Saturday, January 4, 2014

This Is Anxiety - James Hamblin - The Atlantic

"Here's what's worked: nothing." Scott Stossel writes with resignation in the cover article for the current issue of The Atlantic, "Surviving Anxiety." (Inside the magazine it's headlined "My Anxious, Twitchy, Phobic (Somehow Successful) Life".) The story, adapted from Stossel's forthcoming book, tells of his life with anxiety disorder; how he remains high-functioning despite it, and maybe in ways because of it.

The Atlantic editors invited readers to send in stories of their own experiences with anxiety. We said that "several" stories would be selected for publication on As you'll see by the length of this post, I failed handsomely at paring it down to several.

We got so many interesting submissions, and there was even more that I wanted to share than is here. Rather than run three or four people's stories in full, we decided to run parts of many. Forty-three. I also pulled salient quotes from most of the excerpts along the left margin. People interpreted the writing prompt very broadly, so some of it is lighthearted, and some of it is tragic. There is some advice on what works, how to keep perspective, and what makes things worse. In aggregate I hope it reads like a mixtape that reflects how widespread all of this is and how deeply it resonates.

I'd like these to mostly speak for themselves, but I will call out a couple recurring points. Anxiety is not a choice. Don't tell people with anxiety to "stop worrying." Do reassure them. Don't leave them alone. Talk about your anxiety with friends and family. Be attuned and empathetic to it in others. Own your own.

Unlike Stossel, many people have found that certain treatments, behaviors, and ways of thinking about their anxiety can be helpful. Okay, here are your stories.

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Thursday, January 2, 2014

Emergency Visits Seen Increasing With Health Law -

Supporters of President Obama's health care law had predicted that expanding insurance coverage for the poor would reduce costly emergency room visits because people would go to primary care doctors instead. But a rigorous new experiment in Oregon has raised questions about that assumption, finding that newly insured people actually went to the emergency room a good deal more often.

The study, published in the journal Science, compared thousands of low-income people in the Portland area who were randomly selected in a 2008 lottery to get Medicaid coverage with people who entered the lottery but remained uninsured. Those who gained coverage made 40 percent more visits to the emergency room than their uninsured counterparts during their first 18 months with insurance.

The pattern was so strong that it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings.

The findings cast doubt on the hope that expanded insurance coverage will help rein in emergency room costs just as more than two million people are gaining coverage under the Affordable Care Act. And they go against one of the central arguments of the law's supporters, that extending insurance to large numbers of Americans would reduce emergency room use, and eventually save money.

In remarks in New Mexico in 2009, Mr. Obama said: "I think that it's very important that we provide coverage for all people because if everybody's got coverage, then they're not going to the emergency room for treatment."

The study suggests that the surge in the numbers of insured people may put even greater pressure on emergency rooms, at least in the short term. Nearly 25 million uninsured Americans could gain coverage under the law, about half of them through Medicaid. The first policies took effect on Wednesday.

"I suspect that the finding will be surprising to many in the policy debate," said Katherine Baicker, an economist at Harvard University's School of Public Health and one of the authors of the study.

An administration spokeswoman, Tara McGuinness, said that the time frame was too short to expect much of a change, and that over the longer term, use would most likely decline. She pointed to a longer-term study in Massachusetts, which expanded coverage for its residents in 2006, that found an 8 percent decline in emergency department use over a period of several years.

"Medicaid saves lives and improves health outcomes," Ms. McGuinness said. "Plenty of studies show that."

But many economists say that the emphasis on emergency room use, both in policy and in political speeches, is misplaced, as it makes up only a small part of health care costs in the United States. A federal government health survey found that emergency departments accounted for about 4 percent of total health spending in 2010, far less than inpatient hospital visits, which accounted for about 31 percent. Certain populations, however, like low-income people with chronic illnesses, have much higher rates of use.

Dr. Baicker and Amy Finkelstein, an economist at the Massachusetts Institute of Technology, another author, said the increased use of emergency rooms is driven by a basic economic principle: When services get less expensive, people use them more. Previous studies have found that uninsured people face substantial out-of-pocket costs that can put them in debt when they go to the emergency room. Medicaid reduces those costs.

