Considering Cost When Choosing Care

Recently, I was having a conversation about the insanely high cost of health care with a friend. I believe it is unacceptable that we cannot easily look up how much a service will cost before we get it. I would never go to the grocery store, throw a bunch of items in my cart for which the price was not marked, hand over my credit card to the cashier, and agree to pay whatever grocery invoice they send me in three months.

My friend's reaction was, "No one should make medical decisions based on cost."

As a person who has made medical decisions based on cost, I have to disagree.

In an ideal world, every person could afford to undergo any necessary preventive care or medical treatment. Also, in an ideal world, the cost we are billed for care at a given facility would accurately reflect the cost and quality of the procedure or service itself. Furthermore, in this medical utopia, there would be no duplicate tests, no medically unnecessary procedures, etc. And I believe this is the world we should work towards. In my mind, everyone deserves quality, affordable health care. Period.

Unfortunately, we are currently far from this reality.

Let's start with the part about everyone being able to afford medical care. In our current society, at least half of us could not afford a major medical emergency. Many people are just scraping by paycheck to paycheck. In a 2011 research study, as reported on MSN Money, 28% of Americans said they definitely could not come up with $2,000 for an emergency given one month's time, and 22% said they probably could not. That adds up to half of all Americans who would likely be unable to pay a $2,000 medical bill (which is less than the cost of one day in most hospital beds.)

Additionally, in the current medical environment, the same services can cost thousands of dollars more at one facility compared to another, with no difference in medical outcome. And how can you make this cost comparison ahead of time? For many services, you can't. Or maybe you could, but with extreme difficulty and only if you knew how to ask each facility for the information through the proper channels. If you wanted to look up the cost of a heart procedure and the success rate of the surgeons at a dozen facilities in your area, it is likely that you would not know where to begin looking.

And if you were able to locate the information somehow, I guarantee it would leave your jaw hanging, both the sheer amount billed at all of the facilities, and the drastic differences between what is billed at each, unrelated to medical outcomes or actual costs of the procedure.

To solve this issue, my friend would likely say that the government should foot the bill for everyone. And if you believe the government can do this efficiently, let's examine the idea of what that would cost. According to a USA Today article, the average family health insurance policy cost $13,375 in 2009. Let's make a conservative assumption (given that medical inflation is much higher than regular inflation) and assume that increased 5% each year until 2012. That would bring us to $15,483 per household in 2012. Since insurance premiums are directly tied to medical costs, plus the cost of administering the program, if the government were to foot that bill, we can assume it would be at least $15,483 per household. (Side note: I am basing this one-to-one comparison of the potential government's cost with current costs on the evidence of how much it costs the government to administer Medicare Part A versus what it costs private insurance to administer Medicare Part B (the private equivalent of Part A). For the same amount of premium, private insurance carriers cover more services and have profit left over. With the same amount of money, the government can only cover the minimum required by law.) Since "the government's money" is just code for "our taxes,"  we can then assume the average household tax would also have to increase by that same amount to pay for all of the care. Of course, my friend argues that the wealthy should foot more of the bill than the poor, under a progressive tax system. I told her that's just fine, because her individual income at the ripe old age of 24 is about the same as the average household income in this country. So I put her with the elites, and she can take slightly more than her share. (According to the Wall Street Journal, median household income in 2010 was $49,445.)

I am not here to argue whether or not the government should pay the cost or whether individuals should. My only purpose with the above is to point out that medical care is very expensive. $15,000 a year is a lot to most people, whether it is paid through direct premiums or taxes. We consume a lot of care, and most people have no idea that's how much it costs, in total, to pay for the care of the average individual.

Let's examine some other aspects of the cost issue. Our "pay for play" system encourages providers to perform the maximum number of medical procedures in order to be reimbursed, not necessarily those which will provide the best outcomes for the least expense (also known as efficiency). I do believe 99.9% of doctors are genuinely caring and are making sound medical decisions. However, when there are multiple equally good options available, there is no incentive for a doctor or hospital to work for your financial benefit, except from the goodness of their hearts.

I will give you a real-life example from a friend of mine, which occurred within the last year. Let's call my friend Joe. Joe's ten-year-old son injured his arm, and Joe took his son to the pediatrician. The pediatrician told him that Joe needed to get an x-ray and pointed him to the hospital across the street. Now, being the savvy medical consumer he is, Joe asked if there were any other facilities in the area that perform x-rays, such as a freestanding radiology center, but the pediatrician did not know of any. (Hospitals usually charge significantly more for radiology procedures than free-standing facilities, even though they use the exact same equipment, because hospitals have a lot higher overhead costs compared to a smaller facility.) Since the pediatrician said there were no other nearby facilities, seeing no other option, Joe went to the hospital for his son to get an x-ray. After the x-ray, the physicians at the hospital informed him that they were not specialized enough to read the particular x-ray, as the potential fracture was very small and they could not tell for certain if it was broken. They sent Joe and his son to a free-standing orthopedic center to consult another doctor. At the orthopedic center, the doctor told him it would take a long time to get the x-rays from the hospital, but they could just run new ones on site. Since his son was in pain, Joe consented. He ended up having to pay for three different physicians and two of the exact same x-ray procedures, one at a hospital rate, when there was an orthopedist with his own x-ray machine right down the street! It is not that the pediatrician was misdirecting Joe to the hospital in an attempt to intentionally increase the cost of this incident, but even the doctor was taken aback by someone asking about less expensive x-ray options and was unfamiliar with any.

