The Economist: "His is a bold ambition indeed; but this week the president looked a bit closer to fulfilling it."

I've posted an article once before ("4 emails debating health reform!") from the magazine, The Economist.  Their editorials are (I believe) usually thoughtful and objective, and here's what they had to say this week about Obama's health-care speech.  For the wonkier/wonkiest, below that are snippets from a 2nd article that goes into much more detail explaining the significance of this speech where "Mr Obama also unveiled the main elements of his own centrist reform plan for the first time." Click on the link to read the full article at economist.com. 

The art of the possible

A fine, measured piece of oratory from the president. But there is still tough work to do

“I AM not the first president to take up this cause, but I am determined to be the last.” Thus Barack Obama, late in the day, took his quest to reform America’s expensive and flawed health-care system to the floor of Congress with a mighty speech that will surely stand as one of the defining moments of his presidency, whether it leads to eventual triumph or disaster. His is a bold ambition indeed; but this week the president looked a bit closer to fulfilling it.

Politics, as everyone knows, is the art of the possible; and there have been times over this ill-tempered summer when the idea of tackling a system that costs almost twice as much as any other rich country’s, yet yields substandard results and leaves tens of millions of people with no health insurance at all, has seemed simply impossible. Mr Obama has to find a package of policies that is fiscally and politically moderate enough to win over a vital few Republicans to his side (and also prevent the defection of nervous conservative Democrats). But at the same time he has to keep the support of the leftish Democratic Party base, which wants to see a more expansive and costly set of reforms. He may well fail. But on September 9th the president for the first time laid out in some detail what such a plan might look like. Cleverly borrowing good ideas from both sides of the party divide, his proposals at least look like a plausible basis for agreement (see article).

The plan obliges everyone to take out health insurance while creating a tapering subsidy for poorer families to help them afford it. It also requires insurance companies to end various nefarious practices, such as refusing to insure people with existing conditions or cancelling their coverage just when they need it most. To pay for these long-held liberal goals (the cost is put at $900 billion over ten years), the president has committed himself to several policies that Republicans, if only they could remove their partisan spectacles, should applaud.

There is, for instance, a tax on insurance companies that offer “Cadillac” plans to richer individuals; since this will inevitably be passed on to consumers, it is a useful step towards making individuals aware of the cost of their coverage. He has made a cast-iron pledge that he will not sign a health bill that increases the deficit, and has promised automatic spending cuts if savings do not materialise. He wants to set up a new technocratic committee that could mandate changes to the hugely expensive Medicare system of health care for the elderly (an idea that cleverly takes such difficult decisions out of the hands of politicians, who have displayed a lamentable failure to grapple with them). And the president also promised conservatives reform of America’s mad tort system. The risk of being sued pushes up costs, obliging doctors to practise “defensive medicine” in the shape of needless tests and procedures.

Give me public options, but not now

Still up in the air is the trickiest question of all: whether the government should create a “public option”, its own insurance provider, which people could use if they dislike what the free market has to offer. Medical insurers and most Republicans say a public plan would enjoy unfair advantages and destroy competition. Liberal Democrats say the insurers will not cut prices without it. Both sides have a point. This newspaper still thinks the best solution would be to keep the public option as a threat: to set up a formal provision in the bill whereby a public plan would be introduced in, say, five years’ time if certain targets were not met. In his speech Mr Obama hedged his bets, sticking with the public option but signalling a willingness to compromise. This may come back to haunt him. But overall, this performance was a big step forward.

Fired up and ready to go

As Congress returns to work, two big bills before it may determine the fate of Barack Obama’s presidency—and he knows it. First, health care

“THE time for bickering is over. Now is the time for action.” With those fiery words, delivered to a special joint session of Congress on September 9th, Barack Obama made his case for reforming America’s troubled health system....

The speech was a success on several measures. It was passionate, which is essential if he is to win over a sceptical American public and energise his liberal base....

....Reading from a letter he had received from [Senator Edward Kennedy] posthumously, as his widow listened from the gallery, Mr Obama made the moral case for change: “At stake are not just the details of policy, but fundamental principles of social justice and the character of our country.”