Medicaid coverage also reduces the costs of going to a primary care doctor, and a previous analysis of data from the Oregon experiment found that such visits also increased substantially.

"This is just one piece of an increase we found across every type of care," said Bill J. Wright, an author of the new study who is the associate director of the Center for Outcomes Research and Education in Portland, a part of Providence Health and Services, a large health care provider.

The study's authors emphasized that Medicaid had many benefits. Previous analyses from the experiment found that gaining coverage reduced the incidence of depression and increased feelings of financial stability.

The study drew on data from the Oregon Health Insurance Experiment that included about 90,000 low-income Oregonians and randomly assigned about 30,000 of them access to Medicaid. Health experts say the experiment's design — random assignment of coverage through a lottery — allowed them to isolate and evaluate the effects of the program. Such designs are the gold standard in medical research, but are rarely used for domestic health care policy.

Some experts noted that the study measured only the first 18 months after people gained coverage, and that old habits of relying on the emergency room are often hard to shake. It also takes time to find a primary care doctor and make an appointment.

"How to use a plan and when to seek emergency department care involves a learning curve that doesn't happen overnight," said Sara Rosenbaum, a health researcher at George Washington University who was not involved in the study.

Amitabh Chandra, a professor and director of health policy research at the Harvard Kennedy School of Government, said people may often use the emergency room because they need its services. Medicine has become increasingly complex, with teams of specialists using highly sophisticated equipment for treatments that often go beyond the capabilities of the family doctor.

"We often say, 'If this person had just received preventative care at a doctor's office, we would not have seen emergency room use,' " said Dr. Chandra, who was not involved in the study. "But there is only so much that prevention can do."

Professor Rosenbaum pointed out that a lot of the recent growth in emergency department use has been among the privately insured people, not the uninsured. She said insurers often recommend going to the emergency room for quick specialty care, like for stomach pain.

Dr. Wright said that many participants in Oregon were already connected to a primary care doctor, and that it was unlikely that the rise in use had much to do with a lack of access to a physician. The study's lesson, he said, was that new coverage needed to be accompanied by broader changes to the way care was delivered, like those in Oregon and under Mr. Obama's new law.

Heidi Allen, an assistant professor at Columbia University and an author of the study, said much of the non-urgent emergency department use among patients she interviewed happened because those patients could not get same-day appointments with their primary care doctors.

Dr. Chandra, who helped conduct another analysis of emergency department use in Massachusetts after the overhaul, called the Oregon study, with its strong design and clear result, "breathtaking." In contrast, studies from Massachusetts have come up with conflicting findings. His study, for example, found that emergency room use did not change.

"You would conclude what you wanted to conclude depending on which side of political aisle you were on," he said, adding, "Now we have an answer."

Study: Expanding Medicaid doesn’t reduce ER trips. It increases them - Washington Post

As the health-care law expands Medicaid to cover millions more Americans, a new Harvard University study finds that enrollment in public program significantly increases enrollees' use of emergency departments.

The research, published Thursday in the journal Science, showed a 40 percent increase in emergency department visits among those low-income adults in Oregon who gained Medicaid coverage in 2008 through a state lottery. This runs counter to some health-care law supporters' hope that Medicaid coverage would decrease this type of costly medical care, by making it easier for low income adults to see primary care providers.

"I would view it as part of a broader set of evidence that covering people with health insurance doesn't save money," says Jonathan Gruber, a health economist at the Massachusetts Institute of Technology, who has also studied Oregon's Medicaid expansion but is not affiliated with this study. "That was sometimes a misleading motivator for the Affordable Care Act. The law isn't designed to save money. It's designed to improve health, and that's going to cost money."

The Science study is part of a much larger research project that looks at Oregon's 2008 Medicaid expansion, where the state had limited funding to expand the public program to a set number of low-income residents. Oregon used a lottery to determine who would gain access to coverage, and that created a unique opportunity for researchers: The chance to study what happens when some people are randomly assigned to receive health insurance, and others are not.

