the medical field (actually, precisely in oncology)
> and this is someone working in the medical field
Well, yes, even a crackpot can claim to be working in the field.
This in no way supports your claim of “routine” cures through diet. There is no evidence that a fucking keto diet will cure cancer* and it doesn’t pass any sniff test as at the end of the day your body still runs on glucose. This is pretty much an insult to anyone not fortunate enough for their cancer to go spontaneously into remission - and looking at the loon you posted, both he and a family member had some amount of treatment before diet, confounding any claim that diet was responsible for remission.
* whether such a diet can have some survivability benefits or some better or worse outcome is an open question, which has nothing to do with your crackpot claims.
I am only replying to your incendiary comment to say that your characterization is insulting and wrong, "fucking keto diet"(s) are having results for many people, whether you like it or not
Others, please research this person further, he's not a "loon" / "crackpot" just a regular smart young person who also happens to be a cancer researcher.
BTW, keto also cures epilepsy, and that's known since the early 20th century, is that also triggering to you?
Had to login just to counter the epilepsy part of this comment, though I think it applies to the rest of the topic wrt cancer as well. Keto diets can, in some cases, help epilepsy patients, particularly those with certain seizure types or genetic basis. But, like with cancer, epilepsy is complicated both in presentation and cause and to pretend that keto is any way a cure for epilepsy outside of a small minority of patients isn't true. See
https://www.epilepsy.com/learn/treating-seizures-and-epileps...
for high level overview.
It sometimes is enough, sometimes not. But it does have SOME undisputed efficacy and it's an area of legitimate research.
Lol "sometimes is enough, sometimes not" is a bit of a backpedal from definitively putting cancer into remission.
If it's an area of legitimate research for cancer treatment, then why do you lead with a reference to an individual crackpot - instead of even a poorly designed peer-reviewed study in a low impact forum.
Of the millions of possibilities, why do you assume that it was the keto diet of this individual that lead to their remission? Do you lack the imagination that it would likely be something else?
I was referring to epilepsy.
I will not get into further arguments with you re: the "crackpot", insult. Have a nice day.
Third point, and I'm going to end it here: I myself suffered from Multiple Sclerosis when I was younger; it was retrospectively very easy to correlate, at least in a large part, with diet and lifestyle. The changes I had to make to be in remission were DRAMATIC but worth it. I don't think I would've been insulted to read about people in similar situations experiencing remission from lifestyle adjustments, in fact, I would have been extatic to find out I'm not condemned to slowly drift into being eventually wheelchair-bound, as my doctors were predicting.
Also, re: this caricature you make of these "keto" diet cancer plans, it's not true that the "body still runs on glucose", in fact only 25 grams of glucose are manufactured by the liver per day in the absence of dietary carbohydrates. And I don't claim to know the mechanisms, but I know FOR SURE that human beings (and no other animal for that matter) evolved to live on candy bars and sugar water, and that replacing one's diet with something species-appropriate and nutritionally replete is bound to have some effect.
To elaborate: red blood cells are the only part of the body that absolutely _must_ use glucose, and they're not incredibly metabolically active.
Thanks, I didn't know. It's weird to see this misinformation about glucose being the primary fuel for human bodies while it's quite obvious human biology is optimized for fat burning. Glucose is just dealt with in priority because it's only safe in a tight band, and chronically elevated glucose in particular is disastrous to blood vessels. Humans should spend a decent amount of time in fat burning mode with periods of fasting and adequate magnesium intake and exercise for optimal vascular health.
Because it’s not misinformation - the body absolutely needs glucose homeostasis to survive - if you don’t eat carbs it will make it out of protein. The body has numerous mechanisms and basically dedicated organs for the conversion, metabolism, storage, and production of glucose. The whole Krebs cycle is built around the processing of byproducts of glucose - so you’re utterly full of shit that it’s “only safe in a tight band”. That the body can additionally use fatty acids in the form of ketone bodies as a stopgap is a testament to adaptability - but even people on keto require a homeostasis of a close to normal level of blood glucose. And how do they get this? Through the metabolism of proteins which can be amazingly converted to the glucose the body needs to survive.
This is high school level biology, and easily reviewed with 10 minutes on Wikipedia.
I did not say the body can't deal with glucose and as you point out, produce it on demand. What I meant by "in a tight band" was the chronically elevated glucose is damaging to organs as evidenced by what happens in advanced diabetes.
