Posts Tagged ‘health policy’

Stories I Was Planning To Address. They’ll Have To Wait.

Thursday, March 3rd, 2022

The life and death stories coming out of Ukraine, as its people continue to exhibit fierce and inspirational resistance to Vlad the Invader’s barbaric onslaught, tend to suck the air out of any room. Somehow, Joe Biden’s approval ratings, or America’s vitriolic partisan divide, or who will prevail in the midterms or the desperate state of our infrastructure, or the future of our newest Supreme Court nominee, while important at any other time, just cannot compete with Putin’s intentional and indiscriminate killing of anyone, man, woman, child, beloved pet, anyone in the way of his rapacious army. This is causing the most momentous change on the European continent and throughout the geopolitical world in nearly 80 years. And it’s taken only a week.

So, here are some quick takes of the things I would have written about, and maybe will in the future in more depth, were it not for the blackhole-like gravity of what’s happening in Ukraine.

Tuesday night’s State of the Union

Joe Biden’s speech to the Congress and the nation came in two chapters. Chapter One: Ukraine. Chapter Two: His domestic agenda.

Chapter One was riveting, and it appeared nearly everyone sitting on the floor and in the gallery of the House of Representatives was united in support of the West’s monumental pushback to  Vlad the Villain. I thought it ironic they were all sitting in a sacred building where, just 14 months ago fellow citizens tried to steal American democracy, and nearly did. Ironic, indeed, when one considers so many who were sitting on the R side of the aisle now want to look the other way and pretend it never happened.

Chapter Two was pretty much what you’d expect from any State of the Union speech — until the heckling. Representatives Lauren Boebert, R-Colo., and Marjorie Taylor Greene, R-Ga, put on a disgusting display of crass and boorish incivility. These two ladies have never demonstrated having had an original idea in their lives. Why should they? They’re both travelling on borrowed gas, and inferior gas, at that. Boebert, especially, raised poor taste to a new level when she screamed out accusing Biden of killing 13 soldiers during the evacuation of Afghanistan as he was describing the death of his beloved son, Beau, from cancer attributable to burn pits in wartime. These two, both of whom have about as much empathy as a New Jersey loan shark, would be rejected from Dante’s Inferno for giving the place a bad name. (Pity the poor fellow sitting between them  wishing he were anywhere else on earth — except maybe Ukraine)

Why can’t Medicare negotiate drug prices?

When you insure more than 61.2 million beneficiaries you’d think you’d have tremendous leverage to negotiate the lowest drug prices on earth. But that is not the case in the USA.

The Medicare Modernization Act (MMA) of 2003, the one that created the unfunded Part D drug program along with the infamous “doughnut hole,” specifically forbids Medicare from negotiating prices with drug companies, giving that responsibility, instead, to for-profit insurers and Pharmacy Benefit Managers. Health policy Guru John C. Goodman calls the MMA, “arguably the worst domestic policy decision in the history of the country.” At the time of enactment, the Social Security and Medicare Trustees estimated the long-term (75 years) unfunded liability of the MMA’s Part D program to be $17 trillion. The Trustees project that cost growth over the next 5 years will average 7.3 percent for Part D, significantly faster than the projected average annual GDP growth rate of 4.3 percent over the period.

And, still, Medicare cannot negotiate prices.  Result? High drug prices for Medicare and its beneficiaries.

By contrast, the VA is able to negotiate for its nine million veterans enrolled in its health care program, yours truly being one of them. Result? Low cost drugs.

Since passage of the MMA, there have been repeated attempts to introduce and pass legislation that would allow Medicare to bring the full weight of its considerable power to the price of pharmaceuticals. Two things have prevented any success in these endeavors. First, the bottomless well of pharmaceutical industry cash, and, second, members of congress who are the beneficiaries of that bottomless well of cash.

To quote that eminent American philosopher, Mark Twain, “We have the best government that money can buy.”

Federally Qualified Health Centers. Now there’s a well kept secret!

Federally Qualified Health Centers (FQHC) are community-based health care providers that receive funds from the Health Center Program of the Health Resources and Services Administration (HRSA) to provide primary care services in underserved areas. They must meet stringent requirements, including providing care on a sliding fee scale based on a patient’s ability to pay and operating under a governing board that includes patients. Specifically, at least 51% of their Boards must be patients.

By law, FQHCs must treat anyone, regardless of the ability to pay.

