unsportsmanlike conduct

I'm definitely a sports statistics junkie. Maybe this comes from my dad's penchant for setting all the computer passwords in the house to famous baseball players' batting averages. Maybe this comes from my complete inability to perform well at sports, so instead I revel in unimportant factoids.

Either way, I found a story the other day that united my love for sports statistics with health politics. In a survey conducted by National Media, Inc. (conflict of interest possible red flag: this company's a GOP strategy firm), researchers looked at political affiliation of different sports viewers. Check it out:



The researchers also included information about voter turnout and size of viewership for each sport. So for example, while WNBA watchers are the most liberal, they only have a moderate turnout and have a pretty small fan base. Men's golf fans are the most conservative, and although the viewership isn't huge, their voter turnout is easily the highest. And as you might have guessed, overall, sportsfans are mostly republican.

It may not be immediately clear why a GOP strategy firm gives a hoot about the political agenda of sports fans. But here's why: Sports are on TV. Political strategists spend a lot of money on TV ads trying to convince people to vote for so-and-so, to vote against such-and-such issue, etc. With this data, republicans know not to waste their money on buying TV time during WNBA games (although I don't imagine such advertising to cost very much...). Democrats might steer clear of advertising during NASCAR if they can interest more pro tennis viewers.

Now think back to about a month ago, when insurance lobbyists were vehemently advertising against the health reform bill - and community advocates were equally vehement about rallying support for it. All in all, groups on both sides of the issue combined spent well over $200 million in television ads. Even though the people who see these ads during their beloved sports matchups weren't actually the ones who voted on the legislation, you can bet that a good number of them called their Congressmen and Congresswomen after seeing these ads to voice their opinion. And you can bet these ads are going to have an influence on the outcome of the midterm elections in November.

My guess is that we're going to be seeing a lot of political ads this coming September/October/November - certainly not as many as for the presidential race, but probably a good amount will be aired since both House and Senate seats are up for grabs. Even though the bill has been signed into law, many republicans have plans to repeal and debate many of its specific provisions. (But interestingly, even people who were against the bill disapprove of state attorneys general trying to repeal it in court.) GOP strategists will try to make ads that say Congress is too politically lopsided, and that we need more republicans in both chambers. Democratic strategists will try to paint the congress members who voted for the bill as champions who had a role in a historically important reform law. Either way, I can tell you now, the ads are going to be as notoriously rampant and misleading and annoying as ever.

(Speaking of annoying political ads, remember Tim Tebow's terrible pro-life ad during the Super Bowl? GAG. I'd take an angry commercial from Pharma over this any day. Any. Day.)



Everyone should pity us fans of fall sports, for we will certainly be subjected to myriadvertisements. (Play on words alert!) Us poor football fans, especially those living in states whose Congress members voted for health care reform, are probably going to be seeing a lot of attack ad spots against the incumbent democratic official. MLB fans, whose season will be wrapping up just in time for elections, will probably see a good amount of ads from both sides during the playoffs and the World Series; baseball fans are slightly republican, but middle-of-the-road enough for both sides to battle it out during the commercial breaks.

Yes, polticial advertisements can be a great way to engage people in politics, to make them aware of important issues, to share a candidate's views. But most of the time they're filled with half-truths that only obscure the political process. And the voices we hear the most are typically the ones with the most extreme opinions and the ones with the most money. So come fall sports season, I have but two wishes: (1) The Nebraska Cornhuskers will be Big 12 champs and will get to play in a BCS game for the first time since '02, and (2) The ads we all see will be politically honest, fair and informative. And since Nebraska's losing its star DT to the NFL, and since American politics aren't going to be overhauled any time soon, both are unfortunately unlikely.

Ronald McDonald: public health ne'er-do-well, or harmless spokesclown?

Fast food companies are having a rough couple of years. The bad economy took a toll on revenues for almost every major chain. Books like Fast Food Nation and the documentariesSuper Size Me and Food, Inc. have surely been a P.R. nightmare. The recent health reform legislation includes a federal mandate for all chain restaurants to post nutritional information for regular menu items in highly visible spots on the menuboard. (Fun fact: I heard a story on NPR that Starbucks customers had "sticker shock" after learning that their beloved Frappucino had well over 500 calories. In response, Starbucks switched the recipe from whole milk to 2%.)

Rough, right? Well, the hits just keep on coming. Apparently, the advocacy group Corporate Accountability International has called for McDonald's to retire their cartoon spokesclown Ronald McDonald. They say Ronald is a marketing ploy to get kids to eat unhealthy food - and in light of the childhood obesity epidemic, it's unethical for McDonald's to continue to use him to sell Happy Meals. The group held a retirement party in McDonald's homestate of Illinois, and sent "Happy Retirement" cards to McDonald's restaurants all around Chicago.

I wouldn't take this group's efforts too lightly - CAI is kind of a big deal. They're the ones who stomped cigarette spokes-ungulus Joe Camel out of the advertising world. And even though many first believed that a cartoon was harmless, the public ended up siding with CAI's anti-Joe stance. Most now agree that a company that uses a kid-friendly cartoon as a marketing mascot is, intentionally or unintentionally, marketing their products to children. And marketing to children is a real ethical minefield.

So is Ronald McDonald on the same playing field as that malicious dromedary Joe?