Interestingly enough, a few months later, Joe's son had a similar incident with his leg, and they were able to go directly to the orthopedic center. The end result of the care was the same, except it involved significantly less hassle at probably a third of the cost.

One example from my personal life occurred when my husband accidentally cut his arm very deeply. His hand slipped with a knife while chopping tomatoes. One look at the cut told me he would need a couple of stitches, but the bleeding was more or less under control when he held gauze firmly against the opening. I thought of the possibility of going to the emergency room, but I knew that would cost us a couple thousand dollars in this part of the country for something that neither of us considered a true "emergency." Instead, we went to an urgent care center nearby, where a doctor in the office was able to sew it up quickly. Admittedly, it wasn't cheap, but definitely less than the ER. Yet most of my friends and family would never know how much they could save with a little knowledge about the costs of various types of facilities. In this case, I did not even need to know the exact rate we would be charged to have at least a vague idea that the urgent care center was a better bet on cost, probably a much shorter wait for a non-life-threatening injury (plus it would help keep the ER clear for people who really need it), and was perfectly capable of handling the issue.

Another example involves a time when I was not so savvy and later regretted it. When I moved to California, I went to a new gynecologist for the first time. She asked me if I wanted my pap smear to include testing for a whole slew of sexually transmitted infections. Since I have insurance, I figured most of the cost would be covered, and I consented. A few months later, my portion of the lab bill came in the mail, and it was over $400! Yes, my insurance helped, but what was left for me was still a pretty large number. Thankfully, I had been putting money into a Health Savings Account and was able to pay. But had I been one of the 50% of Americans who could not come up with $2,000 for an emergency, I have a feeling $400 would have been quite a hit.

And in retrospect, faced with the $400 balance, I strongly regretted getting the tests. I am married, with no past history of abnormal tests. I am my husband's only partner. The likelihood of me actually having one of those infections was virtually nil, yet I paid $400 to confirm that. I felt as silly as if I had paid to have an x-ray to confirm my arm is not broken, when I have not had any falls and I have no pain. Yikes! I definitely would have taken the cost into consideration when making that decision, had I known what it would be.

If someone else were in my situation, I would now recommend not to get the tests. If the person had lesions or bumps or itching or any other symptom of a particular STI, then that would be a totally different story, and I would tell them to get tested. In that case, I would definitely agree with my friend that it would be a tragedy to have to choose otherwise due to finances. But when someone is as low risk as I am, there is no reason to throw money down the drain - yet I did not even have enough information to make that choice.

Not only that, but had I really needed those tests, there are still ways I could have gotten them for less. In particular, I could have asked my physician to redirect the interpretation work to a freestanding lab, such as Quest, rather than letting the affiliated hospital process them. As mentioned above, an educated consumer should be aware that most things cost more at a hospital.

As a follow-up to that, the latest revised clinical guidelines for pap smears say that a woman over the age of 21 with one partner only needs to be tested once every three years for cervical cancer. I am married, I have never had an abnormal pap, and no one in my family has ever had cervical cancer, to my knowledge. So I do not want to pay for this service every year, when that frequency is outside of clinical recommendations. Not only is it costly; it's also unpleasant. Yet when I told my gynecologist's office that I just wanted a visual exam and my vitals tested in lieu of a pap smear at my upcoming annual exam, the administrative personnel had to go ask around the office "if they can do that." Of the first several people she asked, no one seemed to know, until finally a nurse said it was fine. This is at an office that specializes in women's health! Apparently, no one has ever asked not to have a pap smear every year. Even if my insurance covered the exam in full, nothing is really free. That would be a cost that gets spread across the insurance premiums of all my coworkers the following year (including my own premium.) Now if my doctor had advised me otherwise or thought I was higher risk, I would have taken her educated recommendation over my own. But just a little bit of knowledge about the clinical guidelines from mainstream media (and a push from that $400 bill the previous year) opened up my eyes to ask about what is necessary, and it turns out she agreed that this service is not. Yet had I not taken initiative to ask, the default would have been to provide the testing.

If I was shocked and upset with that $400 invoice my first year, I can only imagine how I would feel if I was in a more sticky place financially. For many people, receiving an unplanned $400 bill in the mail would be devastating. No one should ever be put in that position, where the cost of care is a surprise to them and puts them in a place of hardship. I do understand the argument that it is morally wrong to deny care to someone due to socioeconomic status. I do believe everyone deserves high quality care as a basic human right. I believe that someone facing an illness should get the care they need, regardless of their ability to pay. And I hope to spend much of my life working towards those changes in our society and our health systems. But based on the reality of the current system, which does not do this whole coverage thing perfectly, I also think people should know ahead of time what sort of bill they can be expecting.

