Because the protein nanoparticles are specific to the T-cells that are overly aggressive in destroying beta cells, the vaccine doesn’t appear to harm the other T-cells that keep our immune system healthy. And, it’s possible that this therapy can be tailored to other immune-related diseases beyond diabetes.

JDRF, the Juvenile Diabetes Research Foundation, supported this research. This is why I support them and why I hope you will donate to JDRF, too.

Combine this with some other recently reported research that alpha cells in the pancreas spontaneously become beta cells when the latter are deficient, and you have what we’ve always wanted: a cure for diabetes. I’m being cautious, since nothing has been tested in humans — even at a very basic level — and the process of converting from alpha to beta capabilities is described as “slow.” Still, this is what gives me hope that some day type 1 diabetes will be a thing of the past. . . . Some day soon, I hope.

As a precursor, consider Eric Dishman’s TedMed talk about “moving healthcare off the ‘mainframe.’”

In a nutshell, when people do free association with “healthcare,” this is what they say:

1. Doctor
2. Hospital
3. Illness, sickness, disease

Dishman says this is the old “mainframe” model of health — a model based on reactive, crisis-driven, population-based treatment. Instead, he says (and I agree) that we should focus on a “personal healthcare paradigm centered on the home,” especially for our aging population. This new model would be proactive, pervasive and personalized and would be based on more than just biological lab data.

That sounds very much like what I would like to see in a diabetes solution.

Here’s an example from an an outpatient department from a real hospital* providing more or less the same billable health education service for each patient. The hospital dealt with 25 different insurers. The average payment for each of the roughly 2000 cases was $88.50. One private insurer paid as little as $46 per case, while another paid $146. Medicare provided $89** per case, and Medicaid reimbursed $183. Payments for all of the other cases were somewhere in between, mostly below the average cost . . . except for the smallest payors, who had an average payment of over $278. That’s more than three times the average cost!

Certainly the Medicaid patients aren’t getting $94 more service per case than Medicare patients. And it’s definitely not fair to the patients paying $278 per visit for a half-hour of medical education. Furthermore, I doubt that the hospital would let the department continue to provide its excellent service if it were only getting $46 per patient.

Why is there such a disparity in reimbursement? For one thing, insurance companies can’t collude with each other or with hospitals to say, “We’ve all decided to give you $88.50 per half hour of this kind of medical education.” (But all of the insurers know how much Medicare will pay, so there’s some kind of sharing anyway.)

Beyond regulations to encourage competition, I actually don’t know why there’s such a large difference. I hope that if you know you can tell me. Honestly, I’d love to know more about this. Leave a comment.

* — I haven’t been given permission to say which hospital or which department.

** — Medicare was only about 1/7 of the cases, so it’s not artificially affecting the average payment.

But I have to mention the letter from Rep. Richard Neal (MA-2) that arrived in the mail today. About a month ago, Lisa — my lovely wife and the sobering yin to my raging yang — took my angry rant, gave it focus, and made it more moderate and constructive. We sent a copy to each member of our congressional delegation in the hopes that it would convey some public support for reform. This was the first time I’ve actually sent a letter to a representative or senator, though I have sent some e-mails and made a phone call.

I honestly didn’t expect to hear back from anyone, and we were both really excited to receive a letter that showed that Mr. Neal (or someone on his staff) actually read our letter and took the time to write a personalized, non-form letter back to us after the legislation passed.

Anyway, that’s enough self-indulgence — for now, at least.

Atul Gawande proposes a solution for all sorts of endeavors in his book The Checklist Manifesto: How to Get Things Right. It’s a short, engaging read, and I recommend it for anyone who has to apply knowledge to complete a task. That’s most of us.

We use checklists and recipes in some of our software development processes, and I’m in the process of applying what I’ve learned to improve them. I hope to share some of the results here in coming months — supposing that the final product isn’t too site-specific — but in the meantime, here are my more-or-less raw notes from Gawande’s book, which isn’t specific to any particular industry, although it was written from a surgeon’s perspective.