Economically, yes. I just read a study that said the national health costs of obesity are about the same as the national health costs of smoking - both hovering around $50 billion per year in medical expenditures.

Magnitudinally, yes. For children between the ages of 2 and 19, 17% are obese. For youth ages 11 to 19, 9% are "established" smokers.

Behaviorally, yes. A recent study published in Nature Neuroscience reports that, like drugs and alcohol and cigarettes, high-fat, high-calorie food is addictive.

When you really think about it, the advocacy group CAI isn't making a real stretch here. Like cigarettes, fast food causes loads of downstream health costs; obesity is much more prevalent than youth smoking; and on top of that, like nicotine, fast food is addictive. Many people say, "One happy meal isn't going to kill you." Well, one cigarette isn't either. It's the fact that people who regularly consume fast food are less able to control their urge to eat (much like people who regularly use cigarettes can't control their urge to smoke). And this is what worries Corporate Accountability International.

McDonald's counters these arguments with two key points. One, Ronald is the spokesperson for the Ronald McDonald House, a very active charity organization. They don't want to lose that branded imagery, which makes sense. Two, they say Ronald is, in fact, an advocate for making good choices and for being physically active and for having good meals with family. (I think this second argument is just one of those things spokespeople say because there's no way to refute this. Yeah, in '05 they "slimmed down" Ronald to say he promotes an active lifestyle. But I'm not sure he could have possibly achieved this on a McDonald's diet alone ... he had to have been cheating on his Big Macs with a Subway sandwich.)

I don't think McDonald's has to send poor Ron off to retirement. I think they just need to use him more as a role model for children to make smart choices - and that means making Happy Meals that are actually nutritious. Apples instead of fries. Grilled chicken sandwiches instead of processed chicken nuggets. Milk - plain milk, not flavored and loaded with sugar - instead of soda. Let Ronald show how much he loves vegetables.

CAI has a point that I think we should make sure McDonald's takes seriously. The analogy between the health effects of the cigarettes Joe Camel peddled and the junk that Ronald sells is hard to deny. Sure, keep Ronald around, but make him serve as a role model for making healthy eating choices. The childhood obesity epidemic is only going to continue to grow if big players like McDonald's don't start thinking creatively about how to change the food environment for consumers and their Happy Mealers.

(Well hey, if nothing else, at least we can sleep soundly knowing that they retired the posse from McDonaldland years ago. I'm not sleeping better because of the lessened threat to childhood obesity - I'm sleeping better because these characters are creeeeepy. *Shudder*)

nudge to eliminate pudge

I just finished the book Nudge: Improving Decisions About Health, Wealth, and Happiness, written by economics professor Richard Thaler and law professor Cass Sunstein, both of the University of Chicago. Lovers of Freakonomics or Blink will definitely appreciate Thaler and Sunstein's look into the field of behavioral economics. In one sentence, Nudge is about why people make the decisions they make and how policy can "nudge" people into making better choices.

I realized that the ideas in this book are the theoretical basis for many disease prevention government public health programs. These programs are attempts to improve "choice architecture" - that is, many public health initiatives attempt to redesign the context in which people make choices about their health behaviors in order to improve the chances that people will make the most healthy choice possible (while still giving people freedom of options).

Here's one of Thaler & Sunstein's examples of "nudges":

"[Nudging] is a relatively weak, soft and nonintrusive type of paternalism because choices are not blocked, fenced off, or significantly burdened. If people want to smoke cigarettes, to eat a lot of candy, to choose an unsuitable health care plan, or to fail to save for retirement, libertarian paternalists will not force them to do otherwise - or even make things hard for them. ... [Libertarian paternalists] are self-consciously attempting to move people in directions that will make their lives better. They nudge." (pg 11-12)

I can't stress enough how great this framework can be for public health professionals. We don't want to force people to make a certain health choice - we want to make it easier for people to make good choices, we want to provide incentives for people to make these types of choices, we want people to have as few barriers as possible. What we don't want to do is penalize those who make "the wrong" choices, because taking away someone's choices to behave as they wish infringes on personal liberties.

How about a more concrete example of public health "nudging"?

Like every other man and woman in America, I absolutely adore Michelle Obama. She's young, beautiful, and smart as hell. And, like many of the First Ladies before her, she has taken a national-level role in promoting a cause: encouraging Americans to improve nutrition and increase physical activity. Last week she spoke at the Grocery Manufacturer's Association, calling for major food manufacturers like ConAgra, Kraft & General Mills to reinvent the products that they sell in grocery stores - especially those products that are marketed toward children.

Michelle is asking these food producers to chance the choice architecture for people who shop in grocery stores and restaurants, especially for parents shopping for their kids. Children are drawn to food that's marketed to them during youth television programming, or that's marketed to them by colorful, cartoon packaging. But the food kids gravitate toward are *overwhelmingly* some of the most unhealthy food in the store. Margo Wootan, of the non-profit Center for Science in the Public Interest in Washington, said, "If companies were marketing bananas and broccoli, we wouldn't be concerned. But most marketing is for sugary cereals, fast food, snack food and candy."

The idea here is that childhood obesity has become such a national epidemic because of the availability and affordability of unhealthy food that children want to eat. Michelle is, first, trying to encourage these manufacturers put less salt, fat and sugar in the food marketed to children. Secondly, Michelle is calling for these companies to make labels less confusing for the average shopper - many foods with the word "healthy" on the box aren't. Hopefully, the changes for which Michelle is advocating will (1) make children want to eat food that's better for them, and (2) make it easier for parents to pick out and purchase the healthy food options.