During this passage, he cleverly reminded Americans that leading Republicans currently hostile to Democratic efforts at health reform—including Senators Orrin Hatch and John McCain—had worked hand-in-hand with Mr Kennedy on earlier, smaller efforts at health reform. That points to the second reason to think that Mr Obama’s speech may yet succeed in kick-starting reform this autumn: it managed to position the president as a reasonable and moderate adult in a room full of petty and partisan ideologues....

...He also announced a surprising idea to use executive authority to encourage state-level experiments in curbing malpractice abuses.

Mr Obama also unveiled the main elements of his own centrist reform plan for the first time. He wants to expand coverage to some 30m Americans without insurance, principally by introducing an individual mandate for cover, insurance exchanges, subsidies for the less well-off and heavy regulation of insurers. He also accepted an important proposal to tax the most lavish of insurance plans.

Crucially, he made it plain that he would not accept a health-reform bill from Congress that raises the deficit—not now, not ever. He also vowed that most of the $900 billion his plan will cost—again, the first time he has given a firm figure for his initiative—will come not from taxes on the rich, as the current bills in the House envision, but from internal savings to be realised within the health system.

He offers two reasons to suppose that this claim is not complete bunk. The first is the White House’s support for empowering an independent panel of experts to cut costs in Medicare and other government health schemes. This matters, because Congress has shown it is incapable of making such difficult cuts. More impressive is his vow this week that any final bill must include provisions for mandatory spending cuts that would kick in if budgeted cost savings do not materialise.

Will this speech be enough to get the president’s reform agenda back on track? It just might be. One reason to think so is the deft way Mr Obama signalled a willingness to compromise on the “public option” this week. The left has insisted on a government-run insurance scheme, but this ill-founded idea is strongly opposed by the health-care industry and by Republicans. It also has no hope of passing the Senate, as Max Baucus, the head of its Finance Committee, confirmed this week. Mr Obama voiced theoretical support for the idea, but by also supporting other options—including, crucially, the idea that such a plan could be triggered only if necessary later—he has, in effect, dealt it a death blow.

Several committees in the House have already passed versions of health bills, but all contain the public option and are seen as too far to the left of the Senate—and now, it is clear, of where Mr Obama stands. So all eyes are now on the Senate Finance Committee, where a “Gang of Six” led by Mr Baucus has been working to forge a moderate bill that could provide the backbone for any final health law this year. Mr Baucus this week unveiled his own $900 billion proposal (also a moderate approach without the public option), and announced plans to finalise a bill next week.

Earlier this week that effort seemed to be flagging, as two of the Republicans in the gang, Charles Grassley and Mike Enzi, appeared to be undermining its efforts. That leaves Olympia Snowe, the free-spirited Republican from Maine, as the most courted legislator in recent memory. Mr Obama’s speech and sensible proposals, which are similar to those drafted by Mr Baucus, and his openness to the trigger option favoured by Ms Snowe, can only boost efforts at compromise.

Whether it is enough to keep Ms Snowe and perhaps one or two other Republicans firmly on board remains to be seen. But even if it does not, the next few weeks could yet produce a bill that is better than anything seen thus far and which would be worth passing. He was not the first president, Mr Obama said, to take up health-care reform; but he was determined to be the last.

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Hear me out: This is the time for all of us in health care to act. It will take you 1 min.

Obama did a good job in his speech making clear why we--as individuals & as a country--must succeed on health reform now.  But since most people already understood that urgent need... even more importantly, his speech succeeded in eliciting exactly what this reform means for 3 categories of people--which together include all Americans:

1. people already w/ health insurance (majority),
   
2. Americans without health insurance (~30 million folks), and
   
3. (the following category overlaps onto category #1) those who currently pay the rising bills for the uninsured when they get sick.
   

Take a look at the speech yourself:
[jump ahead 5:00 min to skip the monotonous clapping]

As I watched the speech together with a friend--and noticed that in one after another of Obama's statements, precisely 1/2 the chamber stood up and clapped, while the other 1/2 sat stoically across the aisle--she said, "OH that's why I hate politics!" 

Agreed.  It's as if these Representatives and Senators whom we all elected to act as leaders during this crucial time can't even think with their own brains once in awhile, instead they stick to "party lines" as if those lines were the only hardwired neuronal pathways they owned in their cortex.