There are 1,368 FQHCs in the country. Most have a number of locations, called Service Sites, bringing the total health care locations to 14,200. They welcome people with insurance, but their main targets are poor people who could otherwise not afford health care.

In addition to FQHCs, the Health Center Program also funds Rural Health Centers (RHCs), whose mission is to increase access to primary care services for patients in rural communities.

FQHCs and RHCs are funded annually by congressional approval. Additionally, Section 330 of the Public Health Service Act provides grant awards to eligible health centers and outlines the requirements the centers must meet to be eligible .

Taken together, FQHCs and RHCs are Community Health Centers. They are ubiquitous throughout the country. For example, in my home state of Massachusetts, there are 52 community health center organizations providing high quality health care to some one million state residents through more than 300 sites statewide. For perspective, there are 351 cities and towns in Massachusetts.

Given the woeful state of our nation’s public health system, as was amply demonstrated by our response to COVID-19, it might not be a bad idea to consider the Community Health Center model as we attempt to re-engineer how we deliver health care to all of us.

Just a thought.

 

 

 

News You Might Have Missed To End Your Week

Friday, February 4th, 2022

Interesting weather today, here in the heart of the Berkshire mountains. A little rain, a little sleet, a little freezing rain, a little snow and a lot of ice. The very definition of my newly coined word, quinaryfecta (I toyed with pentafecta).

Governor Baker has asked everyone to stay off the roads, so, here I sit putting together a few stories that might have slipped under your radar.

The cost of health care continues it ever-upward trajectory

In November, the Kaiser Family Foundation published the results of its annual Employer Health Benefits Survey, and 2021 continued what appears to be an unstoppable trend.

More than 155 million Americans get their health care from Employer Sponsored Insurance (ESI). That’s 55% of the working population. There are two facts about this year’s survey I would like to highlight:

First, the annual cost of health insurance for a family is rising faster than both wages and inflation.

To their credit, employers have been absorbing most of the rise in premium costs, but this prevents them from using those funds now going to health care insurance for other worthwhile endeavors, like growing their companies, enhancing their risk management programs, or raising wages.

Second, annual premium costs in 2021 rose 4% over 2020 to a record high $22,221. That’s $1,852 per month. Workers are paying an average of 28% of the cost, or about $500 per month. But that’s before a 2021 average deductible of $1,669, which is 92% higher than ten years ago. In 2021, 85% of workers in ESI plans were subject to a deductible.

As these costs continue their stratospheric rise it’s like employers and employees are side by side trying to outswim a Navy Destroyer ―  with every stroke they fall farther behind.

Speaking of upward trends, let’s consider traffic deaths in 2021

The Department of Transportation just released a statistical projection of traffic fatalities for the first 9 months of 2021 showing an estimated 31,720 people died in motor vehicle traffic crashes nationwide. This represents an increase of about 12% as compared to 28,325 fatalities that were projected in the first nine months of 2020. This is the highest percentage increase over a nine-month period since the Department began recording fatal crash data in 1975. The numbers in 2021 are 32.5% higher than they were a decade ago.

Something weird is happening on our roads. Over the last 45 years, traffic safety engineers and automakers have made remarkable progress in improving the safety of our roads and cars. But they haven’t been able to change the human element, about which we wrote a week ago.

Don’t go by raw numbers, however. The important statistic is the rate of traffic fatalities per million miles driven. From 2011 through 2019, the rate didn’t waffle much, going from 1.09 to 1.10, with a blip up to 1.17 in 2016.

All that changed in 2020, when the rate jumped to 1.35. In 2021, it inched up to 1.36 to prove 2020 wasn’t a momentary aberration.

Secretary of Transportation Pete Buttigieg announced the Department will dedicate significant resources to attack these daily tragedies. We will be paying close attention to this.

Another example of our fragmented health care

The Biden Administration has made it easier for people to get free at home rapid tests. Here at our home, we applied on Day One of the program, and four days later our tests arrived. And the Administration has distributed millions of tests to pharmacies and states. People can go to CVS or Walmart or any other participating entity, buy tests, and get reimbursed by their insurance company. That’s not how other countries are doing it, and they’ve been doing it longer. They’ve cut out the insurer middleman, and have just gone directly to their people with the tests. In the the UK, for example, testing has become a way of life.

The insurer reimbursement issue has become a Medicaid problem for the states. The rules of Medicaid do not allow for it, and, because each state administers the program in its own way, they’re all approaching the problem differently.