There's an important but subtle point in all of this. Michelle is not trying to ban unhealthy food. People can still go to the grocery store and buy their kids donuts if they wish. But if healthy food is marketed to children, and parents can easily understand the nutritional value of the food they're purchasing, they just might be persuaded to put the donuts back and buy some fruit instead. No options are being eliminated - certain options are simply being nudged.

From start to finish of the book, I began to look at public health news with these "nudge" concepts. I think this book could be incredibly important for professionals and students in this field, because it made me understand from a theory-based perspective how public health programs should influence behaviors: through conscious structuring of a people's choice architecture to "nudge" them towards healthy decision-making. Loved the book. And I think anyone in a policy role (or aspiring to be in one) should give it a read.

(And a special shoutout to Brian Merry, second-year public health student, who let me borrow Nudge. Sorry about the coffee stains in Part IV ... turbulence + coffee from the flight attendant = minor spillage.)

reducing your carbon footprint? don't drink outside the box

As if wine needs another reason for us to love it, here's one more: Boxed wine is good for the environment.

This week's New York Times wine blog rekindled my love for all things boxed wine - it's cheaper, it stays fresh longer, and despite the reputation of Franzia and other similarly low-quality wines, there is actually a pretty good selection of high-quality wines that just happen to have bag-in-box packaging. There's a box of cheap sangria in my fridge right now, and it brings me great happiness - it may not be Moet et Chandon, but it's palatable both financially and gustatorily. As one blogger puts it, "Boxed wine may be short on charm, but it is long on practicality." Pretty much the only reason bottled-and-corked wine is so popular today is because of the perception that these wines are finer. Glass packaging may actually be bad for the product - glass allows light through which may degrade the wine, and the cork can seep into the liquid which can taint the flavor.

But my favorite pro-box argument is that boxed wines have a smaller carbon footprint that bottled wines. How exactly, do you ask? Through three main routes:

(1) Less gasoline emissions due to cheaper transportation. Boxed wines weigh less per liter of liquid than bottled wines (cardboard is lighter than glass). Also, greater quantities of boxed wine can fit in cargo areas due to their rectangular and easily-stackable shape, whereas bottled wine is fragile and oddly-shaped, making it difficult to ship. More wine for less gas means fewer carbon footprints!

(2) Cardboard and glass are both recyclable - but it is oftentimes more difficult to locate glass recycling facilities. Also, neighborhood recycling collectors sometimes won't pick up glass because it's too dangerous for the collectors. Cardboard, in most cases, is easier to deal with recycling-wise.

(3) When you open a bottle of wine, you have to finish it within about 48 hours. When you open a box, you've got at least a month. People are more likely to toss out day-old bottled wine due to spoilage - thus, boxed wine can reduces burden created by waste.

Let's not forget that boxes and bottles both contain wine - and while the product may not be identical in flavor, their ingredients are pretty similar. And the health-promoting effects of these ingredients are pretty well-publicized, when consumed in moderation. Because boxed wines are generally less expensive, this allows a greater number of people - of a greater range of income - to benefit.

Boxes do have their environmental drawbacks - the plastic bag inside the boxes is usually not recyclable, and more labor is needed to assemble these boxes (which corresponds with greater manufacturing emissions). But these are tradeoffs which, in the long run, may not outweigh the pro-box arguments.

So would it really be so outrageous to suggest that policymakers subsidize American wine manufacturers who box their wines? In a few years, America will probably be the biggest wine producer in the world, so it's important to think about how this global industry operates. We're trying to be a more environmentally responsible nation, and if there were incentives to try and change the perception of boxed wines, more wineries would box better-quality wines, quality sellers would keep more boxed wines in stock, and more consumers would switch to this packaging style. A decade or so ago nobody with class would even dream of drinking beer out of a can - but breweries knew it was an easier format to ship, and aluminum was easier to recycle. Eventually people came to allow cans to be an acceptable packaging (even New Belgium's Fat Tire is now sold in cans!). Maybe the boxed wine revolution needs a little subsidizing - or just a subtle policy push - in order to get rolling.

Oh, and technically, the most environmentally prudent way to consume wine would be to have your own glass jug and fill it up yourself at local wineries. No cross-country transportation, reusable container, and support of the local business economy. While it's a great idea, not everyone lives near a winery, and I'm not even positive if the owners allow this kind of transaction. I've personally filled up a growler at Lazlo's, a local microbrewery back in Nebraska. Maybe I'll try my luck with the jug at Bishop's down the road.) But it's how many families get their wine in France, and maybe U.S. wineries can accommodate (or at least publicize that they accommodate!) this technique soon.

the ugly side of snow days

The issue: School closings and snow days

The vocab: Snow days are usually perceived as fun and as a respite from the daily school grind - but for some kids who rely on the school's resources, snow days aren't so quaint

The Northeast has been battling record snowfall for the past two weeks - hundreds of flights were cancelled, car accidents abounded, and almost every school from Virginia to Maine was closed for days. (Well, except for Yale, which hasn't declared a snow day in more than 30 years.)