Here is 1 suggestion I have to every single person in the health care profession, including myself as a student.  The simple fact of our profession not only gives us & those we will serve a bigger stake, personally, in the outcome of health reform; but it also truly bestows upon us an added credence when we have something to say (I've seen the special attention paid by politicians to a doctor or nurse at a phone banking or rally for health care; also, see the YouTube below of the ER doc in the audience at a recent town hall).  And what we can say, what we all can absolutely agree upon--but this still is in danger, not because of merit but merely because of political games--is that WE STAND BY THE NEED TO PASS HEALTH REFORM NOW, THIS YEAR.  (Click here if you are willing to make this simple statement to your representatives, it will convince hesitant politicians that the will is there, and it will only take you 1 minute)

Aside from the 1 Senator who wants to block health reform because "it will break" Obama, every single leader and expert of all persuasions knows that achieving health reform is crucial for America's health, economy, and sustainability in the very near future.  We are on an exponential downward path if we keep our current system and don't act now.  And this is another thing Obama got right in emphasizing tonight: that 80% of the components within Health Reform already has bipartisan support (and these include drastic positive reforms such as outlawing insurance companies from denying care based on "pre-existing conditions"--see the last 2 paragraphs of my letter on "Where'd all the fear come from?" below).  However, this crucial national effort is still on the verge of being sabatoged by people like that shameless Senator who wants to "break" Obama by breaking health reform. 

What I respect about some of Obama's big speeches to date is that he (or his speechwriter) gets the precision to tweak out at the exact point of confusion, of our paralysis, the truer narrative of what has really been happening on a national landscape (he did this in his "Reverend Wright/Race" speech, and he did this to some extent here on health reform): "I will not waste time with those who have made the calculation that it's better politics to kill this plan than improve it." 

Agreed.  Whatever your political persuasions, whichever your thoughts on the remaining 20% of health reform still in debate, or even if you don't have opinions on either, let's get ALL OF OUR political leaders to work on improving the health care plan and get it passed, rather than kill it.

Click here it'll take you 1 min.

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Feisty!, fiery!, a.k.a. Anthony Weiner's health care town hall

[Below is an essay published here written by a med student... Read what he now thinks about the impracticality of private insurers, the (un)free market of healthcare, and the 3 words that mock anti-Government conservatives.  Enjoy!]

My name is Cameron Gibson, and I'm an MS1er here at Downstate, and a bit of a closet political junkie.  I spent much of my summer abroad, so when I saw on the news Americans yelling and screaming about something, I assumed that the Yankees had just lost a pivotal game.  When I found out that in fact people were yelling and screaming about health care reform, my interest was peaked.  I couldn’t learn much from the regular media sources (who can?) about these “town hall meetings”, so I thought I should experience one for myself.  So, with my white coat in hand and a bottle of anti-anxiety pills at the ready, I set off to Rep. Anthony Weiner’s town hall meeting last Tuesday.  Suffice it to say, I had to down the entire bottle by the end of the night!...
...and through it all I sat quietly listening to what Rep. Weiner and the audience had to say.  It was exciting, it was scary, but most of all, it was eye-opening.  
Read Cameron Gibson's full essay...

My name is Cameron Gibson, I’m an MS1er here at Downstate, and a bit of a closet political junkie.  I spent much of my summer abroad, so when I saw on the news Americans yelling and screaming about something, I assumed that the Yankees had just lost a pivotal game.  When I found out that in fact people were yelling and screaming about health care reform, my interest was peaked.  I couldn’t learn much from the regular media sources (who can?) about these “town hall meetings”, so I thought I should experience one for myself.  So, with my white coat in hand and a bottle of anti-anxiety pills at the ready, I set off to Rep. Anthony Weiner’s town hall meeting last Tuesday.  Suffice it to say, I had to down the entire bottle by the end of the night!

Now, I feel I must point out the author’s inherent bias.  Since learning anything about the American healthcare system, I’ve always known that something was wrong.  I’m a firm believer that healthcare is an inalienable right, on the same level as freedom of speech and religion.  However, I went to Rep. Weiner’s meeting a skeptic of the “single-payer option”.  After hearing Rep. Weiner--a major supporter of a single-payer system--present his argument, I was practically a convert:

• Private insurers have gargantuan 20-40%! overhead costs. Medicare and Medicaid have ~4% overhead cost.  Therefore, that alone in a single-payer system = a savings of ~$300 billion.   
• A single-payer option is one of the best ways to insure the 47+ million Americans who are currently uninsured.
  
