Posts Tagged ‘health policy’

Can America Fix Its Public Health System?

Wednesday, January 5th, 2022

Despite the cost of health care in America being nearly twice the average of the other 37 countries within the Organization for Economic Co-operation and Development (OECD), we achieve poorer health care outcomes than the average and our life expectancy of 78.9 years is 2.1 years below the OECD average of 81.* The OECD chart below is quite instructive. It shows the nation’s relatively poor health performance, but what I find interesting is the last line: We self-rate our health better, much better, than the OECD average. Friends, we have swallowed the Kool Aid.

If we reach the age of 65 when Medicare becomes available, life expectancy improves to 84.5 years, but that puts us still below the OECD average of 84.9 and 13th from the bottom of the pack. By way of further comparison, the Brits, whose National Health System we so cavalierly denigrate, outlive us by 2.5 years; Canadiens, by 3.2 years. They must be doing something right, and they do it for significantly less money.

One often overlooked and, for the most part, unexamined reason for our high health care costs and sub-par outcomes can be found in our woebegone Public Health System. Of all the gaping holes COVID-19 has exposed in the nation’s approach to health care and emergency preparedness, our Public Health System, fragmented, uncoordinated, underfunded, but critically important, is the deepest.

COVID has turned the health care world upside down, especially in regards to health care funding. CMS reports U.S. health care spending grew 9.7 percent in 2020, reaching $4.1 trillion or $12,530 per person. As a share of the nation’s Gross Domestic Product, health spending accounted for 19.7%, up from 16.8% the year prior.

Less than 3% of that $4.1 trillion went to our Public Health System. Moreover, Trust for America’s Health, a non-partisan organization that tracks health issues, reports public health spending as a proportion of total health spending has been decreasing since 2000 and falling in inflation-adjusted terms since the Great Recession. Health departments across the country are battling 21st-century health care wars with mid-20th-century weapons.

Our Public Health System is supposed to address everything having to do with health, from diseases like COVID-19 to tornados, hurricanes, wild fires, floods, rat infestations, and the like. It lives at the local level, from states, to counties, to cities and towns. My little Berkshire town of Becket, Massachusetts, population of 1,931, has a functioning Health Department.

The CDC, through grants to the states and large cities is the primary funder of federal public health. The system and funding for it worked pretty well until, in 2001, terrorists brought down the Twin Towers on 9/11, killing 2,996 of our fellow citizens. Suddenly, money that had been earmarked for public health was syphoned off for the War on Terror. In attempting to right the ship, Section 4002 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Prevention and Public Health Fund. Also known as the Prevention Fund or PPHF, it is the nation’s first mandatory funding stream dedicated to improving our nation’s public health system. By law, the Prevention Fund must be used “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public health care costs.” The law mandated funding: $18.75 billion between fiscal years 2010 and 2022 and then $2 billion annually thereafter.

The Fund’s intentional mandatory design was meant to ensure consistent, predictable, and expanded resources for prevention and public health that are not always politically viable in the annual appropriations process, where public health and prevention programs compete against other priorities.

The Fund’s statute is broad and authorizes use of funds for a number of activities and grant programs:

The Secretary shall transfer amounts in the Fund to accounts within the Department of Health and Human Services to increase funding, over the fiscal year 2008 level, for programs authorized by the Public Health Service Act [42 U.S.C. 201 et seq.], for prevention, wellness, and public health activities including prevention research, health screenings, and initiatives, such as the Community Transformation grant program, the Education and Outreach Campaign Regarding Preventive Benefits, and immunization programs.

But nowhere in the statute does it say that the President or Congress cannot redirect the Fund’s money for some other purpose. And that is what has happened.

Redirecting the Fund’s cash for some other purpose would not be, per se, a bad thing as long as the new purpose advanced public health. However, political expediency, partisan grandstanding, the republican-led 63 attempts to repeal the ACA, the law that established and governs the Fund, have done damage. For example, in February 2012, Congress passed and President Obama signed legislation to cut the Fund by $6.25 billion over 9 years (FY2013 to FY2021) to correct the Medicare sustainable growth rate and prevent cuts to physician services in the Medicare program (known as the “doc fix”). To believe these measures actually advanced our Public Health System is to believe pigs really can fly.

A less controversial move that still violated the Fund’s legislative intent happened in FY2013, when Republicans, who controlled the House of Representatives, refused to appropriate funding for ACA enrollment activities. In response, the Obama administration used the Fund’s money to do that.

As congressional partisanship deepened in the following years, Republicans began to question the Fund as government overreach, calling it the “Obama slush fund.” In 2017, the Republican-led House passed the American Health Care Act of 2017, which would have cut the Fund by $1 billion. It was defeated in the Senate, but it exemplifies the rancor in the Halls of Congress.

A government’s first duty is to protect the safety of its citizens. The arrival of COVID-19, laying bare our still woeful Public Health System, showed us we were unprepared to address that sacred duty, and more than 800,000 of us have died to prove the point.

We could have done so much better.

 

* These are 2019 numbers, the latest year the OECD is reporting as of this writing. According to the CDC, U.S. life expectancy dropped to 77 years in 2020, which is partly due to 385,441 deaths due to COVID-19 in 2020. We can expect a continued drop in life expectancy being reported for 2021, as COVID deaths in that year totaled 435,755.

 

 

As I Was Saying…

Monday, December 20th, 2021

Having taken a few days off―168 to be precise―your scribe has now returned to the writer’s desk to once more enter the fray.