One thing a lot of us don't think about is the public health trade-off schools make when declaring snow days. School is usually cancelled in the name of student and staff safety - that is, fewer automobile/bus accidents and less exposure to dangerously low temperatures. But there are health risks associated with not being in school, too.

Besides the inconvenience to parents who have to find a last-second babysitter, and besides the inconvenience to teachers whose lesson plans are disrupted, there are negative effects that students must face if school is cancelled. As discussed in stories from both MSNBC and the Newark Advocate, many elementary, middle and high school students rely on free breakfast and free/reduced-price lunch - and their family may not be prepared to provide these meals when their children are unexpectedly home for a few extra meals.

Here in New Haven, most schools were closed at least two days these past couple of weeks. And most of the schools in town have about 60% of their students on the free and reduced-price lunch program. While schools often have a bad rep for the quality of their cafeteria lunch menus, this may actually be the most nutritious meal some kids get that day. In order for a school to participate in the program and receive subsidies from the Federal government, cafeteria food must meet certain nutritional guidelines - with limits on calories and fat, and requirements for vitamin content.

So what can families do when they unexpectedly have another mouth (or so) to feed? In Philadelphia and D.C., where schools were apparently only open one day all of last week, food pantries were either (1) closed due to the inclement weather or (2) running low on food because of the unusually high demand.

Some school administrators in Evansville, Indiana - a midwest town that's no stranger to frequent winter school closings - started a pilot program last week, where kids who were brave enough to trek to one of two local schools could still get a free lunch. (It's unclear whether they had to be eligible for the federal free/reduced-price lunch program, or if just anyone under 18 could roll in.) If a State of Emergency is declared in the city this back-up program would close as well. But when school is closed for several days straight, chances are the city won't be in a snow emergency the entire time - and due to the efforts of this school district kids will have at greater access to nutritious meals in otherwise tough times. And it does put kids at risk - if the weather's bad enough to close schools, it's probably at least mildly perilous to get to school to take advantage of the program. But at least it's a resource that families can use if food options are running low.

Snow days should be fun - it shouldn't be a stressful time where parents have to worry if they're going to be able to feed their kids. The government already has a free/reduced-price lunch program for eligible kids to use during the summer - they should maybe expand this they way schools in Evansville did, so on unexpected closures kids can have access to nutritious food ... and then go play in the snow like kids should be doing!

[And now for your non-public health side note ... while googling Connecticut cafeteria policy, I came across a story about a 55-year-old cafeteria worker in Danbury who got put in jail after getting in a food fight with a fifth-grader. God Bless Connecticut.]

olympians' most dreaded foes: cold and flu

The issue: Olympians' health while competing in Vancouver this month.
The vocab: Banned performance-enhancing substances ... in the International Olympics Committee's eyes, cold and flu medications are equivalent to doping.

The Olympics are always wrought with controversy over alegations of performance-enhancing substance abuse. While the summer games tend to have higher rates of offenders, the winter games aren't immune from illegal performance enhancement. In Turin's 2006 games only one athlete was busted for using a banned substance. But back in 2002 when Salt Lake City was host, seven competitors were caught - including four medalists, all of whom had to forfeit their prizes.

The International Olympic Committee surely prides itself on rigorously ensuring fair competition through frequent testing and harsh consequences.

But has anyone thought about the negative side effects of such stringent substance bans on the athletes in Vancouver this month?



The New York Times came out with a story today about Olympians' battles with their harshest competitors - The Common Cold and The Flu. Athletes have the triple whammy that increases their susceptibility to illness:

1. Being around millions of people, and being in close quarters with fellow athletes in Olympic Village, increases the chance of transmission.
   
2. Intense physical activity suppresses the immune system, decreasing the body's ability to fight off cold and flu.


3. Athletes aren't allowed to take many of the everday cold and flu meds because of the IOC's strict rules against banned substances. Some cold and flu remedies contain stimulants just like the ones in banned amphetamines - in smaller doses, yes, but still detectable via routine drug testing.

Dr. P. Gunnar Brolinson is a team physician at the Vancouver games, and is the author of a 2007 article published in Clinics in Sports Medicine about the immune-suppressing effects of rigorous exercise. In the NYT article, Brolinson says, "The biggest reason for poor performance at an internation, multisport games is a respiratory infection."

So what we have here is a public health tradeoff - do the risks of acquiring a cold or a flu outweigh the risks of allowing these medications?

Until drug testing becomes sophisticated enough to distinguish between a small dose of cold/flu medicine and a true banned substance, Olympians will have to deal with the regulations by becoming more proactive in preventing illness. Vancouver is literally giving away flu vaccines. Over 40% of the city's residents have been vaccinated, and the Canadian Olympians have set a stellar example for their colleagues, with more than 80% of the Canadian team receiving vaccines throughout the flu season. And I suppose you could go one step further like U.S. cross-country skier James Southam, who admitted to carrying a hospital mask in his carry-on bags just in case one of his co-riders was looking under the weather. But recall the reports from the beginning of the swine flu epidemic: there's doubt that hospital masks protect casual wearers all that much. (Plus it makes you look like a massive dork.)

And what if, despite preventive efforts, a cold or flu begins to emerge?

Old school remedies are the answer, in this case. Lozenges, ibuprofen and antibiotics (if necessary) are perfectly fine. Some Olympians are actually spokesmen for anti-cold remedies - U.S. speedskater (and much hunkier without his ridiculous soul patch) Apolo Ohno has an ad for DayQuil/NyQuil. Both of which are allowed by the IOC.