Whereas my friend would say that "no one should make a medical decision based on cost," I would revise her statement to the following:

No one should be denied medically necessary care based on their ability to pay. But also, every consumer should be aware of lower cost options that would offer equivalent care, such as generic versions of drugs, or freestanding radiology, laboratory, and ambulatory surgery centers, when they are available. And every person should be informed of the price of their medical care before they consent to incur the costs. No more surprises.


Photo credits:

• https://secure.consumersunion.org/site/SPageServer?pagename=CRH_pledge
• http://blogs.scientificamerican.com/observations/2011/01/12/cost-of-cancer-care-projected-to-jump-nearly-40-percent-by-2020/

Friendships for the Ages (and Your Health)

Two of my closest friends in the world are visiting me in California this weekend. Sara will be flying all the way from Massachusetts and Pam all the way from Virginia! In honor of their visit, I wanted to write a brief post about friendship and health.

As it turns out, having a complex social network is significantly linked to lower mortality rates. According to a 2010 article in Forbes, researchers from Brigham Young University conducted a mega-study (by combining the results from multiple other studies) and found that those with adequate or high social relationships have a 50% greater likelihood of survival in a given time period than those who are more isolated. Some of the highlights of the study show that, in terms of mortality, low social interaction is:

• as bad for your health as smoking 15 cigarettes a day.
• as dangerous as being an alcoholic.
• as harmful as never exercising.
• twice as dangerous as obesity.

Wow, those are pretty striking comparisons! And it's not just about having one solid friend. Those individuals who have more complex networks, including family, friends, neighbors, coworkers, and such, are better off in terms of health than those who do not engage with such an elaborate network.

Just this week, I read an article on CNN that links living alone with depression. In a seven-year study of 3,500 men and women, among those who lived alone, nearly 25% filled a prescription for an anti-depressant, compared to just 16% of people who lived with a spouse or roommate. Of course, this brings up the question, does living alone lead to depression, or are people who are already more likely to become depressed also more inclined to live alone? I would imagine that the answer is likely a bit of both. Although the study did not show specific causation of depression from the solitude, it seems to correspond, at least in part, to the above article about lack of complex social networks posing a health threat.

An article in the New York Times describes other effects of friendship. One particularly interesting study placed University of Virginia students at the bottom of a steep hill with heavy backpacks and asked them to estimate the steepness of the incline. Some students were placed next to friends and others were placed alone. Those who were next to friends estimated the hill to be less steep, and the association was stronger the longer the friends had known each other. (And how appropriate, since Pam, one of my two friends coming this weekend, went to University of Virginia, where the study was conducted, and has been in my life since first grade. I bet that hill would look like a valley to us! I have known Sara no short time, either - since one fateful day in sixth grade.)

In the training to become a Court Appointed Special Advocate (CASA), I learned that lack of a strong social network for a parent is one potential predictor of child abuse. Raising children is stressful and confusing for many parents. Having the emotional, sometimes financial, and even babysitting support of family can ease the burden of the constant stressors or prevent a parent from feeling pressured to leave a young child alone in order to attend work or run errands (which would constitute child neglect). Having close friends can help an adult stay connected to the outside world and remain emotionally stable. In addition, social contacts can act as accountability partners, guiding and correcting behaviors, or pointing parents to appropriate support agencies and resources, if necessary, while sharing life together.

There are a host of other studies which tout many of the same or similar statistics. Friendship changes our risk of heart attack, depression, death. Friendship helps us rebound from trials. Friendship changes our attitudes and enhances our hope for the future.

I know this firsthand, as I have ridden many ups and downs of life with those who are closest to me. I have had some very dear friends turn me away from the most destructive habits and idols in my life, and I thank God daily for putting them in my path to radically change me. I have made many mistakes that have been deeply hurtful, and my true friends have shown me the strong power of forgiveness. I have received many hours of counsel from the wisdom of those who care about me and have done my best to support them in their times of need, as well. I have been blessed with fun and laughter through friends found in a new place and have felt myself deeply connected to a town where I thought my heart would have no ties. I have no doubt that having these incredible men and women in my life has transformed my journey, character, and outlook. Where would I be without them?

So today, I just want to say that I am thankful for my friends. The statistics confirm what I have known all along. Friends are good for my health!

Unanswered Questions: Baca Ortiz

What is the best thing for an under-funded hospital to do with the little money it receives? This was the question I first asked in 2007, when I was studying abroad in Quito, Ecuador. And I still do not feel that I have a suitable answer. This post is more of a description of my despairing feelings than an offer of solutions. I know that many readers do not like such a lament. But I truly don't have an answer. My hope is that this will at least cause others to ask the same questions, and perhaps it may even inspire a spark of innovation to find an answer.

During the fall of 2007, I had the chance to visit Baca Ortiz Children's Hospital in Quito, the premier children's hospital in the country. It is very difficult to find specific information about the hospital, so I have scraped up what little I could locate to provide a general picture. According to "Volunteers Abroad," Baca Ortiz was founded July 14, 1948. Approximately 140,000 children are treated at the hospital annually. Families come from around the country to the facility, because it offers specialized treatment that is not available in other regions.

The hospital has a paid staff of doctors and nurses, as well as a number of volunteers with a range of skills, from medical professionals, to individuals who visit with the children, to those who help fund raise for the most needy families.