No, I was not sidelined with a case of COVID. Nor did some momentous life experience throw a high hard one to the side of my head and put me on my backside. Family has been fine and health excellent (if you don’t count the shoulder that wants replacement after hitting about 950,000 overheads on the tennis court over the course of too many decades―simple arithmetic).

Being serious though, I’ve thought hard about why I fell victim to a 168-day writing famine, a real writer’s block, and I think it comes down to three things:

1. There is so much bloviation in the internet’s ether that one’s goal should be to subtract from it, rather than add to it. Technology now allows anyone and everyone to label themselves “expert” and throw their intergalactically significant thoughts up against the literary wall to see if any stick. Perhaps 5% are worthy of the effort, and that’s being generous. Ask yourselves how many pundit “opinions” land in your inbox every day. If you’re like me, it’s a lot. Separating the wheat from the chaff can be exhausting.

2. The “new normal” is not. It’s abnormal. For me, it’s like walking into an art museum and finding all the paintings just a little crooked. It’s woozy inducing. Like trying to plant cut flowers, to quote Daniel Boorstin, the late American historian and Librarian of Congress. And calling it the new “normal” is misleading, because “normal” suggests this is what life will be for all of us forever: The Norm. One hopes that, like every other plague in history, humanity will one day emerge into the bright sunshine of maskless and vaccinated good health, with COVID no longer the grim reaper. But that day is somewhere in the fog of the future.

3. The bitter, atavistic, and in many cases downright ignorant partisan wars erupting every day all over the media, social and otherwise, have changed the American landscape. They put in sharp relief the good and the bad of democracy’s fabric. The constant search for “gotcha” moments, the in-your-face bellicosity, the biblical attachment to lies regardless of truth no matter how well-proven, bring out the very worst in all too many people with cruelty as sharp as the edge of an ax. Vlad the Impaler could learn a thing or two from some of these folks who have all the intellectual honesty of a lap dance and whose minds are about as deep as a pool table’s side pocket.

For the last 168 days I’ve been the fly on the wall of the human condition. I’ve watched people as artificial and superficial as a casino lobby jockey for power and influence. While more than 800,000 Americans have died from COVID, self-interest has reigned and hobbled the best efforts of heroically dedicated people devoted to improving the lot of the rest of humanity, the rest of us. This has caused a kind of intellectual paralysis, like being thrown into a deep pit and finding it rough to climb out. Have you felt that way, too?

Three years ago this month. I told the story of how Frederick Banting’s team of himself, Charles Best and James Collip recovered and purified insulin from the fetal pancreases of cows and pigs in 1922, how they successfully tested it on humans, how Banting won the Nobel Prize the following year for his discovery, how the team sold the patent for the discovery to the University of Toronto for $3.00―a buck apiece―and how they and the University agreed to license the manufacturing rights to pharmaceutical companies royalty-free, because, in Banting’s words, “Insulin is my gift to mankind.” The team and the university wanted to incentivize drug companies to improve on the Banting team’s discovery, so the University and Banting agreed to allow the companies to improve Banting’s formulation if they could and patent any new discoveries that arose. Their hope was that drug companies would share their vision of making it possible for Type-1 Diabetics to live high-quality lives and to keep insulin prices low to help them do it.

That was 100 years ago. Today, the Build Back Better bill, the one West Virginia’s Senator Joe Manchin killed yesterday, would have, among other things, let Medicare negotiate prices with pharmaceutical companies for a very limited number of high-cost drugs and would have capped the monthly cost of insulin for many, but by no means all, diabetics at $35. That may still happen, but its odds of passing just went from perhaps to probably not. One wonders what Frederick Banting would think of all this.

At any rate, vacation’s over, and my tiny voice will do what it can to throw light into the dark that shrouds us all.

 

Thoughts Of The Day

Monday, January 18th, 2021

Was Azar intentionally lying, colossally incompetent, or both?

Given the last four years, I’m guessing Door Number 3.

Because both the Pfizer and Moderna vaccines require two shots, administered 21 and 28 days apart, respectively, Operation Warp Speed’s initial plan, announced in early December, was to hold back half the supply to make sure there was enough for the second shots. At the same time, the Trump Administration was saying it would vaccinate 20 million people by the end of the year.

On Tuesday, 12 January, as it became apparent the first doses of COVID-19 vaccinations were proceeding much slower than predicted (the 20 million prediction had turned into an 11.4 million reality), U.S. Secretary of Health and Human Services (HHS) Alex Azar announced the government was making all of the coronavirus reserve vaccine supply immediately available, urged states to provide shots to anyone 65 and older and warned governors that states with lagging inoculations could see their supply shifted to other places.

You could hear the collective country-wide sigh of relief. Help was on the way.

That is, until three days later when we learned the only place the “reserve supply” existed was in Alex Azar’s imagination, because the Administration admitted to state and federal officials it stopped stockpiling the second doses at the end of last year as it attempted to hit the 20 million goal. The reserve supply no longer existed. The states were left to scramble again, as they have throughout the pandemic. Remember the PPE fiasco? States were forced to compete against each other and the Feds to get any. Remember the Administration’s leadership about masking? Neither do I. I could go on.

This latest FUBAR catastrophe led President-Elect Joe Biden to tell the world the vaccine rollout was “a dismal failure.” Seems fairly accurate to me.

“Never ruin an apology with an excuse” – Benjamin Franklin

Here’s the way it worked. After the election, which he lost, Donald Trump spewed lie after lie about how he actually won “in a landslide.” And he convinced millions of people this was so. A new Quinnipiac poll reports 73% of Republicans believe there was “widespread fraud” in the election, which allowed Joe Biden to win. Trump’s two-month assault on truth led to the 6 January armed insurrection.