While it may be tricky for athletes to stay cold- and flu-free during the Vancouver games, the winner of the public health tradeoff is clear: The IOC would much rather risk athletes getting sick than risk allowing athletes an unfair competitive advantage.



[An aside... Chuck Klosterman wrote a fairly famed essay about the Olympics back in 2004 for Esquire magazine. Not public health related, sadly. But as always with this guy, it's a fascinatingly convoluded and hilarious read.]

avatar & james cameron's (inadvertent?) health policy commentary

The issue: James Cameron's interpretation of the future of healthcare

The vocab: Health insurance coverage for veterans

So I finally got around to seeing Avatar. And yes, it was visually stunning and a technical masterpiece and so on. I'll let the reviewers and The Academy do the fawning - for there is health policy subtext to be analyzed.

The protagonist is Jake Sully, a former Marine who was paralyzed from the waist down (which is presumably a war injury). Jake had agreed to travel to the distant planet Pandora and gather information on Pandora's indigenous people for the U.S. military unit stationed there - in return for his intel, the unit's Colonel promised to pay for spinal surgery that would enable Jake to use his legs again. Being the good public health student (read: dork) that I am, I turned to my friend sitting next to me and exclaimed:

"So James Cameron is saying that in 150 years, even though the technology had been invented to reverse paralysis, an injured war vet doesn't get enough health insurance coverage for spinal surgery???"

OK, yeah, the point of the movie is to blow you away with the visuals and submerge you in the blatant environmental commentary - but I got preoccupied for a while with this insurance coverage bit. But then I realized, I don't actually know what the current state of health coverage is for those on active duty and veterans.

When someone is on active duty, they receive insurance through the Military Health System. Those who are honorably discharged are then shuffled over to Veteran's Affairs insurance (or to their employer's or private insurance, if they opt). According to the Veteran's Affairs benefits site, there are two types of benefits: ones for service-connected disabilities (i.e., those that occurred during active duty), and ones for nonservice-connected disabilities. Sully was a victim of the former. He'd definitely be getting some monthly compensation, somewhere between $123 and $2,673, depending on what his "level of disability" was assessed to be. But I can't figure out from the VA's website if his insurance would cover expensive spinal surgery several years after the injury was suffered.

I suppose that's an interesting weakness to point out in and of itself - it's pretty impossible for the average person to easily scroll through veterans' benefits package and actually understand what to expect. For example, the site states that veterans receive a monthly stipend based on percent disability, but it doesn't explain (or link to a site that explains) how percent disability is determined. Part of the Senate's proposed health bill calls for the creation of an Internet site that clearly lists healthcare options and comparisons of benefits packages. Maybe the VA should set an example.

Speaking of health reform, let's look into how the recent healthcare overhaul talks could affect veterans - are we dooming our nation's future vets to unaffordable healthcare services and inadequate coverage for vets with service-related disability? Are we setting the stage for Jake Sully's predicament?

Probably not. First of all, I'd like to think that if doctors in the future are able to reverse paralysis, the VA would be extremely eager to help vets with war injuries (and I'd bet that taxpayers would gladly help share the costs). And secondly, according to The White House Blog, Obama's 2010 budget includes "the largest single-year increase in funding for the Department of Veterans Affairs in three decades, and significantly expands coverage, extending care to 500,000 more veterans who were previously excluded."

So do I buy James Cameron's depiction of a future where a disabled war veteran can't get paralysis-reversing surgery?? Nah. I don't think Congress or taxpayers would stand for it. And I don't think the VA will ever shrink the benefits package - it can really only grow. While the movie is grounded in fantasy and science fiction and imagination, it's simply not believable that Jake Sully wouldn't have health coverage in a non-Cameronsian (read: possible) future.

concussion commotion

The Issue: Concussion policy in all levels of football

The vocab: "Concussion" is a pretty common occurrence and a pretty common word - but let's not forget that it's still a brain injury.

Concussions are pretty common, especially for athletes - there are 3.8 million sports-related concussions every year (and probably millions more that are unreported). Because of its relative ubiquitousness, the public hasn't appreciated the long-term implications of the event. Well, until recently. The official medical term is a "mild traumatic brain injury," a terminology which I think better characterizes the severity of the injury. (And for those interested in the medical background, the fine people at Wikipedia, as always, have a great review.)

Concussions are especially incident in my beloved sport of football. Florida's QB Tim Tebow suffered one in a regular season game against Kentucky that kept him out of practice for a couple weeks, and Cal's phenomenal RB Jahvid Best suffered a reeeeally chilling one that put him out for the rest of the season. Whoever you're cheering for (and trust me, I'm no fan of Tebow), no one wants to see a player hurt. Including Congress.

Congress is looking at legislation that would protect athletes at all levels from exacerbating excessive complications due to concussion. The House Judiciary Committee held a forum today in Houston to talk about how high school football coaches are currently dealing with players who have had concussions. Dr. Bennet Omalu, a forensic neuropathologist and the foremost researcher in football-related head injuries, testified at the forum. He strongly recommends that players under the age of 18 should be required to sit out for three months after sustaining a concussion.