Although Baca Ortiz receives funds from the government, it is significantly under-funded, and families are therefore required to pay for the treatment they receive at the facility.

Based on the accounts of my friend who volunteered at Baca Ortiz regularly and based on the information I received during my time there, the facility itself has so few resources that it cannot stock basic supplies, such as soap, toilet paper, bandages, or medicine to keep on-hand, unless these happen to have been recently donated. If a child is admitted to the facility, his or her family is responsible for providing soap, toilet paper, and other supplies for the child's room. If the child requires any sort of treatment, the family has to go to a local pharmacy and purchase bandages, sterilized surgical instruments, oxygen tubes, anesthetics, sanitizing agents, antibiotics, etc. There is no surplus to have these items readily available.

For many families, this simply means going without sufficient treatment. According to the CIA World Factbook, 33.1% of Ecuadorians live below the poverty line. Many more make enough to be deemed above the line, but are underemployed and still struggle to provide for their families on a daily basis. Additionally, income disparities are extremely pronounced between various regions of the country and between different racial groups.

Families are also provided meal tickets to eat in the hospital's cafeteria a certain number of times per week. For some, these are the only meals they will eat at all due to general poverty or due to the costs of traveling to the hospital and paying for treatment. However, my friend who volunteered handing out meal tickets told me that she frequently ran out before every family had received their share, as the hospital was extremely over-crowded (see the image of children being treated in the hallway on the right due to room shortages) and had a very limited budget to prepare a certain number of meals per week.

Some families have little hope of paying for treatment once they have received a diagnosis, and they go home without assistance. Others may gain funding through organizations that donate specifically for their treatment, such as The Mashi Foundation, which used social workers to identify ten children of highest priority and funded the surgeries for those children in 2010. Assuming that 33.1% of the 140,000 children who visit the hospital in a given year are impoverished, as is the case with the general population, that would be 46,000 impoverished children who come through the doors. Ten funded surgeries is an amazing thing, but it is astonishing to realize that the figure represents only 0.02% of children who are likely too poor to afford treatment at Baca Ortiz. My understanding is that such donated funding is sporadic, at best. Since the need for this type of financial intervention is so overwhelming, the situation is quite desperate and the poorest may never obtain the assistance they need.

After visiting Baca Ortiz, I felt disheartened and confused. Where should the hospital direct its scarce resources? Medicine for those who cannot otherwise purchase it, without which children will suffer from pain or parasites, possibly die from cancer or even treatable infections? Soap to prevent the spread of infection throughout the facility? (It was hard for me to imagine how a hospital functions without having medical supplies on hand, never mind free access to soap? The basic act of washing one's hands is crucial to the prevention of infection, yet some families have to choose between sanitation and medication.) What about meals for those who would not be able to afford a stay without the provision of this sustenance? Without the meal tickets, many families would not only be unable to afford treatment, but could not visit at all due to the extreme hardship it would pose.

I would be interested to hear if you know have ideas about how the hospital can best use its funds. What are ways this conundrum is being addressed in other nations? What has been proven to work? Do you have any novel ideas yourself?



Photo Credits:

• http://www.panoramio.com/photo/48910858
• http://www.trhf.org/Default.aspx?pageId=443933
• http://www.lahora.com.ec/index.php/noticias/show/1101273997/-1/M%C3%A9dicos_despedidos__a%C3%BAn_sin_reemplazos.html
• http://www.ecuavisa.com/index.php?Itemid=96&id=12943&option=com_content

Chocolate to the Rescue

Since I love chocolate so much, I thought it would be fun to explore the health benefits! Not that I'm trying to justify my actions or anything....

As it turns out, chocolate, in moderation, has some of the same properties as red wine. Chocolate is high in flavonoids, a type of antioxidant which may combat aging and heart disease. According to an article on About.com, dark chocolate is eight times as antioxidant dense as some of our favorite fruits, like strawberries. (For more information on antioxidants, which are frequently classified as phytonutrients, check out the first blog post I ever wrote.)

The Cleveland Clinic says that the main types of flavonoids in chocolate are called flavanols, and these have been shown to lower blood pressure and LDL cholesterol. The About.com article mentioned above also says that the affect on LDL cholesterol may be as high as a ten percent reduction! As you may know, when LDL cholesterol oxidizes, it tends to build up and stick to your arteries. In that case, it can block the way for blood flow and increase the risk of heart attack or stroke. Some of the substances found in chocolate prevent the LDL cholesterol from oxidizing (hence the term "antioxidant"), which helps stop the build-up. According to a Huffington Post article, "Research performed at the department of nutrition at the University of California, Davis, found that chocolate thins the blood and performs the same anti-clotting activity as Aspirin." As you may be aware, Aspirin is often prescribed in low doses as a blood thinner for individuals at risk for heart disease. Harvard Medical School also reports that chocolate has been linked to lower levels of C-reactive protein, a marker for inflammation.

Not only does chocolate affect blood flow, but it has also been shown to elevate mood! Chocolate stimulates the production of endorphins, the same chemicals that make us feel happy when we exercise. Chocolate also contains serotonin, which acts as an anti-depressant, in addition to a variety of stimulants, such as theobromine and caffeine. In fact, the Huffington Post article stipulates that the serotonin in chocolate may be a partial explanation for why women crave chocolate during PMS and menstruation, since their natural serotonin levels are typically down on those days.