It is questionable whether he would have persuaded his millions of followers to believe the lies if he had not had profound assistance from Twitter, Facebook and conservative media. Case in point: the conservative outlet American Thinker which, with no investigation,  bought the Dominion Voting Machines stole-the-election line – again and again.

Yesterday, American Thinker “screwed its courage to the sticking post” and apologized. It was not one of those, “We did a bad thing, but we did it because…” things. No, this was an apology that would have made Ben proud. Here it is in full:

We don’t know what prompted American Thinker to so abjectly fall on its sword. I choose to think optimistically, believing journalistic ethics won the day. Regardless, this is how you do an apology.

Speaking of optimism

Why not end on a lighter note?

Back in pre-pandemic times (you remember those, don’t you?), when you wouldn’t think twice about sitting in a pub with friends discussing the metaphysics of Sartre, I once did just that with two friends, one a conservative republican with whom one could actually debate policy issues with smiles all around; the other, an MIT engineering professor.

We were talking about how people so often view the same thing in different ways, which led us to a discussion about optimism. That led to further discussion about the differences between people who were naturally optimistic and those who were naturally pessimistic.

One of us brought up the old glass half full or empty screed. I, the eternal optimist, said to me the glass was always half full. My conservative friend said he couldn’t help seeing it as half empty.

My friend from MIT said, “There’s too much glass.”

Stay safe – and, if you can, optimistic.

 

 

 

 

 

This Is Madness

Friday, November 13th, 2020

Let’s start with the numbers.

Global Cases

Global COVID-19 cases are rising and the rise is accelerating, as documented by the Johns Hopkins Coronavirus Resource Center. There have been nearly 53 million cases around the world, 660 thousand yesterday. There have now been about 1.25 million deaths, and the death rate is also rising.

U.S. Cases

According to the New York Times Latest Map and Case Count, America’s case rate is surging faster than at any time in the pandemic.

Consider these four points from the above chart:

Since the beginning of COVID-19 in the U.S., the health care community has made tremendous gains in treating the disease, that is, in preventing deaths. However, no one yet knows the extent of long-term complications due to contracting the virus. Although COVID-19 primarily affects the lungs, it can damage many other organs as well. This organ damage may increase the risk of long-term health problems. Regardless, deaths are once again rising.

With respect to keeping safe, absolutely nothing has changed since the beginning of the pandemic. Hand washing/sanitizing, social distancing, mask wearing, and testing are, to this day, the only things we can do to control the disease. At some point in the future, perhaps by mid-spring, the vaccine cavalry will come charging over the hill. But until then, we’re on our own. COVID-19 is the enemy, the opposition, and we have to outlast it. Everyone needs to put on the moral cloak of responsibility.

It would be nice if that moral cloak were to become moral leadership from the White House, but the Trump Administration, obscenely obsessed with fighting the will of the majority, has gone AWOL, once again leaving the states to fight the disease by themselves, and most are now fully engaged.

Consider Ohio, where Republican Governor Mike DeWine is doing everything he and his team can to drive home the need for masks, hand washing and social distancing. Case in point: His Department of Health created a compelling video to illustrate the value of social distancing.

One of the most tragic things I have ever observed is going on right now across America. Millions of people have been persuaded the washing, wearing and distancing things are lies meant to steal the soul of the nation in a socialistic, Mephistophelean conspiracy. They believe government is trampling on their “rights.” Meanwhile, many of them get sick, some of them die, and they bring great harm to their neighbors who are trying to do the right thing. This is madness.

It’s Been Quite A Week — Here Are Some Things You Might Have Missed

Saturday, October 24th, 2020

From the Department of There’s No Accounting For Stupidity

Since 1980, the population of Idaho has grown from about one million to nearly 1.8 million, considerably outstripping the rate of growth of its neighbors Montana and Wyoming. Over the last 14 days, all three states have seen large spikes in Covid-19 cases, according to the New York Times’s Covid Map and Case Count. And they’re not alone. All the Midwest and Pacific region states are seeing similar surges. Their governors are faced with balancing increased restrictions with the personal freedom inherent in pioneering individualism.

Nowhere did this daunting task become more evident than Thursday in Idaho, a state that has seen a 55% rise in cases in the last two weeks and where, minutes after hearing local hospitals were approaching full capacity necessitating moving patients to Seattle, of all places, the regional health board voted to repeal the local mask mandate.

The regional board, composed of seven appointed members with no requirement to have any medical experience, voted 4-3 to end the mandate. Health District epidemiologist Jeff Lee had just finished describing how the state’s hospitals were becoming “overwhelmed” by the surge in cases. For example, even after doubling up patients in rooms and buying more hospital beds, the hospital in Coeur d’Alene had reached 99% capacity. But, not to worry, it’s just an eight hour, 493 mile ambulance ride from Boise to Seattle.

“We’re facing staff shortages, and we have a lot of physician fatigue. This has been going on for seven months — we’re tired,” Lee said.

He introduced several doctors who testified about the struggle COVID-19 patients face, the burden on hospitals and how masks reduce the spread of the virus. But that didn’t matter to the Board’s majority who just did not see the sense in masks, no matter what the experts said.

To put a period on the “Health” Board’s meeting, member Allen Banks got to the heart of the matter by denying the existence of Covid-19. Lecturing the medical professionals who testified, he said, “Something’s making these people sick, and I’m pretty sure that it’s not coronavirus, so the question that you should be asking is, ‘What’s making them sick?”

