If they’re not exactly killing us, they will eventually kill the economy. Everyone knows that health care costs are rising, generally much faster than the inflation rate. Many reasons are given for this, including such things as increased costs for medications, the cost of litigation (this one is influenced by whether or not you think there is a “malpractice crisis”), the aging of our population, and the built-in inefficiencies of the insurance industry. Whatever the reasons, though, a recent and telling study by the Congressional Budget Office lays out what most of us already knew: “The long-term fiscal balance of the United States will be determined primarily by the future rate of growth of health care costs . . . .”
We simply cannot sustain a rate of health care spending that is rising faster than the cost of anything else in the economy. In a way, we are victims of our own success in devising new medicines and treatments. But if nothing changes the CBO predicts that by the year 2050 health care would consume 20% of the national economy, a proportion which today is that of the entire federal budget. Clearly, something has to give. What will it be?
The only way I can see for this mess to get fixed is for everyone to agree there is a huge problem that is nobody’s entire fault — it is consumer demand that has largly driven the whole thing. We did it. So we have to dampen that demand in some way. How to do this? I fear ultimately it will come with draconian and inevitably soulless bureaucratic rules. But is doesn’t have to be that way. Each of us has the power to realize that when we demand a new medical service that hasn’t really been shown to work any better than cheaper ones, and when we insist on services shown to be of only marginal benefit, we are robbing from everyone else, especially our children who will be left with the bills. Equally important, when we demand expensive care for ailments that we largely caused in ourselves we are doing the same thing.
We are all a community. We need to solve this problem as a community.
I would think by now, nearly 2008, that I wouldn’t have to write anything about the importance of child car seats. But I find I do, because I still see as I drive adults holding babies and toddlers over their shoulder, often while sitting in the front seat. This has been illegal in most places for many years, but it is still common and it is still stupid and dangerous. I also still see the results–several children each year come through the PICU who were unrestrained passengers in a car accident, and a few of them die.
Here are some statistics on car seats and motor vehicle accidents. (The most recent I could find come from 2003.) For that year nearly 59,000 children under the age of 5 were injured, 8% of them seriously, and about 1% died. This amounted to 471 children. Significantly, over one third of the children who died were unrestrained.
Most of us have been lectured to about these things, but I have found many parents have difficulty understanding notions of statistical risk. For example, one study showed 72% of parents were seriously afraid their child would be abducted by a stranger. That is a legitimate fear, but it is not very likely to happen; in fact, it is vanishingly unlikely. It is only one-fourth as likely as you getting struck by lightning.
My point is that parents should do what they can to reduce the chances of their child suffering harm: by all means tell your child about what to do when approached by strangers, but also please buckle them into a car seat, preferably in the back seat, when you drive anywhere with them, even a short distance.
You can find an excellent overview of all manner of car seats and how to use them here, at the American Academy of Pediatrics site.
I have dealt with pediatric solid organ transplantation quite a bit over the years, both from the perspective of caring for children who receive transplants and for those unfortunate children whose parents choose for them to become organ donors. By solid organs I mean primarily kidney, liver, heart, and lung transplants–bone marrow transplants are somewhat different. Children comprise a small but significant subgroup of organ transplant patients: in a recent survey they accounted for 7% of transplant recipients, a number which had changed little in the previous decade.
Although children accounted for 7% of the recipients, they comprised twice that number of donors–14% of them. Some transplanted organs may come from a living donor; for example, about half of kidney transplants use an organ donated by someone, usually a close relative. (This is possible because we have two kidneys and can live quite normally with only one of them.) Children, however, are not living donors. This means all of those children who donated organs died, and their families made the choice for their child’s organs to live on and give life to another person. And that person was often an adult, because the number of children who donate organs far exceeds the number who receive them as transplants. We do try to match donated organs from children first with another child, particularly if size is important, as it often is for the very small children. But if no child is a match, and size is not an issue (it often is not if the donor is an older child), the organs are given to adult patients.
I have many times been in the position of asking grieving parents to consider donating their beloved child’s organs to another person. I could not find any national statistics about this, but in my personal experience, two-thirds at least of parents I ask make the choice to donate life. I do know the donation rate for adults is far, far lower than that. Children on the whole have healthier organs, and this is reflected by the fact that children who donate are more likely than adults to be able to donate several organs, often three or more. But this is not the reason children represent such a relatively large proportion of organ donors; the reason is their parents, however devastated by the loss of their child, choose this for them. We adults should be so generous with our own bodies.