Despite these health effects, the research comes with a caution! According to the Cleveland Clinic, not all forms of chocolate provide equal benefit. The flavanols naturally found in cocoa are also largely responsible for the bitter taste of unsweetened chocolate. The more cocoa is processed to make the palatable goodies we enjoy, the more the flavanols are depleted. While nearly all of the websites I found agree that dark chocolate contains the most flavanols, the Cleveland Clinic states that recent research shows the level of flavanols is not universally consistent in dark chocolate, as it depends on how the dark chocolate was processed (fermentation, alkalizing, roasting, etc.) Nevertheless, dark chocolate or non-Dutch processed cocoa are typically much better bets than milk chocolate. (So I guess all those years of loving dark chocolate weren't just a result of strange taste in flavors; I was being healthy!)

Many people may worry about the high fat content in chocolate. Interestingly enough, there are three main types of fat in chocolate, each found in about equal proportions, and they are not all considered harmful. According to both About.com and the Cleveland Clinic, one of the fats is called oleic acid, which is a healthy monounsaturated fat that is also found in olive oil. The second is stearic acid, which is a saturated fat, but research has shown this particular fat does not adversely affect cholesterol. The third type is palmitic acid, which is one type of saturated fat known to contribute to higher cholesterol. So the good news is, only about 1/3 of the naturally occurring fat in chocolate is bad for you!

A lot of the problems come in with the ingredients we add to cocoa. Milk chocolate, in particular, typically has added butterfat and significantly more sugar, both of which are linked to a variety of health concerns. And even dark chocolate can be made significantly less healthy by adding caramel, nougat, marshmallow, and other ingredients. These unhealthy additions typically outweigh the benefits of the chocolate itself. Furthermore, consuming a king-sized candy bar is not going to help your heart health. The ideal serving size to maximize the benefit of chocolate is one to three ounces a few times per week. And remember that even healthy chocolate has calories. If you add chocolate to your diet regularly, you may need to exercise more or cut out an equal number of calories from another meal or snack to maintain a consistent body weight.

So the lessons seem to be: enjoy chocolate for the healthy benefits it provides, savor each bite for the delicious flavor, and consume in moderation. Mmmm, chocolate!


Photo credit: http://experiencechocolate.com/

Fotoshop

As a follow-up to my post on obesity and physical appearance, I wanted to share a video that sheds a humorous bit of light on the beauty expectations of our culture. It made me laugh and think! I hope it will do the same for you.

I came across this video while reading a very interesting article on CNN about activists who are challenging popular notions of beauty. A similar theme to the above satire pervades a short film, made by Dove, to show the transformation from natural beauty to makeup model.

As I discussed in my commentary on childhood obesity and appearance, I do believe that the media shapes our sense of what is desirable, and even our concept of what is "normal." Children are especially vulnerable to having their expectations and opinions shaped. Even subtle advertising can make a difference when we consider how often we see the same message day after day. After a lifetime of exposure, it would be naive to assume we don't soak in anything from what we see, hear, and read.

For those who are skeptics, consider this passage from "Cinderella Ate My Daughter," by Peggy Orenstein (pg 17). "...Even can-do girls can be derailed - and surprisingly quickly - by exposure to stereotypes. Take the female college students, all good at math, all enrolled in advanced calculus, who were asked to view a series of television commercials: four neutral ads (showing, say, cell phones or animals) were interspersed with two depicting cliches (a girl in raptures over acne medicine; a woman drooling over brownie mix). Afterward they completed a survey and - bing! - the group who'd seen the streotyped ads expressed less interest and math- and science-related careers than classmates who had seen only the neutral ones. Let me repeat: the effect was demonstrable after watching two ads. And guess who performed better on a math test, coeds who took it after being asked to try on a bathing suit or those who had been asked to try on a sweater? (Hint: the latter group; interestingly, male students showed no such disparity.)"

I encourage you to read the CNN article that led me to this video and other pieces about similar topics. Consider how advertising is affecting our lives, from one math test (per the studies mentioned above) to career opportunities in general, from distorted self-image to unhealthy dieting, from peer relationships in the classroom to expectations in our dating and spousal relationships. All of these aspects of life are profoundly related to our mental, emotional, and physical health.

I hope that being even slightly more aware of how these messages affect us will change both our decisions about the images we choose to allow into our minds and the way we interpret the advertising we do take in. If enough people react against the practices of our media culture, the advertisers will have no choice but to take notice!


For more information on this video, check out Jesse Rosten's website: http://jesserosten.com/2012/fotoshop-by-adobe

Santorum, Snobbery & Schoolin'

I was recently lamenting to my friends that sometimes I wish this were a blog about politics so that I could rant and rave about the lunacy being spewed by the current presidential candidates. Then I decided that I could find a health-related theme for the subject about which I would like to rant as an excuse to do it anyway. So here goes my rant about Santorum's infamous recent comments about higher education.