And the body doesn't need _dietary_ carbohydrates, which was my point. It does absolutely need both proteins and fats without which starvation occurs.
I said the body runs on glucose (ie it is essential for survival) - you claimed that was misinformation (which it isn’t) - I said nothing about dietary carbohydrates.
Blood glucose levels for those on even the extreme keto diets will be regulated in the same range (60-90 mg/dl) as someone on a more conventional diet that does not have impaired glucose metabolism.
People with Type 1 diabetes still need insulin even if they are on a keto diet.
You said "at the end of the day your body still runs on glucose" which is NOT true on a ketogenic diet, as a mere 25 grams are manufactured by the liver as needed for (apparently) red blood cells.
Yes, I agree that ketogenic dieters still have glucose, obviously, my point was about CHRONICALLY ELEVATED glucose being deleterious for blood vessel health, which is widely known and, again, cause of the necrosis seen in late-stage diabetes.
I know of at least one T1 diabetic that is OFF INSULIN on a ketogenic (carnivore) diet.
The efficacy of cancer prevention via fitness, diet and lifestyle far exceed the efficacy of cancer treatment by medicine.
"The right says governments produce a much inferior baby"
Too many Cesarean sections over centuries will yield more narrow female hips.
You will like small butts, and you will lie. [0]
Russians expose their newborns to the cold on purpose, to build immune systems so as to not eventually need as much "Big Pharma". [1]
[0]
https://www.youtube.com/watch?v=X53ZSxkQ3Ho
[1]
https://www.reddit.com/r/interestingasfuck/comments/qinla7/b...
(2007)
Added above. Thanks!
Duh.
Bring back fat-shaming!
This is a 14 year old article (pre ACA) from an associate professor in economics who doesn’t have a degree in economics.
Sigh
Those aren't good reasons to reject an article. Would you mind reviewing the site guidelines? Note that they include: "_Please don't post shallow dismissals, especially of other people's work. A good critical comment teaches us something._" Also: "_Don't be snarky._"
Older articles and historical material are always welcome on HN, if they're interesting. Often they're more interesting than the latest $thing about $current-hot-topic.
As for which credentials professors do or don't have, that seems irrelevant to whether or not the article can be the basis for a substantive, interesting discussion, which is what we care about here.
The main reason to consider this article offtopic for HN would be that it's on a classic flamewar topic. However, those aren't automatically bad. It depends, again, whether the article contains enough interesting information be different (
https://hn.algolia.com/?dateRange=all&page=0&prefix=false&so...
), and can sustain an interesting discussion. After skimming it a bit, I think it probably clears that bar.
I've changed the title from the original, though (because it's provocative and therefore flamebaity) to a representative sentence from the article body, which says what the article is about.
Of course it's still up to HN users to focus on the interesting parts and discuss them thoughtfully, rather than use it as a diving board to spring into pits of hellfire from.
https://news.ycombinator.com/newsguidelines.html
14 years old article is a good reason to take note of it as it shows it is not just some fad but important long-term issue.
I don't think the issue itself is controversial. I was taught at university that our life expectancy is determined roughly speaking one third by our genes, one third by our lifestyle and one third by healthcare.
And then it became apparent that most healthcare interventions (childhood vaccinations, antibiotics, most medicines) that have a big effect are relatively cheap. The most costly interventions have the least effect. We could easily cut the health budget in half with only a marginal decrease of actual outcomes. But it would be very hard to do due to politics, the structure of incentives etc. But we really need to critically examine and educate people that expecting more and more from healthcare despite progress in this field can only lead to diminishing results.
We cannot change our genes (yet) but we need to think more about our lifestyle (obesity, drug and alcohol use) which could provide considerable potential as well.
I generally agree but public sanitation measures including water purification, food inspection, garbage disposal, and sewers also have a huge impact on average life expectancy. Maybe even more than healthcare.
In other words, vaccines are wonderful but if I had to pick between vaccines and clean water I'd take clean water every time.
I'd agree.
My theory is that the reason life span is 20 years less in the developing world is solely due to water treatment issues, resulting in wide-spread hepatitis.
By 60, most people look (and feel) 80 there.
(The classic flamewar topic I was referring to is the U.S. healthcare system)
What specifically has changed since this essay set was published that would render it moot? If "the ACA", what specific ACA policies?