If you are interested in learning more about transplantation in general, this is a good site with useful links to other authoritative sites. If you want to know more of the technical specifics of children’s transplant statistics over the past decade, you can read about it here.
I have a donor’s heart logo on my driver’s license. I encourage everyone to think deeply about doing that, too, as well as telling your family that, should tragedy strike unexpectedly, you wish your organs to live on in someone else.
It is unclear what will happen after the president’s veto of the bill reauthorizing the State Children’s Health Insurance Program (SCHIP) and the inability of Congress to override his veto. John Iglehart, the highly-respected national correspondent for the New England Journal of Medicine, reviews the episode here. It is brief, understandable, and to the point. Whatever you think of the issue, it is clear opponents of the program misrepresented what it was.
But there is a deeper issue — quality, as well as quantity, matters. In a way, the SCHIP debate is about quantityof healthcare because it concerns access to care; children and adolescents are disproportionately more likely than adults to be poor, something SCHIP was designed to address. Another recent New England Journal article shows how qualityof healthcare for children is also a major problem.
This observation goes against the common wisdom, which has been that problems in quality of healthcare are not such a problem for children as they are for adults. The unspoken assumption has been that children’s conditions are somehow easier to diagnose and less complicated to treat than those adults get. So if the child could get to the doctor, then we presumed the child usually got the correct care. This is not true; deficiency rates in the quality of care for children were similar to those noted in adults.
What is the solution? We need to assume children are just as complicated as adults in their healthcare needs.
Doctors do a lot of x-rays on children. Is there a risk to that, or are x-rays completely safe? The answer, for chest, bone, and abdominal x-rays, is that they are very, very, very safe, but not totally risk-free. All of us are constantly exposed to radiation similar to x-rays. It comes primarily from naturally-occurring radioactive things around us, such as radon gas seeping up through the ground, or from outer space in the form of cosmic rays. People living at higher altitudes receive higher doses of such background radiation, amounting to about half again as much for someone living on the Colorado plateau compared with someone at sea level. To put things in perspective, the radiation dose in a single chest x-ray, on average, is similar to the background radiation most of us receive during a ten day time span living our normal lives.
There are several important things to remember about radiation risks. High radiation doses definitely cause death and disease (primarily cancer); the atomic bomb and the disaster at Chernobyl clearly showed this. A second key point is that radiation risk is cumulative over a lifetime. This is an important consideration for children, since they have most of their life ahead of them. Children are also more sensitive to the effects of x-rays than are adults. Still, it is logical to think of routine chest, arm and leg, and abdominal x-rays as being virtually without risk unless the child has already gotten for some reason a large radiation dose in the past.
Computed tomographic scans, CT scans, are another form of x-rays. We most commonly use CT scans to look at a child’s head, chest, or abdomen. The technology produces good images of the organs inside those body regions, and CT scanning has revolutionized how medicine and surgery are practiced. But CT must be used judiciously, particularly in children, because it subjects the child to much more radiation than does a simple chest or abdomen x-ray–200 to 300 times more, depending upon the particular technique used. So if a chest x-ray is the equivalent of ten days of background radiation exposure, a child getting a CT scan receives the same radiation dose as anywhere from five to ten years of normal living. I’ve written more about CT scan risk here.
The future cancer risk to a child from a single CT scan is still vanishingly small, and the benefits of getting the information the CT provides nearly always outweigh this tiny risk. However, this may not be the case for children who get many CT scans or have been exposed to other radiation in the past. Fortunately, this represents a relatively small number of children. There are ways of using reduced radiation doses in children, compared to the doses adults receive for CT. If you are concerned about this issue, ask your child’s doctor about it, or you can read more about it here.
I’ve also posted here about what medical risk means.
We have had several children lately in the PICU with concussions, and in talking with their parents I was reminded again how confusing that term can be to non-physicians. A good way to think of a concussion is an injury to the brain, nearly always a self-limited one, that produces symptoms but no objective damage like bleeding or bruising on the brain. Common symptoms include brief memory loss (often of the several minutes of time around the injury), nausea and vomiting, headache, and dizziness. Children with concussions also may have signs later of irritability, difficulty concentrating, or fatigue. It is not necessary to be “knocked out” to get a concussion.