Some states have made it easier for the safety net program to reimburse pharmacies for providing the tests at no cost. Others are experiencing what CMS described in an 11 January call with the states as “operational considerations and challenges.” Here’s one such challenge: Some states require a prescription for Medicaid enrollees to get anything from a pharmacy. To deal with this, states are making what they are calling “standing orders” to allow enrollees to get free tests at pharmacies without a prescription.

Another challenge for the states: How to get tests to homebound enrollees. Some states are attacking this by setting up temporary mail order programs.

My point here is that each state has to create its own solution. That is counterproductive. All the states are facing the same COVID problems, but each is attacking those problems differently. Throughout, one thing has become clear to the various Medicaid State Directors: the more they communicate with each other, the better off they are.

It is becoming more and more evident that the absence of one cohesive system to guide everyone wastes time and money, and jeopardizes the health of Medicaid enrollees all over the nation.

Have a nice weekend.

 

Medicaid Expansion: An Addendum To My Two-Part Series

Thursday, February 3rd, 2022

Long ago in 2009, I wrote about  a PBS special hosted by Journalist T. R. Reid, in which Reid analyzed the health care systems in five other countries: The UK, Japan, Germany, Taiwan and Switzerland. Reid had spent a full year in those five countries trying to figure out how they provided universal health care at much lower cost than the U.S. with better results. He later published a book about it, The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care (available on Amazon).

The good news is Reid did a wonderful job, both in his book and on his PBS special. The bad news is things in the U.S. have only gotten worse since then. Health care costs as a percent of GDP have increased three percentage points since 2009 to about 20% (the Opioid epidemic and COVID haven’t helped), and our health care outcomes have remained sub-par to the rest of the Organization for Economic Co-operation and Development (OECD), the 38 country organization of which the United States was a founding member 60 years ago.

I was reminded of Reid’s work while preparing my two-part Medicaid expansion series published over the last two days, and I couldn’t help thinking the ACA’s Medicaid expansion provision, for all the good it has done, only aims to put a band-aid on a mortally wounded patient.

In America, health care has become a commodity, a market-driven enterprise. Throughout the rest of the developed world, it is an essential human right; something governments were created to provide and protect. In America, 55% of us have earned the right to health care by working for an employer who provides it. Another 18% of us have earned health care by reaching the age of 65. A further 3.7% have earned it by serving in the military. The remaining 23.3% are on their own, which is where Medicaid comes in. Sadly, it appears many powerful people resent that final group and our inclination to provide them what the rest of the world views as a moral duty.

In America, legend, myth and vulnerable gullibility influence many of our citizens, who have been led to believe any government intrusion into health care will lead to draconian tactics typical of a fascist state (remember Sarah Palin’s death panels?). They don’t seem to realize that health care provided by our Veterans Administration, treating millions of our veterans every year (including this one), is a direct copy of Britain’s. Or that Medicare, our largest insurer with more than 62 million members who, in poll after poll, report high satisfaction with their health care, is modeled on the health care system of Canada.

Maybe American health care is just too big to be redesigned into something that would make us all proud. Too many vested interests, each making boatloads of cash. Each saying they support creating a better system ―  just as long as we don’t touch their sacred slice of the profitable pie.

But when I’m tempted to say, “A plague on their houses,” I think of the Taiwanese, who went from nothing to one of the most technologically advanced, yet inexpensive, health care systems in the world in just fourteen years. And I think of the Swiss, the bureaucratic, economically driven, bankers-of-the-world Swiss, who took off their stuffed shirts and came to see high-quality, affordable health care as the absolute right of every Swiss citizen.

The health care systems in Taiwan and Switzerland have flaws, but, even so, they are light years ahead of the U.S. in terms of quality, cost and universal coverage. If these two totally different countries can do that, I ask you, why can’t we?

Eventually, America is going to have to decide if good quality health care is a basic human right, or a privilege to be earned.

ACA Medicaid Expansion — Part 2: The Opposition

Wednesday, February 2nd, 2022

Yesterday, I wrote about the proven benefits of the Affordable Care Act’s expansion of Medicaid to provide health insurance to millions of our previously uninsured fellow citizens. By way of background, I began yesterday’s column with the following:

According to the Department of Health and Human Services (HHS), there were 48 million uninsured in 2010 when the Affordable Care Act (ACA) became law. Over the next nine years, 38 states, using ACA funding, expanded their Medicaid programs. During that time, the numbers of uninsured fell to 28 million before rising to 30 million in the first half of 2020 due to policy changes to the ACA by the Trump Administration that made it harder to qualify for coverage.