  

Now you’re probably saying, “Wait a minute, there are a number of reasons why we shouldn’t throw out our current system.”  Well, you’re not alone in making this argument.  In fact, there were many people--not even including the folks outside who handed out flyers of Obama’s face with a Hitler-mustache…!--there who were vehemently opposed to healthcare reform, and they made themselves known early in the evening (I think my grandmother in Oregon even heard them!). 

I would now like to elucidate a few of the arguments I heard that night against current health reform W/ the public option, and show why they are inherently flawed:

We can’t afford to reform healthcare!

In fact-and Weiner said this as well-We can’t afford NOT to!

• We currently spend more in real dollars and % GDP on healthcare than most western countries 
• but we are only ranked 37th worldwide by the WHO for quality of healthcare (if you went to Morocco you would receive better care!).   
• While more and more of us can’t afford our healthcare, private insurance continues to bring in astronomical profits year after year.  As things stand, they have no incentive to change the system, If there ever is a dip in their profit margin, all they have to do is raise the premium on their customers and the coffers are refilled! 
  
  

So, without the government stepping in in some form, whether through regulation or outlawing certain practices, we are currently set on a path of economic implosion solely from healthcare costs.

But we are a capitalist society, let the market fix the problem!

Without even mentioning the obvious example of 2008, it has been proven that the market cannot fix all of life’s problems.  Without the government, there would be no freeways, no electrical grid, no public school system (a blessing and a curse, for some), or Medicare/Medicaid (opponents sometimes conveniently forget that these are in fact government programs). 

Regarding healthcare, capitalism is not the most effective economic model because it reduces healthcare to a commodity, equal to insuring your belongings (i.e. renter’s insurance).  This ignores the fact that when someone gets seriously sick and their survival is in question, they can’t just choose not to seek medical help because they don’t feel like it (well, they could, but it would run against their Darwinian instincts).  If my TV is stolen and I don’t have insurance, I’m out a TV, whereas if I’m diagnosed with a curable cancer but have no insurance to pay for it, I either lose my life or go bankrupt (and so do my wife, siblings, parents, grandparents, etc.).  Viewing healthcare as a commodity ignores the reality & human side of healthcare.

The Government is wasteful and does a poor job of running national programs.

3 words: Med-i-care.  Ask anyone over the age of 65 with Medicare how they think the government is doing with their healthcare, and 96% of them will say they’re doing a DAMN good job!  (I’m almost certain that no other health insurance company can brag about such high customer satisfaction).

(This last point has less to do with current proposals for health reform being considered--i.e. Health Insurance Reform W/ the Public Option—and instead is only in response to a government Single-Payer system)

I don’t want my taxes to go up.

Sure, your taxes would probably go up.  You’d be paying more into Medicare, but guess what!  YOU’RE ALREADY PAYING MORE TAXES, just in a different form!  What does the middle class think their premiums are, a gift to their insurance company for doing such a good job?  Premiums have risen so drastically that the average individual now pays over $4000 each year for health insurance with a private insurer.  My question to the nay-sayers then is this: if you had the same coverage as you do now, but never had to argue with your insurance on the phone because of hidden fees, never had to search for a doctor that accepted your insurance, who cares whether the money is going to the private sector or the government!?  In fact, if everyone was paying into the same pot for healthcare, the young and old, sick and healthy, our premiums would probably go down or at least stay the same.  Spread the risk around and no one person is stuck with the bill!

These were just a few of the things that I heard being said/shouted, and through it all I sat quietly listening to what Rep. Weiner and the audience had to say.  It was exciting, it was scary, but most of all, it was eye-opening.  We are the land of freedom, where anyone has the right to express their individuality without fear of persecution or reprisal.  Somewhere along the way we lost our moral compass and veered off-course, to a place where we no longer care about the common good of our society.  We will send millions in aid to Africa every year to help the world’s poor and destitute, but I’ll be damned if I’ll help my neighbor with leukemia.

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"Health Care Sound and Fury"

Health care debate has heated up, some of the added volume to drown actual discussion, other voices shouting to remain heard above the crowd. But this news segment goes on from there to summarize a new PBS documentary, "Money-Driven Medicine," which is gradually earning people's ears & attention, because of its thought and willingness to actually listen & learn from the stories of doctors and patients in America.