• Checklists are all about managing complexity, providing a “cognitive net” against “flaws of memory and attention and thoroughness.” They are “forcing functions . . . straightforward solutions that force the necessary behavior.” A good checklist should help its users “get the stupid stuff right.”
• The project plan is a kind of checklist. And the communication (submittal) schedule is a complexity manager. The idea is to communicate what needs to happen when in a complicated process (like building a skyscraper, writing software, or operating on a patient) and having a process in place to ensure that all of the parties in the project have shared all of the information about changing requirements and problems available at specific times.
• It’s possible/advisable to use tools to manage complexity, conflicts, and information integration. Sometimes the result of using the tool looks like a checklist, but not always. Sometimes it’s a Gantt chart or a cook’s recipe.
• The checklist steward: Anybody can change a checklist, but it has an owner who feeds and waters it.
• Complex situations don’t (usually) require detailed instruction. They do require high-level goals and lots of communication. (Gawande gives the fascinating case study of Wal-Mart’s response to hurricane Katrina in 2005.) Solutions should be simple, measurable, transmissible. They should encourage team interaction and engagement. Project owners should facilitate communication for complex tasks.
• The team huddle helps coordination, and it can help with keeping commitments. It’s important to communicate risks and issues early and often.
• Communication should happen (at the very minimum) during specified “pause points” between transitions in the process. In the operating room, these points might be just before administering the anesthesia, before closing up the patient, etc. In an airplane cockpit, they are before starting the engines, before leaving the gate, before take-off, before landing, and so on. (Figuring out what these are in a software development process is something I’ve already started considering.)
• Aviation uses lots of small checklists. A “normal situation” checklist should be very short. An exceptional situation should be very brief, readable, and actionable, too.
• Good checklists are made by practitioners, usable, available, put into use, about 5-9 items long, tested, and completable in about 60-90 seconds (or less).
• Bad checklists are long, imprecise, vague, hard-to-use, or impractical.
• Cockpit crew have created two categories of checklists: DO-CONFIRM and READ-DO. “With a DO-CONFIRM checklist . . . team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off — it’s more like a recipe.”
• Things that are “never” forgotten by a normal practitioner don’t need to be on a list.
• After they’re put into use, checklists need continuous improvement. They must be revisited and refined. It’s a good idea to put a publication date on them.
• Most people — doctors, financiers, software engineers, etc. — don’t like to use checklists. They consider them neither fun nor in keeping with the “heroic” nature of their role. They feel checklists are “beneath them.”
• Ideally they should be usable and helpful for both novices and old-hands.
• Checklists should not be rigid, creativity- or team-killing exercises. They’re designed to “get the dumb stuff out of the way” and provide the leeway to be creative on the hard/sexy stuff. They’re frameworks for self-discipline and productivity.

Other people’s notes about the book:

• How to write a checklist (What Consumes Me)
• A checklist for your checklists (The Clutter Diet Blog)
• Checklist Manifesto (Lumber Tribe)
• Official book website (Atul Gawande)
• Checking — 1, 2, 3 (Health Man Blog)
• Charlie Rose interview

Do you use checklists? How well do they work for you? What do you like and dislike about them? Feel free to leave your feedback in the comments.

First off, what does the new legislation do? The New York Times and the Washington Post each have good overviews. I honestly don’t understand why these easy-to-understand recaps were so elusive in the weeks leading up to yesterday’s votes.

Who wins and who loses in the healthcare bill? In a nutshell, around 32 million uninsured people and the name-brand drug companies gain the most, followed closely by people with pre-existing conditions. For doctors, hospitals, insurers, and generic drug companies, it’s a mixed bag of gains and loses.

In my opinion, the people leaving the most empty-handed seem to be the Republicans who proposed legislation very similar to this in the 90s but didn’t pursue it aggressively. And then over this last year — depending on your point of view — were either shut out of crafting the healthcare reform law or sat out in protest. Despite claims to the contrary, the plans are very heavily centered in the private sector, bringing lots of new healthcare consumers to private insurers, favoring private insurers over public plans, preserving drug company profits, and bringing federal dollars to hospitals, doctors, insurers, etc.

The costs and benefits for individuals/patients/consumers are mostly positive (in my opinion). There’s more access to insurance and less chance that it will be taken away or capped. New high-risk pools bring insurance options back for many of us. There are some tax increases on the wealthy (families making more than $250K per year would pay an additional tax on payroll and investments). And there are modest (probably too modest) penalties for people who don’t buy insurance; subsidies and low-cost options should make it possible for everyone to buy insurance.

The opinions of working-age people with chronic illnesses are mixed, just like in the rest of the population. Kerri at Six Until Me writes about how she feels liberated to start a new business now that she isn’t tied to one employer for her health benefits. Meanwhile, Sarah of Sugabetic wonders whether we’ll be paying the same amount for our healthcare plus a bit more in taxes. Mainly there’s a lot of wait and see and hope that it makes things better.