Let me start by saying that I am registered as a political independent. I have voted for members of both parties, and it is rare that I agree with either party 100% on an issue. But on this particular issue, I don't see much room to argue with Obama. I know full well that education makes a difference, not only in lifetime earning potential, but also in human health!

For those who haven't heard yet, Rick Santorum called Obama a "snob" for reportedly "saying that everyone should go to college." This was hard for me to believe, but here is an actual video of the speech in Michigan.

Of course, after hearing such a strange insult to our president, I decided to find out what Obama actually said. According to a Politico article, the quote was, "I ask every American to commit to one year or more of higher education or career training. This can be community college or a four-year school, vocational training or an apprenticeship. But whatever that training will be, every American will need more than a high school diploma."

It's hard for me to see how this quote translates into liberal snobbery mandating that everyone must attain a degree. That is clearly a limited and disingenuous reading of what was said. Obama was discussing the fact that increasingly, we are competing globally with countries who are focusing on education. Years down the road, it may become more and more difficult to find a job with only a high school diploma. This is not to say that people who do not go to college are somehow less important, not hard working, or otherwise bad. It is simply to state the fact that job prospects are better for those who attend some form of higher education, and this is becoming more true with each generation.

Consider the current economic issues in our country. According to the Bureau of Labor Statistics, the average unemployment rate in 2010 was 8.2%. However, among those with a bachelor's degree (and no master's) it was 5.4% compared to 10.3% for those with only a high school diploma.

One article I read in the San Francisco Chronicle said that the median annual pay of those 25 years and older with a bachelor's degree is $56,472. That is 70% higher than those without a diploma. That means a person with a college degree may individually earn about the same as the average household income (presumably a measure of the total earnings of multiple persons living together) in our country. According to the same article, 30% percent of adults now hold college degrees, and 94% of parents with children under age 18 expect their children to go to college.

Now to be fair, I do think there are people who are prejudiced against those of a different social class or education level. It's great to speak out against that sort of intolerance. And I agree with Santorum that there are plenty of hard-working people at important jobs without one minute of higher education. I think many Americans, especially in small towns across the nation or in manufacturing centers like Detroit, would echo sentiments of pride in their communities, regardless of the average education levels in the areas. It is even true that some people have gone on to make millions without a degree (Bill Gates, for example - and for him, it was billions). As the Montgomery Gentry song, "Where I Come From," says, "That old man right there in the rocking chair at the courthouse square - I'll tell you now he could buy your fancy car with hundred dollar bills. Don't let those faded overalls fool ya'. He made his millions without one day of schoolin." Pride in your job and loyalty to your friends and family of all social classes are beautiful things. I agree wholeheartedly that education does not make one person better than another. The idea that our worth as a person is not determined by our social status, income, or level of education resonates strongly with my understanding of humanity. Amen to equality before God!

But the fact remains that statistics show average quality of life increases with higher education. No, that does not mean for every person every time. It means for most people most of the time. And I do not in my heart believe that Obama is among the ranks of the socioeconomically prejudiced for acknowledging this. I find it especially improbable that there is much truth behind the accusations of elitism given that Obama's life before running for Congress involved working with residents in the south side of Chicago.

Santorum also berated higher education for "indoctrinating" young people into liberalism. I would agree that there is a left bent in higher education as a whole, but there are a few things to point out here. (1) Not every professor holds the same views. (2) If conservatives do not obtain higher ed degrees, then they cannot become professors. So it stands to reason that if Santorum sees a problem of disproportionate representation among college faculty, he should be encouraging more conservatives to get degrees, not fewer. Hey, if there were enough of them banded together, they could even start new colleges. (3) As my husband intelligently pointed out to me the other day, colleges not only produce liberal thinkers, they also produce deeper conservative thinkers who are able to counter balance the arguments of liberalism. Without a strong understanding of politics, philosophy, economics, and the like, it is pretty difficult to make a believable case against an expert in one of those fields. Please do not mistake me for saying that education is the sole predictor of good ideas. That is certainly not true. But how does Santorum intend to fight "elite leftist" ideas if he has not also read the same texts, analyzed the same arguments, etc.? How can a person condemn a book he or she has never seen? How can an individual make a point against a philosophy he or she has never heard? We need more thoughtful thinkers of all political persuasions, not fewer.

So you may be wondering what this has to do with "mind and body musings?" Well, I found something that clearly justifies this entire rant! Education is also a predictor of....drum roll....health! According to the National Poverty Center, better educated people have lower morbidity for many chronic illnesses and higher overall life expectancy. The NPC also states, "Health behaviors alone cannot account for health status differences between those who are less educated and those who have more years of education."  The policy brief I read suggested that some likely contributing factors to the health gap are complicated relationships between education and family background, effects of poor health in childhood, greater resources associated with more education, a learned appreciation for positive health behaviors, and social networks, among other mechanisms.

As I discussed in a previous blog post, education is also related to health literacy. To reiterate some of the statistics from that piece, the National Assessment of Adult Literacy targeted a portion of its latest assessment using health care related questions. The study found that among adults who never completed high school, approximately 49% had below basic health literacy, compared to 15% of adults who completed a high school diploma with no post-secondary education and just 3% of adults with a bachelor's degree. Low health literacy can inhibit someone's ability to read health pamphlets, follow medication instructions, make medical decisions when caring for a loved one,  understand post-operative instructions, or complete other similar tasks.