Most people are in favor of the proposed changes in policy - as Dr. Omalu outlines in his book Play Hard, Die Young, because football

players are subjected to repeated head injuries, they are much more likely to suffer from dementia and depression later in life. There are obviously immediate dangers, too. Matt Blea, a high school football player from San Jose, was in a coma for 17 days after getting knocked out in a game on Thanksgiving day - it was a very scary situation for everyone involved (Blea is reportedly recovering tremendously, but will probably never play football again ... but hey, at least he got to meet Heisman runner-up Toby Gerhart [In the pic, Blea is on the left and Gerhart is on the right]), and Californians have since rallied together to enforce more regulations that would protect high schoolers from head injuries.

Interestingly, and I suppose as we have all come to expect, not everyone is in support of Congress stepping in. Two Republican congressmen from Texas, Ted Poe and Lamar S. Smith, are critical of the proposed legislation. According to the New York Times, Poe is quoted as saying,

I mean, if Congress gets involved, it would seem to me it would be the end of football as we know it. We would all be playing touch football on these fields.

The man's got a point. I mean, people know what they're getting into when they strap on those helmets and allow 300-lb linemen knock them over. (I can just hear Colorado coach Dan Hawkins gearing up to reprise his famous, exasperated one-liner: "It's division one football!!") And I'm sure Poe wants coaches to be responsible when making decisions that affect players' health. It's just a matter of whether or not Congress should intervene.

The NFL has set a really stellar example for NCAA and high school football policy. They NFL conducted its own study about the long-term effects of repeated head injury (and while it suggested that players are at a higher risk for dementia, the results were statistically inconclusive ... for now), and they already held forums with the House Judiciary Committee about how they'd like to change head injury policy. The NFL's going to (1) institute stricter league-wide return-to-play guidelines and (2) require every team to hire an independent neurologist, who must be consulted before the player can even come to practice.

[A quick side note that's more about research than policy... Current and former players are getting pretty gung-ho about helping brain injury researchers, all for the benefit of future generations of players. A dozen or so NFLers have volunteered to donate their brains to the Boston University School of Medicine after their death. Kind of icky, but kind of cool.]

Because the NFL is a centralized and unified league (the same is basically true for the NCAA, it's just much larger), they can make these sorts of guidelines, fund the provisions, and actually monitor their enforcement. But there isn't a similar nationwide cohesive entity for high school and youth sports - and perhaps it's appropriate for Congress to enforce federal legislation to protect players. And in an effort to ease the financial burden for schools (and players' parents), the federal government proposed an Act that would give $10 million to high schools and middle schools so that coaches could accurately assess concussions.

Concussions have deserved attention for a long time - and there is basically a consensus amongst players and coaches and politicians (and anyone else you possibly think of) that concussions need to be dealt with in a more consistent and medically-sound manner - especially in younger players. [And, by the way, I'm irrationally excited to see BU's analysis of the NFL brain autopsies, even though it'll be a couple decades. Brain research is cool, but brain research on football players is waaay off the cool charts.]

how well wellness programs are doing

The issue: Employer wellness programs that provide incentives for employees to be healthier

The vocab: Incentives - how are they earned? The not-so-subtle difference between incentive-participation and incentive-attainment programs.

What's an easy solution to employers' rising healthcare costs? Make employees pay to have unhealthy habits. America's health

insurance system pretty much operates on the employer-provider model. People expect that the

ir employer provides a health benefits

package. Now some employers are holding

their employees accountable for the healthcare costs they generate by instituting incentives for employees to engage in healthy behaviors (such as exercise and eating right) and to disengage in unhealthy behaviors (such as smoking and having poor nutrition).

One example is Johnson & Johnson's wellness program, which is highly cited as one of the most successful large-scale employee intervention programs to date. If J&J employees participated in a yearly

health screening, they would be eligible for a $500 health insurance benefit. Those who had no "risky" health indicators were given the money; those who were "risky" (that is, they had indicators of risk for obesity, cardiovascular health, cancer, diabetes, or accidents/injuries) were required to participate in an intervention program in order to remain eligible for the money. The disease-specific intervention programs were fairly low-commitment - most entailed simply attending regular health education and preventive counseling sessions. In only 5 years, the percentage of J&J employees who were identified as "high-risk" decreased significantly pretty much across the board of health problems. But was this cost-effective? Probably. By some calculations, the $500 investment by J&J was more than compensated by its returns - less employee healthcare costs, fewer sick days from work, and a more productive workforce in general.

Great, right?

J&J's program is what I'll call an "incentive-participation" program. While J&J is obviously interested in the outcome of the interventions, employees received the bonus bucks just as long as they participated. That is, their incentive was not dependent on the actual health outcome - it was dependent on whether or not they tried.

Well, some employers have taken it one step further, utilizing "incentive-attainment" programs. In order for employees to receive some benefit, they need to be below a threshold risk (for example, they must be below a certain BMI or they they must not smoke cigarettes daily). Trying isn't enough - results are what matter here. It's the same principle as the "incentive-participation" model. The employer simply expects more.

Safeway has gotten a lot of media attention for using this type of incentive structure. Employees are regularly tested on BMI, blood pressure, cholesterol and tobacco usage. If they pass on all four measures, employees are given a sizable reduction in their health insurance premium (roughly 20% off). If they don't pass, they're given one year to show improvement in the health measure. If the employee improves, they're reimbursed for the past year and are given the reduction for the subsequent year; if the employee does not improve, they're back at square one. If you're wondering if this is all legal, it is. Well, within certain limitations. (The fine people at Harvard have a pretty good overview of what employers are legally allowed to do.)