Previous research on the Oregon Medicaid expansion has found that enrolling in the public program increased hospital visits, primary care trips and prescription drug use. That left an unanswered question: Were new Medicaid enrollees going their primary care doctor instead of the emergency department, or, were they using more of all types of health-care services?

This study suggests the latter answer: With financial barriers removed, Medicaid patients see their primary care doctor more -- and also go to the emergency department at an increased frequency. Medicaid enrollees made, on average, 1.43 trips to the emergency department during the 18-month study period, compared to an average of 1.02 visits among those who entered the Medicaid lottery but did not gain coverage.

Medicaid coverage also increased the probability of having any visit to the emergency department by 7 percent. The researchers also looked at the types of visits and found no decline in use of the emergency department for primary care treatable conditions among those who had enrolled in Medicaid coverage.

"Part of what makes emergency department use interesting is there are different theories about what to expect," lead study author Sarah Taubman, also at the Harvard School of Public Health. "There's one theory that it increases, because insurance pays for emergency room care that would lead people to use more than if they faced the full cost. The other theory is that, by paying for primary care visits, insurance may lead to a decrease in emergency department use. We looked at this and, taken altogether, we see a net increase.

Twenty-five states and the District of Columbia expanded their Medicaid programs under the Affordable Care Act, extending coverage to all adults who earn less than 133 percent of the federal poverty line, about $15,000 for an individual and $31,400 for a family of four. Two more states, Indiana and Pennsylvania, are seeking to move forward with the health-care law program at a later date.

Although the Affordable Care Act initially mandated that all states expand their Medicaid programs, the Supreme Court ruling in June 2012 found that provision to be too restrictive, allowing each state to decide whether to participate.

Some governors have cited a reduction in emergency department visits as a reason to expand the public program.

"Today, uninsured citizens often turn to emergency rooms for non-urgent care because they don't have access to primary care doctors -- leading to crowded emergency rooms, longer wait times and higher costs," one fact sheet from Michigan Gov. Rick Snyder (R) states. "By expanding Medicaid, those without insurance will have access to primary care, lowering costs and improving overall health."

And, when Congress was debating the Affordable Care Act in 2009, Health and Human Services Secretary Kathleen Sebelius cited the high number of uninsured Americans being seen at the emergency department as a reason to pass the law

"Our health care system has forced too many uninsured Americans to depend on the emergency room for the care they need," she said in a July 2009 statement. "We cannot wait for reform that gives all Americans the high-quality, affordable care they need and helps prevent illnesses from turning into emergencies."

Gruber, the MIT economist, doesn't see the Harvard study as a compelling case against expanding Medicaid. There are still other benefits to insurance coverage, he says, that aren't about saving public funding. Separate research on the Oregon expansion, published last spring in the New England Journal of Medicine,  found Medicaid enrollees to have significantly lower rates of depression and were more able to pay their medical bills.

"The overall notion is we're getting people more health care," Gruber says. "There are huge improvements in mental health. For those who want to argue that expanding Medicaid is a free lunch, this is bad. But that was never the right argument."

Tuesday, December 31, 2013

I Had My DNA Picture Taken, With Varying Results -

I like to plan ahead; that much I knew about myself before I plunged into exploring my genetic code. I'm a healthy 28-year-old woman, but some nasty diseases run in my family: coronary heart disease,rheumatoid arthritisAlzheimer's and breast cancer.

So I decided to read the tea leaves of my DNA. I reasoned that it was worth learning painful information if it might help me avert future illness.

Like others, I turned to genetic testing, but I wondered if I could trust the nascent field to give me reliable results. In recent years, a handful of studies have found substantial variations in the risks for common diseases predicted by direct-to-consumer companies.

I set out to test the tests: Could three of them agree on me?

The answers were eye-opening — and I received them just as one of the companies, 23andMe, received a stern warning from the Food and Drug Administration over concerns about the accuracy of its product. At a time when the future of such companies hangs in the balance, their ability to deliver standardized results remains dubious, with far-reaching implications for consumers.