That penetrating question came from a gentleman with a Ph.D. in chemistry from the University of Colorado, who for 30 years has worked in medical research in biotechnology and pharmaceutical development.

Dr. Banks would make a wonderful addition to the White House Coronavirus Task Force.

How cold is cold enough?

Have you stopped to consider the logistics of delivering upwards of 200 million doses of a future Covid-19 vaccine? That’s a lot of syringes. If you laid them end to end they would stretch from the North Pole to the South Pole, about 13,000 miles.

And the vaccine would have to be kept cold, very cold. Just how cold you ask? Try minus 103 Fahrenheit. That’s nearly four times colder than your home freezer, colder even than Antarctica in the dead of winter.

This is a complex challenge. For months, manufacturers, federal and state governments, and large health care systems have been quietly planning how to navigate this ultra “cold chain” that stretches from vaccine manufacturers to hospitals, nursing homes, doctors’ offices, and many far-flung clinics. Now that Pfizer has announced it plans to apply for emergency-use authorization designation in late November for its vaccine currently in Phase 3 trials, solving the cold problem becomes more urgent.

The nation’s governors wrote the Trump Administration last Sunday expressing concerns about the supply of ultracold freezers and dry ice — already experiencing shortages. Pfizer says it has developed specially designed, temperature-controlled shipping packages, using dry ice, to keep its vials at roughly minus 103 below Fahrenheit for up to 10 days. But what happens if the doses are not used in ten days? This is what is confounding the governors.

This issue is even more difficult than it appears, because the vaccines of both Pfizer and Moderna, another leading vaccine developer in Phase 3 trials, require two shots within 21 and 28 days, respectively. The situation is eased somewhat, because Moderna’s vaccine, at around minus 4 Fahrenheit, does not require the same ultra-cold storage temperature as Pfizer’s.

Might be a good time to buy stock in a maker of dry ice.

High Deductibles: Another nail in the rural hospital coffin

Since 2010, more than 130 rural hospitals have closed, 15 thus far in 2020. One mostly overlooked reason is the health insurance deductible. Depending on the plan (employer-sponsored, ACA Marketplace, etc.) a family deductible can range from $0 (but the out-of-pockets are huge) to well over $8,000.

Families in rural communities often face deductibles in the $2,000 to $4,000 range. And when family members require hospitalization, it often happens they cannot pay the deductible. Rural hospitals are forced to eat this less than tasty bill, send it to a collections company, or set up a payment plan with the patient. They prefer the payment plan route, but this significantly delays getting the money, and the bill is often reduced because of the patient’s economic circumstances. So, the hospital goes further in the red and its patients go further in debt. The pandemic has only exacerbated this problem.

Just another example of our nation’s dysfunctional health care “system.”

How to get rid of an irritating federal employee

Despite a great swath of the public thinking otherwise, federal employees can be fired, although it is true that this happens rarely. Of the 2.1 million federal employees about 10,000 are terminated annually, according to the Merit Systems Protection Board (MSPB).

Firing a federal worker is similar to what would occur in the private sector, with one twist. In both settings, best practice recommends, and the federal system requires, the three step verbal warning, written warning, termination process. The twist comes after that. Federal employees can appeal to the MSPB, and the appeals can take a long time to adjudicate.

This past week, the Trump administration threw an interesting log on the fire when the President issued an Executive Order stripping long-held civil service protections from employees whose work involves policymaking. This will affect tens of thousands of workers, and will reduce them to being, for all practical purposes, “at will” employees, meaning they can be fired for cause or not for cause at a moment’s notice.

Under this order, federal scientists, attorneys, regulators, public health experts and many others in senior roles would lose rights to due process and in some cases, union representation, at agencies across the government.

These are not politically appointed employees who require confirmation to their positions, whom the president can terminate or have terminated by whim. Rather, they are professionals who serve as a cadre of subject-matter experts for every administration. I will let you consider the possible ramifications of this Executive Order, which to me seem profound. The Order, while not affecting a majority of the government, could upend the foundation of the career workforce by imposing political loyalty tests.

It is possible, with less than two weeks before election day, this may be more symbolic than real, because the Order requires agencies to indicate employees who would be affected by 19 January 2021, a day before the next inauguration. If Joe Biden wins the election he would be unlikely to follow through on the president’s order. But if Donald Trump is re-elected, this tectonic Order will monumentally reshape the federal service.

Think about that. Please.

 

 

 

 

Like BBs In A Boxcar

Monday, October 12th, 2020
Turning and turning in the widening gyre   
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world….
The best lack all conviction, while the worst   
Are full of passionate intensity.
          The Second Coming, by William Butler Yeats

 

One thing COVID-19 has certainly done is to expose many of the foundational flaws in America’s healthcare house that Jack built, the house that “cannot hold.” From the Trump administration’s helter-skelter response, to the unequal treatment of Blacks and Latinos, to the near total reliance on China for PPE, to the exacerbating plight of rural hospitals, to jaw-dropping surprise bills, to something as granular as the price of insulin, and the list goes on.

To illuminate the dire situation even more, the Kaiser Family Foundation last week published its annual Employer Health Benefits Survey, which showed the average annual premium for a family of four has grown 4% over the last year, more than doubling the rate of inflation, and has now reached $21,342, with worker contributions averaging $5,588. Add in the average deductible of $4,000, along with copays of $40, and employees get their hair-raising, once-a-year healthcare sticker shock.