In another related post, I described some of the connections between food insecurity and obesity. Since food insecurity is a socioeconomic issue, and lack of education is a predictor of lower earnings, these problems are a likely link between education and health. Some of the issues I discussed in more detail in that post include fewer full service grocery stores in lower income neighborhoods, lower quality produce, a greater prevalence of fast food, fewer parks or recreation centers, and less access to health care, among other concerns.

I believe that Santorum was misguided in his Obama name-calling on the higher education topic. He was speaking to a crowd in Detroit, and it seems likely to me that he was catering to his audience. I'm not even going to get into Santorum's campaign goals from past years related to higher education (but please do Google the topic - he used to think college was a good idea). Suffice it to say that a quick glance at Santorum's own life and credentials makes it clear that his education got him where he is today and that he intends to provide the same for his children (just like 94% of parents hope for their own kids, as mentioned above).

As LZ Granderson of CNN put it, "Granted, some of us are gullible enough to give each other high-fives because Rick Santorum called Obama a snob for promoting a college education. But the rest of us look at 'Slick Rick's' college degree, law degree and MBA, and the fact that he's sending his kids to college and owns at least six properties, and has earned millions, and wonder - What is he talking about?"

I have been wondering that myself.

The Obesity Epidemic and Physical Appearance: The Heart of the Matter

"The LORD does not look at the things man looks at. Man looks at the outward appearance, but the LORD looks at the heart." ~1 Samuel 16:7b

You may have heard about the Georgia campaign against childhood obesity that has started a major conversation around the country. Many bloggers seem to have opinions about the controversial ads. Since I have written several posts related to childhood obesity, I thought I should chime in, as well.

To put it bluntly, I don't like the ads. I find them offensive and unhelpful.

The ads feature pictures of overweight children with captions like, "It's hard to be a little girl if you're not." They were intended to grab the attention of passers-by and to get a conversation started. As I mentioned in my post on Childhood Obesity and Food Insecurity, the organization that ran this campaign, Strong4Life, conducted a study which showed that 75% of parents of obese children in Georgia do not think their child has a problem. So start the conversation they did, by thrusting all the negative stereotypes of obesity even more directly in the faces of the public.

My main gripe with this ad campaign is that it fuels the negativity about physical appearance with which overweight children are almost certainly already bombarded on a regular basis.

Now don't get me wrong. I do think childhood obesity is a serious problem. I think doctors need to be straight with parents. I think parents need to come to grips with reality. And I even think it's ok to discuss your child's weight problem with him or her under most circumstances. But I do NOT think it is ok to make this an issue of physical appearance.

While the ads may have aimed to show many effects of obesity through their captions, the message they sent loudest of all was, "See the image of this body? It is not acceptable. And you need to fix it."

I believe the appropriate way to address the issue of childhood obesity is from the perspective of the health and lifestyle effects of carrying excess weight. This focus shows concern for a person's well-being, not critical or self-righteous judgment.

The Health Consequences

According to the Centers for Disease Control and Prevention (CDC), in a study of five to seventeen year olds, 70% of obese youth had at least one risk factor for cardiovascular disease. Obese adolescents are more likely to develop prediabetes, a condition of elevated blood glucose that can lead to type II diabetes. According to the Mayo Clinic, type II diabetes itself, which used to be called "adult onset diabetes," is growing in prevalence among children, largely due to the obesity epidemic.

The CDC also states, "One study showed that children who became obese as early as age 2 were more likely to be obese as adults....and are therefore more at risk for adult health problems, such as heart disease, type 2 diabetes, stroke, several types of cancer, and osteoarthritis."

The Lifestyle Consequences

Not only does a high Body Mass Index put children at risk for chronic disease, but it may inhibit them from participating in activities they do (or would) enjoy, such as sports, dance, music, and theater, which often require stamina and endurance that may be limited by excess weight. For a young adult, obesity may even affect his or her stamina or self-confidence in sex. (Now that's a good reason to get fit, right?)

Where The Ads Went Wrong

Unfortunately, the negative effects of obesity don't end there. Obese children are more likely to be bullied or to experience depression. Obese adults are more likely to experience discrimination on the job (as often as racial discrimination, according to one study, and possibly more often than age or gender discrimination).

And this is where I think the Georgia ads get the issue wrong. While I think we should be campaigning to "change" obese people for the benefit of their physical health, longevity, and a better lifestyle, I think we should be campaigning to change ourselves for the problems that result from discrimination based on physical appearance. Judging anyone by physical appearance is not a problem with the person being judged; it is a problem in our own hearts and minds. Sure, some people's appearances may be a clue as to what is going on inside their heads or hearts, but this is not a universal truth. No person's worth is based on his or her appearance, and we should not perpetuate that myth ever.

To tell our children that we agree with the world's judgement that worth can be based on appearance is a tremendous mistake. To love someone despite their imperfections is not the same as tacit approval of their every choice. It is the nature of love itself.