For one Canadian’s perspective — which sounds a lot like what my Canadian coworkers have said, though from a somewhat religious perspective — check out what Sarah at Emerging Mummy. She prefers universal, single-payer healthcare and doesn’t understand (or like) the tone of the last couple weeks down here.

Almost in the background of the healthcare debate, there’s healthcare. Not many doctors write on weblogs compared to patients. “Who has the time for that?” they ask. (It’s too bad, because patients are putting a lot of effort into our own health 24/7 and exposing our difficulties and vulnerabilities; but . . . that’s a post for another day.) Anyway, two cardiologists with blogs engaged in a thought experiment about what would happen to two hypothetical patients — one wealthy, one not — who are having heart attacks in England and the US.

If you really, really want more political and media meta-analysis about what happened, check out Dan Kennedy’s as-always well-written take on David Frum, Paul Krugman, and Rep. Steven Lynch (D-MA).

As for myself, I feel surprisingly upbeat. Soon I’m sure I’ll feel like Debra Gordon, who wants to pull the covers up over her head, but for now I’m happy. Because hopefully things like this and this will be leaving our social discourse.

Yes, I’m watching C-SPAN right now, waiting for the vote. But it’s making me nervous. (Presently, Minority Leader Boehner is getting roundly shouted down. But he’s also getting some “Amens!” from the chamber, too. So there’s at least a little bit of bipartisanship in the House. Ha!)

I will continue thinking about healthcare and writing about it here. Because tomorrow, however the votes are cast, I will still have diabetes; it will still be expensive; and there will still be a lot of work to do.

And it’s abundantly clear from what’s being said by both sides, there’s still a lot of need for more facts.

“I yield back the balance of my time.”

Now, don’t get me wrong. I love the Tour de France, and I find cricket intriguing. I also really like bratwurst — almost all sausage, in fact — but I’m pretty sure that I wouldn’t want to eat it (quite as much) if I watched it being made. The same goes for Washington. I enjoy being in DC. I love the architecture and the museums and the people. Being inside the Capitol really is an amazing experience. But the act of getting legislation passed fills me with something between disgust and despair. And every time I have to fret over how a bill is made, I wish just a little bit more for a benevolent dictator. (Not really, but you probably get a sense of my frustration.)

This almost makes it look glamorous…

I prefer policy to politics. So I usually shrug and say, “This is what I would like to see, and I don’t really care very much how it gets passed.” Don’t get me wrong, I have my principles. There are things I think government should do when it can and actions that I absolutely think should never be taken. For the most part, though, I’m pretty flexible. I like bipartisanship, and I believe that compromise isn’t a bad thing. The perfect should not be the enemy of the good.

But this healthcare bill is so weak, so imperfect — not to mention so awfully crafted and politicked — that it took me a bit of mental back-and-forth before I could answer the question my vote-counting colleague asked. “How would you vote on the bill?”

First off, it’s absolutely clear to me and to the majority of Americans that we must do something with respect to healthcare. It’s too expensive; it’s getting more expensive; and we don’t get as much out of our healthcare dollars as people in the rest of the world do. There are about forty million uninsured Americans, and most of us have insurance at the whims of our employers and insurance providers. There’s an enormous amount of ineffective spending, and a lot of our spending doesn’t seem to make us that much healthier. We need to make some large, systemic changes to our healthcare system.

I’m not certain exactly what’s in the bill and its amendments — the various bills and amendments run to thousands of pages of text — but I am not impressed with what I’ve heard. Yes, it should bring down insurance premiums for those of us with private insurance already because it will bring more people who are relatively healthy into the pool of the insured. (Although that certainly hasn’t happened in Massachusetts despite the presence of Commonwealth Care, at least not for the average Bay Stater.) And the CBO claims that it will reduce the federal debt by $130 billion over the first 10 years and $2 trillion almost $1 trillion over the next 10. (I need to do more research to understand exactly how they arrived at these figures. I suspect that there are enough systemic changes in the bill to produce some real savings, but I don’t know if the actual costs will come down or if we’ll just see smaller increases.)

Mostly I’m disappointed because I would like to see the bill do more. My British coworkers like the National Health System — a single-payer, completely taxpayer-funded health system. My Canadian coworkers think all of the talk about national healthcare in Canada killing people is utter bullshit and fear-mongering. I look at France, which also has a single-payer system, and I see better results for patients at a lower cost per capita.