In 2020, the U.S. is spending 18% of GDP on healthcare, according the Office of the Actuary within the CMS. For years, I’ve been quoting Herb Stein’s Law: “If something cannot go on forever, it will stop.” And for years, I’ve been wrong. This cannot be sustainable, but so far it has been.

A distant second-most-costly-country-in-the-world is Switzerland, at 12.1% (which is what the U.S. spent 30 years ago in 1990). The Swiss, as do many other OECD countries, have a decentralized system similar to ours, a blend of public and private-pay healthcare, with two important differences: First, since 1996, government, wanting to spread the pool, has required the Swiss people to purchase healthcare insurance, similar to the Affordable Care Act’s individual mandate (which Congress eliminated when it passed the Tax Cuts and Jobs Act of 2017, effective 1 January 2019). The result is for more than 20 years the Swiss have nearly 100% participation, but not the U.S.; our rate of the uninsured is going up, not down, made worse, much worse, by job, and consequently health insurance, losses due to the pandemic. Second, government plays a large role in establishing prices, especially for pharmaceuticals.

I think we can say with total certainty that, regardless of what you hear or read, nobody knows what healthcare in America will look like a year from now. If Trump wins reelection and republicans hold the senate, the ACA, or what’s left of it, could find itself buried deep beside Davy Jones’s locker at the bottom of the ocean, and what would come after that? Back to square one. People, our fellow citizens, our friends and relatives with chronic conditions, would once again find themselves walking down the edge of an economic razor blade.

There are four possible outcomes:

  1. Trump wins and republicans hold the senate, as above;
  2. Trump wins and democrats take the senate, resulting in stalemate, but the Trump reality show continues;
  3. Biden wins and democrats take the senate, in which case big changes are coming; and,
  4. Biden wins and republicans hold the senate, resulting in stalemate, but we’re saved from Trump’s histrionics (one hopes).

Options three and four spare us the president’s governing style, which is to say, chaos. For four years we have been subjected to his whipsawing and dangerous administration. His policies, personality and pronouncements seem to bounce around like BBs in a boxcar. Never more so than in the last few weeks. Things change by the hour. Nothing is predictable, except unpredictability.

We are moving inexorably into the winter of our continuing discontent. God help us all.

COVID-19 Update

Friday, September 18th, 2020

To close out your week we offer a few items that may have flown nap-of-the-earth under your radar.

The AstraZenica/Oxford vaccine bump in the road

On 8 September AstraZenica (AZ) halted its Phase 3 study, because one of its study participants came down with Transverse Myelitis, a neurological condition affecting the spine and caused by infection, immune system disorders or other disorders that can damage or destroy myelin, the fatty tissue that protects nerve cell fibers.

The UK has allowed AZ to restart its study there (AZ is a UK-based company), but as of this writing, the U.S. has not. In fact, in an interview with Kaiser Health News, the National Institute for Neurological Disorders and Stroke’s Avindra Nath said “the highest levels of NIH are very concerned.” According to Nath, the NIH has yet to access tissue or blood samples from the patient, who was part of the U.K. portion of AZ’s Phase 3 study. NIH believes AZ is being far too coy with its data. Nath called for the company “to be more forthcoming,” adding that “we would like to see how we can help, but the lack of information makes it difficult to do so.”

Given this halt in the U.S. study, it is not inconceivable that, if the AZ vaccine, known as AZD1222, proves efficacious and safe in the UK, regulators there could approve it for general use well before the U.S. does. This would not make our Commandeer in Chief happy.

The Mask versus Vaccine dust up

Speaking of the Commander in Chief, he recently took CDC Director Dr. Robert Redfield for a quick walk to the woodshed for suggesting during testimony to a Senate subcommittee, “Masks are more guaranteed to protect me against COVID-19 than a vaccine.”

President Trump, who is not a doctor, but repeatedly plays one on TV, took exception to this. He publicly chastised Redfield for his comments and said a vaccine could be available in weeks and go “immediately” to the general public. Diminishing the usefulness of masks, despite a wealth of scientific evidence to the contrary, he said his CDC chief was “confused.”

Well, no, he wasn’t. Redfield told subcommittee members that if everyone in the U.S. would wear masks in public the pandemic could be under control within 12 weeks. His issue with a vaccine lies in its degree of immunogenicity, which he suggested would be in the area of 70%, meaning if 100 vaccinated people are exposed to the virus, 30 of them will have insufficient protection to ward it off. Those 30 will probably be comprised of groups who are most susceptible to the vaccine now, like the elderly.

People, masks will be with us for a long time.

Health insurance losses

Before the pandemic, 49% of Americans got health insurance through employer sponsored insurance (ESI). COVID-19 has reduced that percentage, because 6.2 million of our neighbors have lost their jobs and, consequently, their health insurance. When you factor in spouses and children, the number of people who have been shoved out the door into the COVID cold becomes 12 million.

Researchers at the Economic Policy Institute (EPI) have recently documented the losses in a new study. Researchers Josh Bivens and Ben Zipperer write:

  • Extreme churn after February 2020 has led to very large losses in ESI coverage. In March and April, for example, new hiring led to 2.4 million workers gaining ESI coverage each month, but historically large layoffs led to 5.6 million workers losing coverage each month. This rate of lost coverage—over 3 million workers—dwarfs a similar calculation for the number of workers losing coverage each month during the biggest job-losing period of the Great Recession (September 2008–March 2009). Our analysis using the monthly, high-quality measure of the total number of jobs in the economy from the Current Employment Statistics (CES) program of the Bureau of Labor Statistics (BLS) is consistent with 9 million workers having lost access to ESI in March and April 2020 but 2.9 million workers having gained coverage between April and July 2020.