To watch the full PBS documentary see below:

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Where'd all the fear come from? Somewhere that led to my mom's email inbox

My mom received an email about "Health Care Info," from a large community listserve, sent by a person who received the email "routed from a credible former colleague," originally written by... Who knows; maybe Sarah Palin? Here is my response:

The first sentence is not only written to scare (with no explanation whatsoever), but it is a complete outright lie: "...is over 1,000 pages long and puts the government in charge of our health care system."  The mention of 1,000 pages is a pointless scare tactic (as someone said, the last Harry Potter book was >700 pages long), and nothing proposed by anyone even comes close to "government in charge of our health care system." 

For the past 30 years, it is the insurance companies who are already dictating how doctors practice, and what care patients can or cannot get.  This has happened while every year there are over a million more Americans without health insurance (this year now there are 48 million uninsured), many of these uninsured people either get very sick or end in the hospital--which all Americans have paid for via high & rising premiums, and bankrupt public hospitals--while insurance companies have shown record profits year after year & their CEOs earn increasing salaries in the millions. 

If you or anyone you know have ever dealt on the phone with an insurance company trying to deny you care, I strongly urge you to read this New York Times article on Wednesday explaining why.   This former executive in the health insurance industry, who's job was to devise ways to scare Americans from important health reform (just like the email below), reached his conscience and now is speaking out strongly in support of needed health reform.

Insurance companies are also afraid of & against progressive ideas like the Health Info "Exchange" (mentioned in the email below) which will promote free-market competition and make it much easier for you to individually compare & contrast different health plans (currently, sorely lacking), and therefore improve health coverage + bring down premiums by competition.The types of rules that health care reform plans indeed want to enact that do affect health care are things like requiring all health insurance plans to cover annual checkups, cancer screenings--saving lives & saving costs by preventing end-stage hospitalizations--and to outlaw insurance companies from denying care based on "pre-existing conditions."  These are all changes in the current Health Insurance Reform that everyone (except insurance company CEOs & others people trying to scare Americans) agrees are good and necessary.

Therefore, I would indeed agree with going online "AND WRITE YOUR REPS"--as the email below urges you--but I would advocate for contacting them in support of real substantial health reform aspects like these (instead of the vague scare tactics announced elsewhere).
-Abe

 [The original email forwarded, forwarded, forwarded, from some unidentified "guru," into my mom's inbox is right here below:]

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Saturday's Health Care Rally @ Times Square

See slideshow of Healthcare Rally also in New York Times.

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New York Times Op-Ed: Health Care Fit for Animals