This is true of COVID too. Instead of actually looking at stats, and realizing that, for instance, 75% of all "COVID deaths" (a bloated stat if there ever was one) were obese people, stressing being healthy and losing weight instead of assuming vaccines (the ones that don't keep you from getting or spreading it) were the miraculous cure would have made a world of difference.
The US adult obesity rate is 42.4% [1]. To get to 75% of deaths being obese people, you'd need about a 4x death rate of obese people compared to non-obese people. Most obese people find it extremely hard to stop being obese and often fail despite immense effort.
Meanwhile, getting a COVID vaccine reduces the chance of death by >10x at a cost of <$40 per person. My impression is that vaccines are unusually cost-effective medicine and that the low-impact medical spending is elsewhere in the system, but it is nonetheless thought-provoking to consider this specific example.
[1]
https://www.cdc.gov/nchs/products/databriefs/db360.htm
> Most obese people find it extremely hard to stop being obese and often fail despite immense effort.
I used to help out at a slimming group. Like many self-improvement quests, the effort waxes and wanes. Much as I wished for people to achieve their dream of being slimmer, and even though their wishes and often their attempts were laudable, I wouldn't call them "immense". They're people, most wanted an easy fix and struggled to remain dedicated when faced with the harder bits.
This. It's not hard to make the necessary changes if sufficiently motivated. In fact, formulating the motivation is kind of the only step, everybody, and I mean *EVERYBODY* can achieve appropriate weight and even above-average fitness if following the right precepts.
Why do you assume this is a matter of motivation, or that motivation is not itself a component of obesity as a disease?
Our urges to eat and be lazy are also a consequence of our health and diet. They are not coming out of some pure rational willpower plane.
Sorry, I'm not sure I expressed what I meant clearly so I'll try again: I mean that it's sufficient to be motivated WHEN armed with the proper knowledge; I think many people fail DESPITE being motivated because they are simply misinformed as to what works.
Yes, reading my comment again it doesn't seem I was saying that. Anyway, I don't think that much motivation is required, and if a diet / lifestyle change is hard to stick to, it's often because it's a misguided strategy. For illustration, counting calories while not making qualitative changes in the composition of the diet is just simply never going to work, long-term. Some foods are just too hyperpalatable, too prone to form emotional / addictive associations, but conversely that also implies those dietary changes will have to confront some emotional regulation issues as well. It sounds complicated, but I don't know, I think looking at how widespread the overweight issue is nowadays we have to conclude almost all of us are doing something wrong wrt to diet and lifestyle.
I'd rather reshape the environment we all live in. And yes I mean soda bans and the like.
Oh I agree, I think we've been greatly underestimating how damaging all these are and so should be treated like cigarettes with very heavy taxation that should go towards subsidizing healthy food.
It could be true that obese have 4 times higher death rate. Note that obesity often comes together with diabetes and cardiovascular diseases which increase the risk even more.
Vaccines are effective, they reduce death rate approximately 10 times. It still seemed quite high that several EU countries have reintroduced restrictions despite good vaccination uptake.
Besides this is about long-term issues, not just covid or something we can fix in 1 or 2 years.
> Most obese people find it extremely hard to stop being obese and often fail despite immense effort.
Calories in vs calories out. Simple as that.
Ok, how does that explain why some people want to eat even when they're full, while others feel full after eating a grape (exaggerating)?
It doesn't.
Weight is a direct results of the calorie equation.
Appetite is regulated by a bunch of different factors. Actually, when you think about it, someone could live just fine being constantly hungry (so completely broken appetite signals) in a food scarce environment.
You’re fighting a billion years of evolution screaming at you to bulk up in case there’s a famine. Good luck.
That's a bit illogical isn't it? Better to put the food in your pockets than in your stomach.
even bariatric surgery seldom produces thinness. It only makes a very obese person only mildly obese, optimistically. The diet and fitness industries are worth billions of dollars, with pitifully poor results to show for it. Biology is fighting all efforts to make humans thinner.
But vaccines ARE the miraculouse cure, at least in my country the high case load is because of unvaccinated or not fully vaccinated people.
If about 80% of the population took it, we wouldn't have any problem.
Of course previous health issues matter when you get sick and of course we should encourage healthier living, but we won't change this in the next 6 Months, for that we have a vaccine.
In my country ~80% of the population took the vaccine and we still have many problems. Right now it's even the region with the highest vaccination rate that has the biggest wave.
It would've probably been much much worse without the vaccines, but they are sadly not a miraculous cure that solves all problems.