Bivens and Zipperer say about 85% of those who lost ESI coverage were able to gain at least some coverage either through a spouse’s plan, the Affordable Care Act or state Medicaid programs, but that still leaves about a million laid off workers and their familes with nothing. Bivens, Zipperer and others argue the job losses have only worsened the public health crisis created by COVID-19.

Of course, recognizing that millions of people losing employer sponsored health insurance is a public health crisis is not the same as fixing the system to prevent it from happening again. However, as I have written before, having exposed gross inadequacies in the nation’s health care system, COVID-19 also provides opportunities for improvement. What is needed now is the determined motivation and will to make that happen. That is a Herculean task about which I wish I were more optimistic.

Sisyphus Must Have Felt Like This

Wednesday, September 16th, 2020

The COVID-19 boulder, full of facts, lies, information, misinformation, disinformation, and just plain delusional thinking keeps rolling back down the mountain. Try as we might, it’s certainly difficult to make sense of COVID-19. But we keep trying, anyway. As in:

Unions during COVID-19

I have written previously about the perplexing case of union participation in America. In 1960, about a third of hourly workers belonged to unions. In January of this year, the BLS reported that number had dropped to 10.3%. Yet, in the same press release, the BLS reports:

Nonunion workers had median weekly earnings that were 81 percent of earnings for workers who were union members ($892 versus $1,095).

Right now we won’t get into why this puzzling paradox exists, except to say we now have another log to throw on the pyre.

A new study authored by researchers at George Washington University, the University of Pennsylvania Perelman School of Medicine and the Boston University School of Medicine, published in Health Affairs, found that having a unionized workforce at a nursing home greatly reduces the likelihood that residents or staff will die from COVID-19. From the study’s Abstract:

Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions.

The study analyzed data from more than 300 nursing homes in New York from March 1 through May 31. The authors conclude the unionized health care workers in the nursing homes were able to negotiate for more PPE, higher pay, and better working conditions.

During the pandemic, New York has suffered nearly 7,000 nursing home deaths, more than any other state except New Jersey.

My take on this? If you have loved ones who may be headed for a nursing home, it might be a good idea to ask if the staff is unionized.

Avoiding medical care during COVID-19

Since early in COVID-19, we’ve known that many people, fearful of the disease, have put off getting routine, or, in some cases, emergency medical care. What we have not known is what demographic groups are doing that and to what degree. Now, the CDC has put a full stop period to that issue.

In its 11 September weekly Morbidity and Mortality Report, the CDC published a comprehensive analysis concluding 40.9% of U.S. adults delayed or avoided medical care as of June 30. This includes urgent or emergency care (12%) and routine care (32%). Regarding what population segments are doing this, the study had this to say:

The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults versus non-caregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions† versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18–24 years versus adults aged 25–44 years (aPR = 1.5); and persons with disabilities§ versus those without disabilities (aPR = 1.3).*

So, Mary, taking care of her aged mother at home, foregoes either emergency or routine care at nearly three times the rate of Sarah, her next door neighbor who is not burdened with an aged relative, because she doesn’t want to bring COVID-19 home to Mom. Even more troubling is that people with two or more co-morbidities forego care at nearly two times the rate of people without such underlying conditions.

The CDC’s paper advises that, “… urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm.”

Enough said.

*By way of example for the statistically challenged, an adjusted prevalence ratio of 2 means that the prevalence of cases among a study group is 2 times higher than among the control subjects. It’s calculated through a series of regression analyses. There. Now you know.

U. S. life expectancy

COVID-19 has sucked all the air out of any national attempt at healthcare reform, while revealing in sharp detail the foundational flaws in the current system. Eventually, however, America is going to have to confront this issue in a meaningful manner. Healthcare cost in America is still twice the average of all 37 member countries of the Organization for Economic Cooperation and Development (OECD), and Americans still have poorer health and lower life expectancy than the average of the member countries (78.7 versus 79.5)

In its latest Health At A Glance publication, the OECD updated its life expectancy data, as shown here:

There are many cracks in our healthcare house that Jack built. Ignoring them is not a strategically viable plan for improvement, improvement that all citizens deserve.

To quote the venerable A. E. Housman, “Terrence, this is stupid stuff.” Another example of our woebegone healthcare system.

Trump’s Nevada rally

Last night, during an ABC-TV Town Hall Meeting President Trump once again pilloried cities and states run by Democrats and blamed their leaders for any problems with the response to COVID-19.

A little contextual background is required here. On 14 April, Trump asserted “absolute authority” to control the nation’s response to the pandemic, saying, “When somebody is president of the United States, your authority is total.” He made it clear he would be in charge and the states would have to fall in line.

Two days later, he reversed himself on a call with all the governors, telling them, “I’ve gotten to know almost all of you, most of you I’ve known and some very well. You are all very capable people, I think in all cases, very capable people. And you’re going to be calling your shots.”

Since then, he has repeatedly repeated the “You’re on your own” line. The result, of course, has been that we have seen 51 different plans and approaches  with varying degrees of success.

Nevada, one of the “you’re on your own” states, is still in the midst of a tough fight against the disease with a Daily Positivity Rate of 7.1% and a Cumulative Positivity Rate of 10.2% as of 10 September.