I understand that a single-payer, national healthcare system is scary to some. Even many people on Medicare or who use the VA and BIA hospitals — all of which are single-payer, tax-funded systems that are quite effective at delivering services and holding down prices while keeping their members happy — are worried that additional governmental involvement will ruin what they’ve got. While I understand that people are afraid, I don’t understand why they’re afraid. It seems to me after looking around the world that a single-payer system is the most effective option for insuring everyone, lowering costs, eliminating health-related bankruptcies, creating a “wellness” mindset, fostering efficiency, and bringing healthcare to traditionally underserved areas.

But even if you think a single-payer system is too scary or radical, there are things other nations do that we could adopt as well. For example, the government might…

• Allow importation of drugs from other nations with the same pharmaceutical standards as the United States. If a drug costs 50 cents per dose in Canada, there’s no reason it should cost many times more in the United States.
• End the absurd prohibition against states and Medicare bargaining for lower drug prices.
• Encourage competition between private insurance providers nationwide but make them nonprofit entities. (This is what Germany and Switzerland have done.) Insurance companies would compete to include people into their pool instead of excluding them, since the government would (almost certainly) provide subsidies for the chronically ill, the poor, and the elderly. Keeping customers healthy would lower costs; and by competing on service, the hope is that happier patients would also buy homeowners’ or life insurance from the same company.

These are things the current bill does not do. And I don’t understand how the bill is supposed to bring down healthcare costs overall. I do believe that it will reduce the amount that the federal government has to spend in “uncompensated care” provided by hospitals to people without insurance; but how does that translate to less total spending as measured in costs per capita or as a percentage of GDP? As far as I can tell neither the Senate nor the House bills actually constrain or reduce costs.

I am glad that the current bill tentatively slated for a vote in the house will cut the number of the uninsured by 2/3 — though it will still leave 10 million people without the ability to afford insurance. And I’m glad that it will eventually prevent insurance companies from dropping sick people or charging us more.

It’s unclear whether the reconciliation bill contains a nationwide public option with a reasonably large (though not necessarily all-inclusive) set of covered conditions and therapies — possibly a plan similar to the health insurance program that federal employees and Congress members can buy into. Such a program should prevent a race to the bottom between states (the way that interstate insurance competition probably would) at the same time that it provides a nationwide platform for insurance competition.

But I don’t understand why the many of the bill’s key provisions don’t start for four or eight years. And I’m certainly not happy with how the Senate and House leadership have been presenting the bill to the American people. Nor am I happy with how the Republicans have been staunchly opposed to the numerous good ideas that it contains.

But it’s a bill. And it’s here. And it needs to get a vote.

So back to the question of whether I would vote for it if I were a Congressman. Would I hold my nose and ignore all of its flaws? Or would I hold out for a better bill?

Ultimately, I would vote for it. There are two steps that we have to take to improve the health of Americans and the health-related competitiveness of the US economy. One is getting everybody covered so that everyone can get well or remain healthy. The other is lowering the costs of healthcare. A bill that does one without the other is incomplete, but it’s better than no bill at all.

I would vote for the bill but also be very honest with Americans. The speech might start a little something like this: “We passed a historic health insurance reform act that provides nearly universal coverage for all Americans. It was difficult to do, and it exposed many of the cultural fault lines in this country. Ultimately, it showed us that we are a nation which cares about our fellow citizens — all of them — as much as we care about ourselves. That was the easy part. Now we have to start the process of fixing the fundamental problems in the healthcare system that we hold so dear, so that we can afford the wonderful thing that we’ve just done. it’s going to involve some tough choices, but other countries with more limited resources than ours have made the necessary changes; and now they have better health than we do. It’s about time that we catch up.”

That sure sounds a lot better than the other speech members of Congress might have to give if they vote against it and it goes down to defeat: “As a nation we can’t afford our healthcare spending, but we’ve decided to wait until a later date and start over from scratch in the hopes of finding a better and/or more bipartisan bill. I hope you can hold on a little longer while your elected officials figure out what’s actually important to us as a nation.”

In short, I’m an engineer.

But I have to say that the uncertain future of healthcare change — I’m hesitant to call it “reform” or “improvement” these days — is really dragging me down. It challenges my fundamental belief that we can come up with good, equitable solutions to social and governmental problems, that we can form a more perfect union. It’s getting harder for me to push down the unwelcome, paranoid, elitist, (probably) untrue feelings that the demagogues are tricking the hoopleheads into ruining my life for inscrutable (but certainly nefarious) reasons.*

But that’s not really helpful. So today I’m going to muddle through in the only possible way I can: by writing unit tests, going to meetings, and listening to Tracy Chapman. (Oddly Tracy’s music — I’ve seen her twice, so we must be on a first-name basis by now — usually cheers me up by reminding me that it could be worse, that it was worse in the late 80s and early 90s, that there’s pain and heartbreak, that we’ve got to keep going.) Because if I can’t make things better right now, at least I can calmly carry on get excited and make things. I can keep doing what I do well and wait to get back into the right frame of mind to think about healthcare again.