My experiment ran into hurdles from the start. After I ordered 23andMe's saliva test kit, which for $99 promised a report on more than 240 health conditions and traits, it turned out that I could not legally send it in; the New York State Health Department forbids any labs that lack a state permit to accept specimens from a health-related test. Luckily, my in-laws mailed it from their home in New Jersey.

Then I learned that the other two companies I planned to approach were no longer offering genetic testing. Additional research led me to two more: Genetic Testing Laboratories and Pathway Genomics. G.T.L. charged $285 for a report on 25 disease risks, and required a professional sample collector to draw blood; Pathway charged $399 for a report on 24 disease risks. (In 2010, Pathway planned to sell its saliva test kit at Walgreens, but abandoned the idea after the F.D.A. challenged the sales. Now Pathway requires a doctor to order a kit on a patient's behalf.)

After my tests had been sent, I braced myself for the revelations about my DNA. It took about two months to receive all the results, and when I did, the discrepancies were striking.

23andMe said my most elevated risks — about double the average for women of European ethnicity — were for psoriasis and rheumatoid arthritis, with my lifetime odds of getting the diseases at 20.2 percent and 8.2 percent. But according to Genetic Testing Laboratories, my lowest risks were for — you guessed it — psoriasis (2 percent) and rheumatoid arthritis (2.6 percent).

For coronary heart disease, 23andMe and G.T.L. agreed that I had a close-to-average risk, at 26 to 29 percent, but Pathway listed my odds as "above average."

In the case of Type 2 diabetes, inconsistencies on a semantic level masked similarities in the numbers. G.T.L. said my risk was "medium" at 10.3 percent, but 23andMe said my risk was "decreased" at 15.7 percent. In fact, both companies had calculated my odds to be roughly three-quarters of the average, but they used slightly different averages — and very different words — to interpret the numbers. In isolation, the first would have left me worried; the second, relieved.

Medical ethicists and other experts have a different kind of worry about results like these: a lack of industry standards for weighing risk factors and defining terminology.

"The 'risk is in the eye of the beholder' standard is not going to work," said Arthur L. Caplan, director of medical ethics at the New York University Langone Medical Center. "We need to get some kind of agreement on what is high risk, medium risk and low risk."

Several other problems may account for my discrepancies. The genetic testing that these three companies offer is premised on reading segments of DNA called SNPs (pronounced snips), for single nucleotide polymorphisms. But these segments, which have been linked to diseases in research studies, vary among people.

Scientists have identified about 10 million SNPs within our three billion nucleotides. But an entire genome sequencing — looking at all three billion nucleotides — would cost around $3,000; the tests I took examined fewer than a million SNPs.

"Imagine if you took a book and you only looked at the first letter of every other page," said Dr. Robert Klitzman, a bioethicist and professor of clinical psychiatry at Columbia. (I am a graduate student there in his Master of Bioethics program.) "You're missing 99.9 percent of the letters that make the genome. The information is going to be limited."

Companies choose which SNPs to read. By comparing the technical reports provided with my results, I found that my tests sometimes relied on different SNPs to assess the same condition, like coronary heart disease. Each test studied four to 15 markers, with almost zero overlap, though two tests reached similar conclusions about my odds.

In the case of rheumatoid arthritis, though, the tests examined the same five markers, plus a few others, and delivered contradictory interpretations.

J. Craig Venter, chief executive of his namesake institute and of Synthetic Genomics, was a pioneer in sequencing the human genome in 2000. Though he issued recommendations to genetic testing companies four years ago to help them improve their predictions, he remains skeptical of their clinical value.

"Your results are not the least bit surprising," he told me. "Anything short of sequencing is going to be short on accuracy — and even then, there's almost no comprehensive data sets to compare to."

Another source of variation was in the estimates of average risks. For example, 23andMe listed the typical odds of obesity at 59 percent, while G.T.L. listed them at 30 percent.

But the major issue, experts say, is that the causes of most common diseases remain unknown. Genes account for just 5 to 20 percent of the whole picture.