http://www.nytimes.com/2009/08/27/opinion/27kristof.html?_r=1

By NICHOLAS D. KRISTOF

Opponents suggest that a “government takeover” of health care will be a milestone on the road to “socialized medicine,” and when he hears those terms, Wendell Potter cringes. He’s embarrassed that opponents are using a playbook that he helped devise.
“Over the years I helped craft this messaging and deliver it,” he noted.
Mr. Potter was an executive in the health insurance industry for nearly 20 years before his conscience got the better of him. He served as head of corporate communications for Humana and then for Cigna.
He flew in corporate jets to industry meetings to plan how to block health reform, he says. He rode in limousines to confabs to concoct messaging to scare the public about reform. But in his heart, he began to have doubts as the business model for insurance evolved in recent years from spreading risk to dumping the risky.
Then in 2007 Mr. Potter attended a premiere of “Sicko,” Michael Moore’s excoriating film about the American health care system. Mr. Potter was taking notes so that he could prepare a propaganda counterblast — but he found himself agreeing with a great deal of the film.
A month later, Mr. Potter was back home in Tennessee, visiting his parents, and dropped in on a three-day charity program at a county fairgrounds to provide medical care for patients who could not afford doctors. Long lines of people were waiting in the rain, and patients were being examined and treated in public in stalls intended for livestock.
“It was a life-changing event to witness that,” he remembered. Increasingly, he found himself despising himself for helping block health reforms. “It sounds hokey, but I would look in the mirror and think, how did I get into this?”
Mr. Potter loved his office, his executive salary, his bonus, his stock options. “How can I walk away from a job that pays me so well?” he wondered. But at the age of 56, he announced his retirement and left Cigna last year.
This year, he went public with his concerns, testifying before a Senate committee investigating the insurance industry.
“I knew that once I did that my life would be different,” he said. “I wouldn’t be getting any more calls from recruiters for the health industry. It was the scariest thing I have done in my life. But it was the right thing to do.”
Mr. Potter says he liked his colleagues and bosses in the insurance industry, and respected them. They are not evil. But he adds that they are removed from the consequences of their decisions, as he was, and are obsessed with sustaining the company’s stock price — which means paying fewer medical bills.
One way to do that is to deny requests for expensive procedures. A second is “rescission” — seizing upon a technicality to cancel the policy of someone who has been paying premiums and finally gets cancer or some other expensive disease. A Congressional investigation into rescission found that three insurers, including Blue Cross of California, used this technique to cancel more than 20,000 policies over five years, saving the companies $300 million in claims.
As The Los Angeles Times has reported, insurers encourage this approach through performance evaluations. One Blue Cross employee earned a perfect evaluation score after dropping thousands of policyholders who faced nearly $10 million in medical expenses.
Mr. Potter notes that a third tactic is for insurers to raise premiums for a small business astronomically after an employee is found to have an illness that will be very expensive to treat. That forces the business to drop coverage for all its employees or go elsewhere.
All this is monstrous, and it negates the entire point of insurance, which is to spread risk.
The insurers are open to one kind of reform — universal coverage through mandates and subsidies, so as to give them more customers and more profits. But they don’t want the reforms that will most help patients, such as a public insurance option, enforced competition and tighter regulation.
Mr. Potter argues that much tougher regulation is essential. He also believes that a robust public option is an essential part of any health reform, to compete with for-profit insurers and keep them honest.
As a nation, we’re at a turning point. Universal health coverage has been proposed for nearly a century in the United States. It was in an early draft of Social Security.
Yet each time, it has been defeated in part by fear-mongering industry lobbyists. That may happen this time as well — unless the Obama administration and Congress defeat these manipulative special interests. What’s un-American isn’t a greater government role in health care but an existing system in which Americans without insurance get health care, if at all, in livestock pens.

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Join "Rally for Health Care Reform" this Saturday!

Saturday, August 29

Downstate Contingent Joining

UNITY RALLY FOR HEALTH CARE REFORM

(Please join at any point!)

10am-12pm:

· TABLING @ GRAND ARMY PLAZA

· Gathering signatures supporting a public option (for Sen. Schumer)!

· Flyering for the 2pm rally at Times Square to demonstrate our support for PROGRESSIVE health care reform!

• RSVP here!

12pm: leave together for Times Square

2pm-4pm:

· HEALTH INSURANCE REFORM RALLY @ TIMES SQUARE

· A partnership of NYC grassroots groups and Organizing for America

· Speaking program begins at 2pm. Arrive early!

“It's our health care. It's our time. Save the date to make your voice heard.”

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Helping Primary Care NOW!

In regards to a proposed 8 percent increase in reimbursement rates to primary care physicians in the 2010 Medicare fee schedule, an email from the American Academy of Family Physicians notified me that "As you would expect, the subspecialists are mobilizing their members to oppose this change."
On the other hand: Below is the "comment" I left at the Regulations.gov webpage to show my support, and if you believe so too, you can do so too here.

I am happy/relieved to hear of this proposed 8% increase in Medicare reimbursement rates to primary care physicians. Happy because it is the first I have learned of an indication that consideration for primary care is valued; relieved because even in my brief introduction into medicine so far it has been hard not to become cynical sometimes about where I was headed.

Whereas access to primary care has

proven to be the leading indicator for an individual's and community's health, the reputation of primary care medicine has sunk to the bottom of the barrel, in the eyes of this whole generation of students entering the medical profession. Primary care physicians "make the least," "are the most ignored and undervalued in society," and they "are not respected"--these are just a few of the "truisms" I have heard mentioned by many peers so far.

I am on my way to become a second year medical student, and one of the few medical students remaining these days thinking of pursuing primary care medicine (down to only about 1% of us, in fact, despite an exponential explosion in the nation's impending need). I urge all of my peers & our political leaders to push & pass this increase in reimbursement to primary care physicians. If so, this will help encourage more future physicians to fill the much-needed primary care roles that will accompany America's increasing demand and (hopefully) expanded health insurance coverage. If not, the alarming trend of medical students' aversion to primary care will continue, and folks like me will be even lonelier, and maybe even altogether discouraged.