It sounds a little harsh, right? But the logic is sound. Safeway is giving monetary incentives ABOVE what's normal. They're not exactly penalizing people for not being healthy, they're just rewarding those who are. And the outcomes-based incentive may actually be a creative way to address national health problems. Here's an excerpt from Safeway CEO Steven Burd's editorial in Wall Street Journal:

Safeway's plan capitalizes on two key insights gained in 2005. The first is that 70% of all health-care costs are the direct result of behavior. The second insight, which is well understood by the providers of health care, is that 74% of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable.

Not a bad argument, really. And Burd has bigger plans for his program. There's some proposed legislation in the Senate (affectionately dubbed "The Safeway Amendment") that would raise the amount of reimbursement employers can offer from 20% of the employee's coverage to 30%. This would increase employee motivation to participate and strive to be healthier.

Well, theoretically. As you can imagine, this approach has gotten some legit criticism. The authors of a recent New England Journal of Medicine article argue (1) that it is unfair to not reward people who are earnestly trying to improve their health but are, for whatever reason, physically unable, and (2) that such a program worsens already existing inequities. Let me explain that second point a little further. The authors write:

There is a social gradient [in employees' ability to improve health]. A law school graduate from a wealthy family who has a gym on the top floor of his condominium block is more likely to succeed in losing weight if he tries than is a teenage mother who grew up and continues to live and work odd jobs in a poor neighborhood with limited access to healthy food and exercise opportunities.

On top of that, there's some doubt that the program is even effective in changing the health profile of the Safeway workforce. The problem with the incentive-attainment structure is that it assumes people can change because they want to and because they try. But there are serious barriers to success that the employer would need to keep in mind (like helping the aforementioned single mother get gym access and be able to locate and afford healthy food) - and overcoming those barriers is going to be much more costly than simply the 30% reimbursement. If Safeway is willing to foot the extra bill for the people who need extra help, then the incentive-attainment program makes perfect sense. But the program becomes much less cost-effective when you start adding in these equalizers, and it's unlikely that Safeway (or any company, for that matter) would be willing to finance a wellness program that comprehensively.

Employer wellness programs are ubiquitous - and in some peoples' eyes, they're expected. But you have to read the fine print about whether you'll receive incentives for participation or for attainment.

do people support health reform, or "health reform"

The issue: Kaiser Family Foundation's recent poll about Americans' knowledge of and opinions on healthcare reform

The vocab: If people are in favor of the idea of "healthcare reform" vs. if people are in favor of the specific provisions of healthcare reform

Not surprisingly, Americans are split pretty evenly on whether they support or oppose Obama's health reform bill - however, when respondents had the specific provisions of the proposed legislation explained to them, they generally supported healthcare overhaul more.

This month's Kaiser Family Foundation poll found that while only 42% of people said they supported the bill (and 41% oppose), there tended to be much higher rates of support when they were told about reform's specific aims. Here's an excerpt from Kaiser's press release:

"After hearing that tax credits would be available to small businesses that want to offer coverage to their employees, 73 percent said it made them more supportive of the legislation. Sixty-seven percent said they were more supportive when they heard that the legislation included health insurance exchanges, and 63 percent felt that way after being told that people could no longer be denied coverage because of pre-existing conditions. Sixty percent were more supportive after hearing that the legislation would help close the Medicare “doughnut hole” so that seniors would no longer face a period of having to pay the full cost of their medicines."

These findings suggest, basically, that while people tend to have opinions on a general abstract idea of "healthcare reform," these opinions may not reflect how they would feel about the legislation if they were more aware of its specific, tangible aims. Check out the numbers. (The full results I'm discussing start on page 9.) Not surprisingly, though, not every aspect of the bill was embraced by the public. People weren't so stoked about (1) the projected price tag, nor (2) the possibility of being mandated to have health insurance. Respondents said that they were less likely to support a bill with these provisions attached - but the way people would actually weigh these downfalls against the potential benefits wasn't surveyed.

Even though healthcare reform has been on the national agenda for almost a year now, the average American doesn't know a great deal about what changes could be imminent. Perhaps health reform advocates have been going about garnering public support all wrong. Senate democrats have been trying to convince people that health care reform is needed - but maybe all they really need to do is explain it.

The moral of this story is that lawmakers may be too hasty in using broad, abstract phrases like "health reform" and "healthcare overhaul" - the general public would be able to more accurately figure out their stance if the bill were explained in more specific terms. Maybe information about how the bill helps small businesses, Medicaid recipients and the millions of uninsured Americans will help people realize that they're actually in favor of the bill; maybe information about the cost of the program or about the anticipated date of full implementation (not until 2013) will help people realize that they're actually against the bill. But at this point, it seems like too many people are relying on party affiliations and inadequate information in forming their opinions - and not enough on their support of the actual makeup of the bill.

brown vs. coakley: and who can be trusted to define "quality healthcare"

The issue: The Massachusetts Senate seat, which opened up after the death of former Senator Ted Kennedy

The vocab: Improving the "quality" of healthcare Americans receive. Which candidate defines the word quality most appropriately?