"Even if they are accurately looking at 5 percent of the attributable risk, they've ignored the vast majority of the other risk factors — the dark matter for genetics — because we as a scientific community haven't yet identified those risk factors," said Dr. Wendy Chung, an associate professor of pediatrics and medicine and the director of clinical genetics at Columbia.

Environmental factors play a role. A study published in 2007 demonstrated this link: After pregnant mice were exposed to various levels of a chemical, their genetically identical offspring were born obese and yellow or small and brown.

There are only 23 diseases that start in adulthood, can be treated, and for which highly predictive tests exist. All are rare, with hereditary breast cancer the most common. "A small percentage of people who get tested will get useful information," Dr. Klitzman said. "But for most people, the results are not clinically useful, and they may be misleading or confusing."

23andMe declined to comment for this article. Jim Bentley, the chief operating officer of General Genetics Corporation, which owns G.T.L., said test results should be interpreted with professional guidance: "Because of the complexity of genetic testing results and other factors that have a role in determining the long-term potential health risks a person may face, such as environmental conditions and personal health habits, G.G.C. requests its customers provide information that would allow us to send the results of our predisposition test to a physician."

The chief medical officer of Pathway, Dr. Michael Nova, said: "Pathway Genomics is accredited by the College of American Pathologists, and accredited in accordance with the U.S. Health and Human Services' Clinical Laboratory Improvement Amendments of 1988. As such, we are held to a higher standard for report accuracy than our unaccredited competitors."

To be sure, my tests did provide some beneficial information. They all agreed that I lack markers associated with an increased risk of breast cancer and Alzheimer's.

That said, they were testing for only a small fraction of the genetic risks for these diseases, not for rare genetic variants that confer much of the risk. I could still develop those diseases, of course, but I don't have reason to pursue aggressive screenings as I age.

In June, the Supreme Court prohibited the patenting of genes that exist in nature. But the ban did not apply to DNA created in the laboratory, leaving the door open to additional patents in the field. That will encourage the industry to gather big bio-banks of people's genomes — the more, the better.

In the wake of the F.D.A. warning, 23andMe has stopped providing data on health risks, and a class-action lawsuit alleges that the company's results are "meaningless." The company's supporters have launched a petition to protest the warning.

Until and unless the predictive science improves, experts advise consumers to take most of their results with a grain of salt.

The tests "may be interesting as a kind of entertainment," Dr. Caplan said, "but do not take them seriously yet in driving your health care or your lifestyle."

He added: "If you want to spend money wisely to protect your health and you have a few hundred dollars, buy a scale, stand on it, and act accordingly."

Roughed Up by an Orca? There’s a Code for That -

Know someone who drowned from jumping off burning water skis? Well, there's a new medical billing code for that.

Been injured in a spacecraft? There's a new code for that, too.

Roughed up by an Orca whale? It's on the list.

Next fall, a transformation is coming to the arcane world of medical billing. Overnight, virtually the entire health care system — Medicare, Medicaid, private insurers, hospitals, doctors and various middlemen — will switch to a new set of computerized codes used for determining what ailments patients have and how much they and their insurers should pay for a specific treatment.

The changes are unrelated to the Obama administration's new health care law. But given the lurching start of the federal health insurance website,, some doctors and health care information technology specialists fear major disruptions to health care delivery if the new coding system — also heavily computer-reliant — isn't put in place properly.

They are pushing for a delay of the scheduled start date of Oct. 1 — or at least more testing beforehand. "If you don't code properly, you don't get paid," said Dr. W. Jeff Terry, a urologist in Mobile, Ala., who is one of those who thinks staffs and computer systems, particularly in small medical practices, will not be ready in time. "It's going to put a lot of doctors out of business."

The new set of codes, known as I.C.D.-10, allows for much greater detail than the existing code, I.C.D.-9, in describing illnesses, injuries and treatment procedures. That could allow for improved tracking of public health threats and trends, and better analysis of the effectiveness of various treatments.