Sincerely, Abraham Young

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NYT: Wisdom on ankle injuries!

How to Fix Bad Ankles

By Gretchen Reynolds

July 8, 2009, 10:30 am

[Click on link above to NYT article for video on ankle exercises!]

Ankles provide a rare opportunity to recreate a seminal medical study in the comfort of your own home. Back in the mid-1960s, a physician, wondering why, after one ankle sprain, his patients so often suffered another, asked the affected patients to stand on their injured leg (after it was no longer sore). Almost invariably, they wobbled badly, flailing out with their arms and having to put their foot down much sooner than people who’d never sprained an ankle. With this simple experiment, the doctor made a critical, if in retrospect, seemingly self-evident discovery. People with bad ankles have bad balance.

Remarkably, that conclusion, published more than 40 years ago, is only now making its way into the treatment of chronically unstable ankles. “I’m not really sure why it’s taken so long,” says Patrick McKeon, an assistant professor in the Division of Athletic Training at the University of Kentucky. “Maybe because ankles don’t get much respect or research money. They’re the neglected stepchild of body parts.”

At the same time, in sports they’re the most commonly injured body part — each year approximately eight million people sprain an ankle. Millions of those will then go on to sprain that same ankle, or their other ankle, in the future. “The recurrence rate for ankle sprains is at least 30 percent,” McKeon says, “and depending on what numbers you use, it may be high as 80 percent.”

A growing body of research suggests that many of those second (and often third and fourth) sprains could be avoided with an easy course of treatment. Stand on one leg. Try not to wobble. Hold for a minute. Repeat.

This is the essence of balance training, a supremely low-tech but increasingly well-documented approach to dealing with unstable ankles. A number of studies published since last year have shown that the treatment, simple as it is, can be quite beneficial.

In one of the best-controlled studies to date, 31 young adults with a history of multiple ankle sprains completed four weeks of supervised balance training. So did a control group with healthy ankles. The injured started out much shakier than the controls during the exercises. But by the end of the month, those with wobbly ankles had improved dramatically on all measures of balance. They also reported, subjectively, that their ankles felt much less likely to give way at any moment. The control group had improved their balance, too, but only slightly. Similarly, a major review published last year found that six weeks of balance training, begun soon after a first ankle sprain, substantially reduced the risk of a recurrence. The training also lessened, at least somewhat, the chances of suffering a first sprain at all.
Why should balance training prevent ankle sprains? The reasons are both obvious and quite subtle. Until recently, clinicians thought that ankle sprains were primarily a matter of overstretched, traumatized ligaments. Tape or brace the joint, relieve pressure on the sore tissue, and a person should heal fully, they thought. But that approach ignored the role of the central nervous system, which is intimately tied in to every joint. “There are neural receptors in ligaments,” says Jay Hertel, an associate professor of kinesiology at the University of Virginia and an expert on the ankle. When you damage the ligament, “you damage the neuro-receptors as well. Your brain no longer receives reliable signals” from the ankle about how your ankle and foot are positioned in relation to the ground. Your proprioception — your sense of your body’s position in space — is impaired. You’re less stable and more prone to falling over and re-injuring yourself.

For some people, that wobbliness, virtually inevitable for at least a month after an initial ankle sprain, eventually dissipates; for others it’s abiding, perhaps even permanent. Researchers don’t yet know why some people don’t recover. But they do believe that balance training can return the joint and its neuro-receptor function almost to normal.

Best of all, if you don’t mind your spouse sniggering, you can implement state-of-the-art balance training at home. “We have lots of equipment here in our lab” for patients to test, stress, and improve their balance, Hertel says. “But all you really need is some space, a table or wall nearby to steady yourself if needed, and a pillow.” (If you’ve recently sprained your ankle, wait until you comfortably can bear weight on the joint before starting balance training.) Begin by testing the limits of your equilibrium. If you can stand sturdily on one leg for a minute, cross your arms over your chest. If even that’s undemanding, close your eyes. Hop. Or attempt all of these exercises on the pillow, so that the surface beneath you is unstable. “One of the take-home exercises we give people is to stand on one leg while brushing your teeth, and to close your eyes if it’s too easy,” Hertel says. “It may sound ridiculous, but if you do that for two or three minutes a day, you’re working your balance really well.”

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