* — I do recognize that there are legitimate reasons for disliking the current proposals and/or the way that the legislation might be passed. I’m limiting my resentment to those who object with questions like “Why now? Why here? Why so far-reaching? Why should I give up anything I’ve got? Why should I pay anything to help someone else?” despite all of the evidence of the need for change in order to improve the health, economic security, competitiveness, and essential fairness of the nation.

It seems like I have a lot of answers about healthcare, but I really don’t. However, I do have some anecdotes and a few facts. And I have done some research when prompted or to fact-check other people’s claims. I even have a lot of opinions that I usually try to keep to myself.

But mostly I have a lot of questions and a rubric for evaluating options. I have a lot of questions. That’s what I do: I ask myself questions that I’d love to have answered before I come up with a firm opinion, if I come up with one at all.

I’ll tell you what I wonder, and I would love to know your questions about healthcare reform and costs.

Here are some of my questions, which I’ll number in case you want to provide your own answer:

1. How should we pay for insurance?
2. How much should individuals have to pay for their healthcare? Should everybody pay the same amount? Should we have tiers of service? Should it be tied to income? Is the important thing equality of coverage or equality of access?
3. How would allowing health insurance competition across state lines impact costs, benefits, and outcomes?
4. Would cross-border insurance competition lower insurance premiums? If so, what are the mechanisms? Would it cause a “race to the bottom” in covered services?
5. What are “health insurance compacts?” Are they run by states, nonprofit organizations, or for-profit companies? Would they promote competition, lower costs, lead to cuts or improvements in covered services, etc.?
6. What’s the proper amount of regulation of insurance companies and healthcare costs and services?
7. How would simplification — going from 51 or so different regulatory schemes and hundreds of insurance plans to a dozen or fewer — affect costs, coverage, and patients’ health?
8. What should be mandated? Why should this vary by state? What’s the right way to determine what’s covered?
9. If we continue to have a system with different mandates, aren’t we going to end up exactly where we are now, with some people covered for some illnesses and others not?
10. What’s the proper role for federalism in healthcare?
11. Does actively preventing chronic illness cost more than treatment?
12. How much of our healthcare spending is attributable to “unnecessary” incentive-based, fee-for-service activities? What are these “unnecessary” services?
13. Is radiology too expensive? Do hospitals buy the appropriate power of scanner? Is there a point where spending more doesn’t get us better results?
14. What impact would electronic health records have on costs and outcomes?
15. What is the cost to hospitals, governments, and the insured for “uncompensated care” provided to the under-insured?
16. Is it okay to bring currently healthy individuals into the insurance pool (thus lowering premiums per capita) without enacting a plan to reduce total healthcare costs at the same time? How will we sustain momentum for cost containment if we don’t?
17. What are the subsidies for insurance premiums and/or healthcare costs that are part of the (current) Democratic plan? How much are they? Who would get them? Where do the funds come from?
18. How do the plans proposed by the House and the Senate reform delivery to “ensure better outcomes” as Kent Conrad (D-ND) said they would on “Meet the Press?”
19. How does the Medicare pricing and reimbursement model impact providers, patients and costs?
20. What does the Congressional healthcare plan do to Medicare? Would the President’s plan move people to Medicaid, as the GOP says? How would it affect taxes, the costs to the states, insurance premiums?*
21. Why does everyone hate Medicaid?
22. Will the fees in the President’s plan increase the cost of healthcare, as John Kyl (R-AZ) suggests? What are these fees?
23. How much healthcare do we really need? Is there a target number?
24. What is the rationale for more government involvement? How do we know its influence won’t mess everything up or politicize coverage?
25. Why aren’t the administrative costs and overhead lower for private insurance companies?
26. With as many people paying so much for care, everybody must know someone who is having a hard time or paying a large part of their income. Why isn’t there something like a “pink ribbon campaign” to mobilize for lower healthcare costs?

Okay, now it’s your turn. Feel free to give voice to what you know in the comments, and please share your own questions. Opinions are fine, but data/evidence-based opinions are even better. Everything civil is welcome.

* — Senator Lamar Alexander (R-TN) said some rather unflattering things about the Democrats’ plan Sunday on ABC’s “This Week.” They’re all unsourced, so I’m going to leave the actual claims unstated. But it’s worth checking them out.