Officials at the Centers for Medicare and Medicaid Services declined to be interviewed about the new codes. But a spokeswoman said that the agency was "committed to implementing I.C.D.-10 on Oct. 1, 2014, and that will not change."

In a letter in November, Kathleen Sebelius, the secretary of health and human services, told Senator Jeff Sessions, Republican of Alabama, that the Medicare and Medicaid officials were working diligently to help doctors get ready. "I.C.D.-10 is foundational for building a modernized health care system that will facilitate broader access to high quality care," she wrote.

Still, the troubles with have given new ammunition to those urging a go-slow approach on I.C.D.-10 and have made it harder for the government to stand behind assurances that the transition will go smoothly.

"Failure to appropriately test I.C.D.-10 could result in operational problems similar to what the Department experienced with the rollout of," the Medical Group Management Association, which represents the business managers of medical practices, said in a letter this month to Ms. Sebelius.

The Medicare and Medicaid office now appears to be open to greater testing of the system. Also this month, the Obama administration relaxed some deadlines for parts of the health care law, and some deadlines under a separate law for enacting electronic medical records.

"I think that people at C.M.S. understand the stakes with respect to I.C.D.-10 in a heightened way as a result of," said Linda E. Fishman, senior vice president for policy at the American Hospital Association.

Dr. John D. Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston, said the need to prepare for I.C.D.-10 and the Affordable Care Act and to achieve so-called meaningful use of electronic health records all at once could overwhelm computer staffs throughout the health care industry.

"It's just this collective sum of activities that exceeds the capacity of the system to absorb it simultaneously," he said.

He said his hospital was spending $5 million this year on I.C.D.-10, $7 million for the Affordable Care Act, $2 million on meaningful use, and $3 million to comply with a federal health care privacy law. "Basically, I'm not doing anything but federal regulatory mandates," he said.

I.C.D.-10 has already been postponed by a year. It was originally scheduled to go into effect this past Oct. 1, which would have coincided with the rollout of the insurance website.

Some health care executives say predictions of a fiasco next Oct. 1 will prove as erroneous as those that said civilization would collapse on Jan. 1, 2000, because computers could not handle years beginning with a 2 instead of a 1 — the so-called Y2K issue.

"It's not going to be a shock to the industry to confront this," said Christopher G. Chute, professor of biomedical informatics at the Mayo Clinic. "We've literally had seven or eight years to anticipate it."

survey by the American Hospital Association this year found that about 94 percent of hospitals were moderately to very confident about being ready on time. Both the hospital association and America's Health Insurance Plans, which represents insurers, said that their members had spent a lot of time and money getting ready for I.C.D.-10 and that the changeover should not be postponed again.

I.C.D.-10 is the 10th revision of the International Classification of Diseases, which is issued by the World Health Organization, though countries can modify it.

Having a common global code allows for easier collection, comparison and analysis of the causes of death and illness. Most other countries have already adopted I.C.D.-10, at least for record-keeping and in some cases for reimbursement.

The classification was first issued in the 1800s. An early one listed "visitation of God" as one cause of death.

But as medical knowledge and technology have improved, more codes are needed. I.C.D.-9, which allows codes of up to five characters, has about 14,000 codes to specify diagnoses and 3,000 to specify inpatient procedures. The code, which has been used in the United States for medical statistics since 1979 and for billing since 2002, has run out of room to incorporate new knowledge and technology.

I.C.D.-10, with codes containing up to seven digits or letters, will have about 68,000 for diagnoses and 87,000 for procedures.

While I.C.D.-9 had a single code for certain repairs to blood vessels in the head and neck, I.C.D.-10 allows specification of the particular vein or artery and the particular procedure used. Extra codes allow recording of whether a patient was visiting the doctor for the first time or a subsequent time for a particular problem, and whether broken arms and some other injuries occur on the left or right side of the body.

There are dozens of codes dealing just with the big toe — contusion of the right great toe, contusion of the left great toe, with damage to the nail or without, initial encounter or subsequent encounter, blisters, abrasions, venomous insect bites, nonvenomous insect bites, lacerations, fractures, dislocations, sprains and amputation, not to mention the vague "acquired absence of unspecified great toe."