On 24 June, Nevada Governor Steve Sisolak imposed certain restrictions, among them the requirements that all Nevada residents wear masks when in public and that no more than 50 people, socially distanced, congregate in one place.

Enter Donald Trump and his the-sky-is-the-limit indoor rally of last Sunday evening at Xtreme Manufacturing in Henderson, Nevada. Fire officials estimated the size of the crowd was 5,600 people, nearly all of whom were maskless (except for the people right behind Trump who were constantly on full TV view).

Just as we saw in Tulsa after his previous rally, we’ll probably see a spike in cases in Nevada in two to three weeks.

Beyond the nonchalant and willful endangerment to peoples’ lives, what bothers me most of all about this event is Donald Trump’s cavalier and metaphorical raising high of his two middle fingers to Nevada’s scientifically-based efforts to keep its citizens alive. After repeatedly telling the nation’s governors they should do what they think they need to do to combat COVID-19, this “law and order” president, without compunction of any kind, imperiously violates the law while telling his large crowd Nevada’s Governor Sisolak is “a hack” and “weak.”

Allow me to close with Joseph Welsh’s question to Senator Joe McCarthy on 9 June 1954: “Have you no decency, sir?”

 

The Pledge, AstraZenica’s Hiccup, An Important WCRI Study, And An Homage To Bourbon!

Wednesday, September 9th, 2020

Having put The Insider on pause for a few weeks to have some fun researching pandemics in earlier times (they were awful) and to improving my tennis game (it’s pretty good), we now dive back into the blogging fray. Today, we get a running start.

The Pledge

At a press conference on 24 August, President Trump and FDA Commissioner Stephen Hahn trumpeted (pun very much intended) the FDA’s Emergency Use Authorization (EUA) of blood plasma to treat COVID-19 patients.  The Trump/Hahn announcement came less than a week after officials at the National Institutes of Health (NIH) had put a hold on releasing the EUA, saying randomized trials were needed before such an action could occur. The President disagreed, saying, “There are people in the FDA and actually in your larger department [HHS] that can see things being held up and wouldn’t mind so much — its my opinion, a very strong opinion — and that’s for political reasons. We are being very strong and we are being very forthright, and we have some incredible answers, and we’re not going to be held up.”

In yet another example of Olympian Hyperbole, a disease to which Mr. Trump seems to be terminally infected, he also called the EUA a “truly historic announcement,” which puts it alongside something like the Emancipation Proclamation.

Like most of Trump’s hyperbolic pronouncements, the blood plasma EUA created quite the controversy, especially when the FDA released the comments of one of its own scientists tasked with reviewing the appropriateness of the same blood plasma EUA. That scientist— displaying far less enthusiasm than Trump and Hahn, and whose name was redacted from a memo released by the agency — wrote that the data:

 “…support the conclusion that [convalescent plasma] to treat hospitalized patients with COVID-19 meets the ‘may be effective’ criteria for issuance of an EUA. Adequate and well-controlled randomized trials remain nonetheless necessary for a definitive demonstration of … efficacy and to determine the optimal product attributes and the appropriate patient populations for its use.”

After the 24 August press conference, it took about 1.5 nanoseconds for Joe Biden and many media pundits to accuse Trump and Hahn of politicizing the EUA to influence the coming election.

Which brings us to The Pledge.

On 8 September, wanting to get out of firing range, the CEOs of all the leading Western developers of COVID-19 vaccines vowed to only file for FDA approval after demonstrating safety and efficacy in their Phase 3 trials. Their Pledge and descriptions of all nine trials can be found here.

The Pledge also promises all the developers will share some, but not all, of their data to propel their vaccines to the finish line. However, although every CEO wants their vaccine to be the first approved, not one of them wants to get there only for the world  to discover they’ve cut corners and now endanger humanity. These are people who want to go down in history for the right reason.

Mr. Trump will push, prod and kick these vaccine developers to get one of their efforts approved before 3 November. But I have a 95% confidence level none of them will buckle under that pressure. I sure hope I’m right.

AstraZenica’s Hiccup

In an example of the caution just described, yesterday AstraZenica announced  it was putting its Phase 3 vaccine trial on hold, due to a suspected serious adverse reaction in a participant in the United Kingdom.

This is not an uncommon happening in vaccine development, but it does show how fraught with uncertainties these trials can be. It proves that AZ’s data and safety monitoring group is doing its job, and that’s what is supposed to happen. I previously wrote about all the leading COVID-19 vaccine candidates, as well as ChAdOx1, the one being tested by AstraZenica in partnership with the University of Oxford’s Jenner Institute.

It is entirely possible we will experience more bumps in the road before one of the developers wins FDA approval.

An Important, New WCRI Study Is Released

Low back pain (LBP) is something that has afflicted humanity since Homo Sapiens decided to stand straight and walk upright. And it’s been the bane of claims adjusters since Otto von Bismarck, Germany’s Iron Chancellor, created the first workers’ compensation program in the 1880s.

Back injuries are the leading cause of all musculoskeletal claims, which are the leading cause of all workers’ compensation claims, and have been since it seems forever. If you’ve ever looked at a workers’ compensation loss run for any hospital in America, you’ll know what I mean.

One of the myriad treatment modalities for these claims is physical therapy (PT). However, it’s always been a bit of a crap shoot as to when to prescribe PT for a patient beset by a work injury resulting in low back pain.

Now, the Workers’ Compensation Research Institute (WCRI) has produced a study that convincingly puts the matter to rest. The study’s conclusion: the earlier PT is begun, the better.