Let's start by breaking down who's backing the two candidates. It's not particularly relevant to the issues themselves, but fascinating nonetheless...

The pro-Brown celebrities: Scott Brown and his family are practically celebrities in their own rights - Scott was a star athlete in high school and played college ball at Tufts (and, in a baffling decision for an aspiring politician, posed very nude for Cosmopolitan magazine); Scott's wife, Gail, is a popular Boston-area television news reporter; One of Scott's daughters, Ayla, competed for 3 weeks in the fifth season of American Idol. On top of this all-star family cast, Scott Brown also has the support of ex-Red Sox pitcher Curt Schilling (who actually even contemplated running for the seat himself) and ex-BC quarterback Doug Flutie.

The pro-Coakley celebrities: President Obama is backing Martha Coakley, as well as the late Ted Kennedy's widow, Victoria Kennedy - i.e., some of the most powerful Boston-area political voices.

Tomorrow, Massachusettans will cast their votes in the Senate race between Republican attorney Scott Brown and Democratic Massachusetts Attorney General Martha Coakley. While there's been a lot of controversy bubbling over the negative campaigning that the candidates

have directed at one another (in fact, Brown is filing a defamation claim against Coakley for some mailings her party sent out), the biggest issue here is the implications in the healthcare reform vote.

Currently, there are 59 Senators who have voted in favor of the president's health care reform bill. The Senate needs 60 votes to push the reform through the Senate - and Coakley if elected, will be that 60th vote. If Bay Staters instead elect Brown, he has vowed to be the 41st vote against reform, which would effectively kill the legislation. According to the most recent poll, Brown (with 50%) leads Coakley (with 46%). While Brown's lead is within the statistical margin of error (translation: statistically, Brown and Coakley are tied), he's a lot better off than he was expected to be. Massachusetts is a predominately Democratic state - only about 13% are registered Republicans - and the state hasn't had a Republican senator since 1972. For Brown to even be in the same ballpark as Coakley is a testament to the voters' recognition of the implications of this race.

According to their campaign web sites, here are the candidates stances on health care issues:

• Coakley: She supports Obama's health care reform because she believes it will increase medical insurance coverage, will improve quality, and will lower costs (due to greater industry transparency and a change in the way incentives are used).
• Brown: He plans to vote against the reform bill because he believes it will raise taxes, will increase government spending, and that it compromises quality of care (especially for elders on Medicare). Instead, Brown is in support of bolstering the existing private insurance system, making it more affordable for people to obtain insurance.

Yes, it's undeniable that health care reform will lead to more government spending to pursue its goals of covering the uninsured; the question here, really, is if the spending is worth it. Both candidates want more people to be insured (but really, what reasonable person wouldn't?), but have different routes to achieving it - and the federally-funded vs. free market solution is a partisan debate as old as Lou Holtz.

But what I'm fascinated by is this: Both of the politicians claim that their solution will lead to a better healthcare quality. They can't BOTH be right (although I suppose, theoretically, both could be wrong). If we look at the evidence, who is being most empirically truthful?

First, let's operationalize the buzzword "quality." A high-quality health care system, according to the U.S. Agency for Healthcare Research & Quality, is one that does "the right thing at the right time in the right way for the right person and having the best results possible.” Translation: Every patient has different needs, and a good system allows healthcare professionals to address those needs in such a way that every person has the best health outcome possible.

How do we determine "quality"? Central to Obama's health reform bill is the utilization of comparative effectiveness research. The health outcomes of different treatments are compared (i.e., for different conditions, different levels of severity, by gender, etc.) with the goal of figuring out the optimal evidence-based treatment for different types of patients. This info would be distributed to healthcare professionals as well as patients. This would lead to (1) all stakeholders knowing more about their treatment options, and (2) less utilization of unnecessary and ineffective treatments, thereby saving money and healthcare resources. (The Kaiser Family Foundation has a great review of this concept, for those interested.)

Actually, private insurance companies are also in favor of improving quality/lowering costs using comparative effectiveness research. The real difference between the two perspectives is who is doing the research. Either the insurance company would figure out the best practices themselves, or the federal government would do the research. The biggest problem I see in the private market research is with the credibility of their findings. We make pharmaceutical companies hire third-party analysts for their clinical trials data for this very reason - when a private company holds a financial stake in the outcome, their results could very easily (and are quite probably) biased. Sure, the federal government isn't perfectly transparent, but we certainly can't expect private businesses to be more transparent.

Both Brown and Coakley are claiming their political standpoint to be more conducive to high quality healthcare. But Coakley's got the upper hand: When it comes to being able to trust the conclusions of quality/effectiveness research, this is best left in the hands of the federal government, which is required to be transparent and will be thoroughly scrutinized if it biased results in any way. Private companies may very well have health's best interest in mind, but because the industry doesn't lend itself to the same level of scrutiny and peer review, I'm not sure if private insurance company's findings would be trustworthy.

Both candidates claimed that their standpoint on health care reform would "improve quality," and as is evident, these claims can't be taken at face value. It's clear how Coakley's health reform "yea" vote would improve quality, but the same can't be said for Brown's "nay." Massachusettans cast their ballots tomorrow, and I hope everyone who votes has looked past the celebrity battle and has looked into the legitimacy of the aspiring Senators' rhetoric.