Concussions are very common. For children, contact sports and accidents are the most common causes. In fact, twenty percent of all high school football players will have at least one concussion during their brief football careers.
There is no specific treatment for concussion other than to make sure the child does not have another blow to the head while the brain is still recovering from the first one — if that happens there can be serious consequences. Repeated concussions can cause long-standing brain damage. You can read more about concussions, especially guidelines about when it is safe for athletes to compete again, here and here.
As I write there is a looming battle between Congress and President Bush over reauthorization of the State Children’s Health Insurance Program, or SCHIP. The program ends at the end of the month unless it is reauthorized. SCHIP provides health insurance to children in families with too much income to qualify for Medicaid but too poor to afford healthcare. It is a complicated question, well reviewed in a recent New England Journal of Medicine article here. The controversy boils down to what we think the government’s role should be in providing health care to children. Most support helping the truly poor, those below the federal poverty threshold of an income of $20,650 for a family of four, but many balk at giving public money to families making as much as twice that. Another issue is that the SCHIP reauthorization bill, as with many bills, was quickly laden with extraneous add-ons.
I support SCHIP because, without it, children in families slightly above the poverty line suffer. When these children get seriously ill they will end up in PICUs like mine anyway, and if they have no insurance the government usually ends up with the bill. If these children had insurance for preventative care, they may well have not needed the expensive PICU in the first place. I would much rather see a comprehensive overhaul of our medical system, but I despair of that ever happening until the inevitable time in the future when things really do fall apart. Meanwhile SHCIP is a band-aid, but I think it is a needed band-aid.
Addendum: Here is an update–it looks as if some compromise will pass. Whether the president will sign it is another matter, of course.
Another addendum: Here is another update–a compromise passed both houses. It’s still unclear if the president will sign it.
Update: President Bush has vetoed the bill. It is unclear at this point if Congress will have sufficient votes to override the veto, but most expect that the Democrats will try to do this. They will need to attract Republicans to do so.
I’m always on the lookout for useful books to recommend to parents about their seriously ill children. It was a lack of such a book for parents of children in the PICU that led me to write my own book. But my perspective is inevitably skewed by being on the doctor side of the equation; I can’t really see things as a parent does, even though I am one myself. If you know of any particularly good books to help parents of seriously ill children I would appreciate hearing from you about it, especially why you think it is a good book.
No matter how you feel about Michael Moore, his new movie has highlighted an often overlooked issue in healthcare: many who think they have insurance find that, when they need it, their coverage falls short. I don’t think of his movie as a true documentary because he is, as usual, highly partisan in how he presents things. He is a polemicist, and opinionated polemicists are always loud and sometimes obnoxious. They are also wrong at times.
None of that matters here to me. What he has accomplished is to get this issue to the forefront, at least for a while. Even the New England Journal of Medicine is talking about Sicko; you can find a fairly dispassionate discussion about the movie here. It is a good review of the situation, and I recommend it.
For myself, I have encountered families who suddenly find their insurance contains key coverage gaps regarding what their critically ill child needs in the PICU, or at least in how reviewers at their insurance company interpret that coverage. It is difficult enough to have a child in the PICU; haggling with an insurance company over the telephone can add a crushing additional emotional burden to their situation. All parents want the best for their child, so a PICU admission is not the appropriate time to ask them to weigh the costs of a particular treatment and decide on that basis if they want it or not.
Medicaid is the huge cooperative state and federal program that pays for health care of children in lower income families. Just how low a family’s income needs to be to qualify varies from state to state. The official federal poverty line, when last I checked, was $18,400 for a family of four; some states allow a family to make a little more than that and still qualify.
Medicaid covers around a third of the children in America. One would then expect, all things being equal, that one fifth of the critically ill and injured children in our PICUs would be Medicaid patients. This is not so; about half of such children are enrolled in Medicaid. Why is that? Are poorer children over twice as likely to become critically ill as more affluent children? I don’t know the answer to that question. I do know that children on Medicaid often find it difficult to get regular medical care, meaning any chronic problems they have, like asthma and diabetes, often don’t get optimal management. This makes it more likely they will end up seeing me in the PICU when their problem gets out of control.
Whatever your political persuasion, I encourage you to find out more about this vital issue. You can find some excellent links elsewhere on this site to help you get started. The problem of how to fund health care for poor children won’t go away. It affects everyone who votes, pays taxes, and is concerned about children – in other words, all of us.