Some will say that obesity is lethal, so we should go to extremes to curb or prevent it, even if it means hurting someone's feelings. I would agree that a little hurt feeling in the context of an intentional and caring conversation about health is well worth it. But in my view, to bring appearance into the conversation is not simply about a little hurt feeling; it may impose long-lasting damage. It is beyond a mere temporary pain when we tell a person, with a mind and heart, that our love is contingent on a particular physique. Appealing to a child's vanity may provide short term success, but it ultimately sets the child up for long term problems. To shame a child into losing weight is putting a skewed view of personal worth on a pedestal and sacrificing the ultimate mental health of the child in order to serve the false god of physical perfection.

The Media Has The "Judgment" Thing Covered

Children are already besieged by an unending stream of messages about their physical appearance.

I recently read a book called, "Cinderella Ate My Daughter," by Peggy Orenstein. While I lamented the disorganized and desultory nature of the book to my book club friends and thought the author made some grand leaps of logic, the overarching theme of the work stuck with me. Children are exposed, almost from birth, to a plethora of marketing images that tell them they need to fit into a specific mold. For girls, this mold largely leads to the conclusion that to be cool and accepted is to be "hot." A woman's worth comes from her physical appearance.

Anyone who watched the Superbowl ads will likely recall the GoDaddy segments featuring scantily clad women enticing the watcher to go to GoDaddy.com to "see more." I would not have known that this is a domain name registration site had my husband not told me. Photographers secretly take pictures of every inch of cellulite on an actress at the beach and enlarge the images for the covers of the magazines we see in the grocery store. We even grow up watching soap and deodorant commercials that tell us if we buy the product, we can look like the model.

I am pretty sure I get the point already. My cellulite is not acceptable, my breasts aren't perky enough, and I would never be called beautiful by a major news outlet.

For a kid being exposed to this constant marketing, the idea that certain body types are more valuable may become deeply ingrained. This can lead to bullying (by the kid who thinks others are unacceptable) or a sense of shame (for the kid who thinks he or she is the unacceptable one). In some cases, both lines of thinking may be at work in the same child.

One Piece of Evidence: Eating Disorders

It's all well and good for me to say that this is having a negative impact on obese children (and on all children, really), but what is the evidence?

I submit that one important signal of the impact is the growing prevalence of eating disorders among youth. According to a study published in the American Journal of Preventative Medicine, as cited by the National Eating Disorder Information Center (NEDIC), girls who reported body-based teasing by family members were 1.5 times more likely to engage in binge eating and extreme dieting behaviors five years later. A Canadian study also cited on the NEDIC site showed that 37% of girls in grade nine and 40% of girls in grade ten wished they were thinner. Even among those considered a healthy weight based on BMI, 19% believed they were too fat and 12% reported attempting to lose weight.

According to the National Eating Disorders Association, the number of young women aged 15 - 19 diagnosed with eating disorders has risen every decade since 1930. But it is not only teenagers who are affected. Psychotherapist Abigail Natenshon was cited in a recent Parenting magazine article as saying that "the average age for the onset of anorexia used to be 13 to 17. Now it's 9 to 12, and children as young as 7 have been diagnosed." In this same article, I learned that 10% of adults with eating disorders showed clear symptoms before the age of ten, and more than 60% of elementary and middle school teachers report that eating disorders are a problem in their classroom. Did you read that? Elementary school! In a 2010 article from Health Day, I learned that the Agency for Healthcare Research and Quality found that hospitalizations for eating disorders jumped 119% for kids under age 12 between 1999 and 2006. 

 Not only that, but anorexia has the highest mortality rate of any mental illness. The South Carolina Department of Mental Health website cites a study conducted by the National Association of Anorexia Nervosa and Associated Disorders, which reported that 5 - 10% of anorexics die within ten years of contracting the disease, 18 - 20% within twenty years, and only 30-40% ever fully recover. Other sources show lower numbers - the ANAD website itself now says that the American Journal of Psychiatry (2009) concluded that the ultimate mortality due to eating disorders is 4% for anorexia nervosa, 3.9% for bulimia nervosa, and 5.2% for eating disorders not otherwise specified. One of the reasons the statistics may vary between sources is that deaths related to eating disorders may be recorded under other causes, such as heart failure. Regardless, anorexia still stands at the top of mental illness mortality.

My Take

While it is important for us to recognize and address the growing obesity epidemic in our country, it is also worthwhile to pay attention to the unintended consequences of the strong rhetoric around the issue. At the same time obesity rates are growing, so are those of eating disorders and unnecessary dieting among youth. And this is only one of the potential problems that arise with such a strong focus on physical appearance. There are undoubtedly countless other emotional, relational, and even physical effects.

By not telling obese kids that they look "different," we are not hiding the truth from them. Many children who are overweight, and even many who are not, are already keenly aware of how their bodies are being scrutinized. The magazines they read, the television ads they see, the kids who bully them, the employers who don't promote them, are all sending them that message already. It's true that some parents and kids need a wake up call from a medical professional telling them they are on an unhealthy path. But the message we need to send is to take care of your body, for your own health's benefit, for the enjoyment of life, and for the sake of the work that God has for you in your time here.

Who you are and your personal worth as a human being are not based on how you look. 

Period.