I.C.D.-10 has been the subject of jokes, however, for its catalog of possible injury causes, like those burning water skis. There are codes for injuries incurred in opera houses and while knitting, and one for sibling rivalry.

When it first proposed moving to I.C.D.-10, the Medicare and Medicaid Services office estimated it would cost the government and industry $1.64 billion over 15 years on training, software changes and lost productivity. But it also said the system would bring $4 billion in benefits over that time, from more accurate claims and improved health care.

Lee Browder, national director of the Professional Association of Healthcare Coding Specialists, said the transition should not be too hard for coders. He compared it to the introduction of the extra four digits on ZIP codes — there were many more codes, but the concept was the same as before.

The transition could be tougher for doctors, because they will have to be more specific in describing a patient's condition.

The government has said Medicare contractors will have a week of testing in early March during which doctors and hospitals can practice submitting claims. But the Medical Group Management Association and the American Hospital Association, among others, are pushing for more testing.

Rhonda Buckholtz, vice president for I.C.D.-10 education and training at the American Academy of Professional Coders, said postponing the deadline would just push the problem down the road.

"It doesn't matter what deadline we get," she said. "We'll find a way to not meet it."

Sunday, December 29, 2013

Living Sick and Dying Young in Rich America - Leah Sottile - The Atlantic

We were standing at Target in an aisle we'd never walked down before, looking at things we didn't understand. Pill splitters, multivitamins, supplements, and the thing we were here to buy: a long blue pill box—the kind with seven little doors labeled "S M T W T F S " for each day of the week, the kind that old people cram their pills into when they have too many to remember what they've already taken.

My husband, Joe Preston, shook his head. "Do I really need this?"

I grabbed it off the shelf and threw it in our basket. And when we got home, Joe—then a fit and fairly spry 30-year-old man with a boss-level beard—stood at the kitchen counter, dropping each of his prescriptions with a plink into the container.

I guess it's true that life is full of surprises, but for the three years since Joe's crippling pain was diagnosed as the result of an autoimmune disease called Ankylosing Spondylitis, our life has been full of surprises like this one. Pill boxes, trips to the emergency room, early returns from vacation. Terms like "flare-up" have dropped into our vocabulary. We've sat in waiting rooms where Joe was the only person without a walker or a cane. Most of our tears have been over the fact that these aren't the kind of surprises either of us thought we'd be encountering at such a young age.

But here's the thing: We recently realized we weren't alone. Almost all of our friends are sick, too. When we met our friend Missy Narrance, Joe found solace in talking to her about his health. She's 29 and has been battling lupus and fibromyalgia for the past 10 years. She's been through chemotherapy twice, and her daily symptoms are so extreme that she was granted federal disability status when she was just 23 years old. In our close group of friends—who range from 25 to 35 years old—we know people with everything from tumors to chronic pain. Sometimes our conversations over beers on a Friday night turn to discussions of long-term care and miscommunication between doctors.

I thought this would be the time when we'd be preparing for the rest of our lives: earning money, going on fun vacations, having families, building our careers. And we are, but at the same time, we're doing it while we're trying to manage pain symptoms, chase down prescriptions, and secure stable health insurance. When I was in college, I remember being prepared to survive in the workforce, but I don't remember a class that told me how to do that if half of your household is in so much pain on some days that they can't get to work. I'm barely over 30. I thought I had so much more time before I had to think about this stuff.

I wondered if this was normal. Do we know so many people who are dealing with pain because people are just getting sicker in general?

I found out that they kind of are. It turns out that chronic conditions like what Joe and my friends are dealing with are one of America's biggest health emergencies. And it's one that many people say we're not prepared to deal with.

Despite the fact that America shells out more money on healthcare than any other country in the world, according to a report by the Centers for Disease Control and Prevention—and a hefty 75 percent of those dollars are going toward aiding people with chronic conditions—almost half of American adults had at least one chronic condition in 2005.

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