Vaccines won't help _at all_ if your immune system is completely compromised by other health issues.
They absolutely help if everyone else gets vaccinated, which is what the person you’re replying to said.
No they won't because COVID spreads from vaccinated people too.
Also my point is there is no use to any vaccine if underlying health is not addressed in tandem.
You're approximately half as likely to get infected (and therefore become infectious) if you're vaccinated. Especially when the R0 is already hovering near 2, vaccines can mean the difference between COVID dying out in your area and COVID rampaging through the area, developing mutant strains as it goes. So your claim ("Vaccines won't help _at all_ if your immune system is completely compromised by other health issues.") is false.
I do not disagree with your point that the vaccine does not work on people who have an immundefect.
But that point was never in dispute, at least not in my comment.
Of course it would be great if the vaccine would also stop the transmission, but even if not, if less people get sick, less people will spread it, which will lead to smaller clusters.
It also allows the medical system to keep on working and providing the best medical help to people who do get sick.
Of course covid-19 is still an ongoing situation, viruses mutate, situations and recommendations change, but I don't see any indication that we can protect the population and even more the vulnerable population without a high enough vaccination rate.
Edit: Wording
To be accurate, there are no COVID vaccines by the official definition. There is only pharmaceuticals being labeled as vaccines.
Real vaccines induce immunity.
"An ounce of prevention is worth a pound of cure" - old proverb
Fit, healthy, people are dying left and right.
There are risk factors, but don't start thinking you're invicible for not having them. The adaptive immune system is slow, vaccines prime it to react faster with more specific antibodies.
Dying of pneumonia does not feel good. It makes grown men cry and beg. Strongly recommend against.
But those "fit, healthy" (the genuinely so, I'm not sure I even agree with the characterization for many of the mediatized cases), are OUTLIERS. Yes, you are never invincible, but it's 100% correct to characterize Covid as a disease of the metabolically dysfunctional. Sadly, this is a HUGE percentage of the population of the world nowadays, which seems to be the point of the article (disclaimer: in true HN tradition, I haven't read it)
Traditionnal post-downvote comment:
Covid affects those:
- on immunosuppressant medication most often for a PREVENTABLE "lifestyle" disease
- otherwise negatively affected by said disease, particularly in the vascular system, we know that Covid kills most those that have hypertension, long-term vascular damage from chronically-elevated blood sugar, etc.
- nutritional deficient / malnourished (low vitamin D, absence of sunlight, etc. etc.); this is also very common
> this is a HUGE percentage of the population of the world nowadays,
And thus make up a sizeable amount of COVID patients. I see nothing noteworthy here. Having a preexisting condition makes you suffer more when you contract an infectious disease. I'd expect the same things you said could be repeated for influenza, pneumonia, or anything else. For that matter, how much worse do obese patients fare when recovering from a broken leg? Are fractures then a disease of the metabolically dysfunctional, as you put it?
What's noteworthy is *vascular* health is particularly important, thus chronically-elevated blood sugar which is *eminently* resolvable by lifestyle intervention, is the main culprit. So I don't follow your comment.
Jumping from vascular health to blood sugar level is a non-sequitur. There are many other aspects of vascular health.
And nothing is easy about a lifestyle intervention, it is in fact one of the hardest and least likely to hold kinds of medical treatment.
chronically-elevated blood sugar is quite probably the #1 cause of vascular problems (heck, it's highest association is with hypertension, these go hand in hand), hypertension is itself often associated with a common magnesium deficiency (stiffness is what happens when magnesium is insufficient and calcium is overexpressed, I mean this is the basic role of magnesium in the cell, "relaxing" the contraction brought on by calcium), this is schematic and a layman view but I believe basically correct
What lifestyle diseases are you thinking of that are commonly treated with immunosuppressants? Diseases like psoriasis and rheumatoid arthritis are commonly treated with immunosuppressants and are not considered lifestyle diseases.
these both OFTEN have dietary triggers that are possible to discover with certain elimination diets
again, I'm not here to go on long arguments while being called a loon, which I'm bound to when touching this subject
sticking closer to home, tldr; I had MS, treated it with an elimination diet and other lifestyle changes, barring this intervention, I'd be on immunosuppressants
but I didn't intend to make this the larger part of my argument, as the main issue is with people facing blood sugar control problems brought on by "extremely western" (sugar|processed|junk)-food-laden diets