The study, The Timing of Physical Therapy for Low Back Pain: Does It Matter in Workers’ Compensation?, is based on a review of  nearly 26,000 LBP-only claims with more than seven days of lost time from 27 states, with injuries from 1 October 2015, through 31 March 2017, and detailed medical transactions up through 31 March 2018.

One of the many reasons this study is important is that PT can sometimes be the last resort, not the first, in many cases being recommended only after opioids and other invasive procedures have been tried.

The WCRI study found:

  • Later timing of PT initiation is associated with longer temporary disability (TD) duration. On average, the number of TD weeks per claim was 58 percent longer for those with PT initiated more than 30 days post-injury and 24 percent longer for those with PT starting 15 to 30 days post-injury, compared with claims with PT within 3 days post-injury.
  • Workers whose PT treatment started more than 30 days post-injury were 46 and 47 percent more likely to receive opioid prescriptions and MRI, respectively, compared with those who had PT treatment initiated within 3 days of injury. The differences between PT after 30 days post-injury and PT within 3 days post-injury were 29 percent for pain management injections and 89 percent for low back surgeries.
  • The average payment for all medical services received during the first year of treatment was lower for workers with early PT compared with those with late PT. For example, the average medical cost per claim for workers who had PT more than 30 days post-injury was 24 percent higher than for those who had PT within 3 days post-injury.
  • Among claims with PT treatment starting more than 30 days post-injury, the percentage with attorney involvement was considerably higher (27 percent compared with 13–15 percent among those in the early PT groups) and workers received initial medical care much later (on average 18 days compared with 2–3 days in the early PT groups).

If you’re a claims adjuster wary of incurring the cost of sending injured workers with resultant low back pain to PT, this study should make you press the “Reset” button in your mind.

And, finally, an homage to bourbon (which is also good for low back pain)

In the constant sea of terrible, divisive, set-your-hair-on-fire news, we now row to a bipartisan safe harbor: Bourbon.

In the halls of Congress, bipartisanship seems to have gone the way of the Woolly Mammoth. But, reader, that is not the case in the case of Bourbon! That’s because on 2 August 2007, Congress ratified a bill designating September as National Bourbon Heritage Month. More notable, however, is that it passed unanimously. Thus, history shows that amid the countless issues and places and opinions that divide us, nothing unites Americans like bourbon.

And that aint all. A 1964 act declared bourbon “America’s Native Spirit,” making it the only spirit distinctive to the United States, if you don’t count the “spirits” the QAnon folks are worried about.

So, although I can’t stand the stuff, on this first day after 2020’s Labor Day as we all get sucked along the giant tube of political rigarmarole, you might want to consider the nationally endorsed benefits of America’s Native Spirit. Things will still be dire, the President will continue his hyperbolic rants, many of your fellow Americans will continue to “choose liberty” over masks, but you? You’ll hardly notice any of it.

 

 

When This Is Over, We Must Do Better!

Thursday, August 6th, 2020

For decades, we have swept our health care problems under the rug for posterity to trip over.    And right now, posterity is flat on its face.

Let me ask you this: Whether you believe high quality health care is a basic human right or just a privilege to be earned (I argued the former here), what do you think about 5.4 million Americans losing health insurance in the middle of the worst health care crisis in more than 100 years, because they lost their jobs?

One of the many terrible things COVID-19 has done is to expose our health care foundational flaws for all the world to see. For example, if there is ever a time not to lose health insurance it is during a pandemic. Another deep and open wound suddenly exposed to bright light is the abominable, even obscene, way in which COVID-19 has been allowed to impact the African American, Native American and LatinX communities. Health care is neither universal nor applied equally throughout the country.

As far back as 2008, I, along with others, documented the many ways our health care system, if you can call it that, lags behind the rest of the developed world*, in some case far behind. This, despite costing twice as much as the average of the other 36 member countries in the Organization for Economic Cooperation and Development (OECD), 25 of whom are members of the European Union. Since then, except for the passage of the Affordable Care Act (ACA), things have only gotten worse, and the ACA has been flayed, gutted and nearly beaten to death more than once. It should not, but it does to many, come as any surprise that the EU countries are performing significantly better in the battle against COVID-19 than we are, despite having a total population that is 27% greater than America’s. These two charts prove the point:

First, Population – From the World Bank:

Second, COVID-19 cases – from Johns Hopkins University and Statista as of 30 July, seven days ago:

What more does one need to see to conclude America’s response to COVID-19 has been tragically woeful?

Yesterday, I was speaking with a friend, a pulmonologist who has been on COVID-19’s front lines in Massachusetts since March. He and his patients, a number of whom are no longer with us, have been through a lot. His biggest complaint? The lack of “consistent, cohesive and comprehensive leadership from the federal government.” He said, “I’m a God-fearing man, but right now my God is science.”

The rug under which we swept our problems has been pulled up, and bad things have crept out into the light of day. But COVID-19, for all its horror and misery, has presented us with an opportunity. When this is over, and someday it will be, we will have an opportunity, nay, an imperative, to build a better American health care program, less fragmented, less costly, less complicated, and universally provided to every person within the confines of our nation’s borders. If the leaders we elect have even a modicum of courage, if they have entered public service to actually serve the public – all of it – we and they may be able to take the iniquity of this virus and leverage it to the point where health care in this nation, rather than having to be earned as a privilege, available only to people who can afford it, becomes a basic human right for all of us.

* The link is to the conclusion of a 5-part series. For the first four parts, enter “The best health care in the world” in the search box on the right sidebar