There are now twelve states left that have refused to take advantage of the ACA’s provisions to expand Medicaid, a move that would significantly lower the number of uninsured people within their borders.

The states in orange are the states that have refused to accept Medicaid expansion and the significant federal dollars that go with it. The orange states are all “red” states.

Today, we’ll examine the reasons governors and legislatures in those 12 states give for not accepting the massive federal funding coming with ACA expansion. Tomorrow, I’ll offer an opinion and a plea for building a better system.

But first, we’ll need to set the stage.

The rate of uninsurance in non-expansion states is nearly double that of expansion states.

A word about the uninsured in non-expansion states. As the above chart shows, nearly 22% of them live in rural areas. The majority of these Rurals are registered Republican voters. They are also white/non-Hispanic and less educated than their urban counterparts. Medicaid expansion would be of great benefit to them. But their governors and legislators refuse to expand Medicaid to help these people and the rest of their uninsured populations. Why?

What is even more perplexing is why the rural uninsured continue to vote for people who refuse to help them improve their health care lot in life.

There is another darker result of not expanding Medicaid, and it concerns people of color. People of color, especially the uninsured, have faced longstanding disparities in health coverage that contribute to disparities in health. The states that expanded Medicaid following passage of the ACA saw significant decreases in these disparities from 2010 through 2016; the non-expansion states did not. Beginning in 2017, the Trump administration implemented policy changes that made it harder to qualify for Medicaid. The result was a reversal of progress made during the prior six years; the number of uninsured began growing again, and, once again, people of color were the hardest hit.

Just another example of the cultural and moral divide in America.

Governors and legislators opposing expansion offer 3 primary arguments:

The state cannot afford it.

This is political theatre. The federal government pays 90% of the cost of expansion, the state the remaining 10%. States that have expanded coverage have demonstrated affordability by moving  funds from other areas that, because of expansion, will not need as much money. In Michigan, for example, the state budget realized substantial savings in correctional health care and community mental health when some of the expenses of these programs were shifted to Medicaid. Taking into account other economic effects of expansion, such as increased tax revenues from increased economic activity, Medicaid expansion was a net benefit to the state’s budget. Moreover, the Families First Coronavirus Response Act, which was signed into law on 18 March 2020, included a provision for the federal government to assume a larger share of existing Medicaid obligations in every state, freeing up state Medicaid funds for other uses — like expanding coverage. The “We can’t afford it” line does not hold water.

Allowing people to access Medicaid will discourage them from working.

Multiple studies have found no evidence that expanding Medicaid is a disincentive to working. A typical finding is, “We find that although the expansion increased Medicaid coverage by 3.0 percentage points among childless adults, there was no significant impact on employment.”*

Expanding Medicaid will only add more people to a broken system.

Opponents of expanding coverage often deride Medicaid as a low-quality program. Yet a majority of people in the U.S. — Democrats, Republicans, and independents alike—believe that the program is working well. In states that have not expanded Medicaid, a clear majority favor doing so. Most Medicaid enrollees are quite happy with their coverage, reporting higher rates of satisfaction than people with private insurance.

The arguments listed above are the three reasons most often cited by leaders in the 12 non-expansion states for their opposition. There is one argument that goes unexpressed, but is often present: People who are uninsured are uninsured because they lack the money to become insured. They lack that money because they never worked hard enough to get it. They are irresponsible. Consequently, society does not owe them a free health care lunch.

Over the last two days, I’ve tried to counter that “thinking” with clear, hard, proven, factual data. None of it has been opinion (if you ignore my comment yesterday about Senator Ron Johnson, that is). I’ve tried to demonstrate that all the arguments in opposition are nothing more than groundless opinion.

I end with these questions: Is health care a basic human right? Does society owe its poorest decent health care, or must they earn the privilege? How do we answer the murderer Cain’s question in Genesis 4:1-13, “Am I my brother’s keeper?”

We need answers to those questions.

*Leung and Mas, Employment Effects of the Affordable Care Act Medicaid Expansions, 25 March 2018, in Industrial Relations, A Journal of Economy And Society.

 

 

 

The Proven, Credible Benefits of ACA Medicaid Expansion — Part 1

Tuesday, February 1st, 2022

According to the Department of Health and Human Services (HHS), there were 48 million uninsured in 2010 when the Affordable Care Act (ACA) became law. Over the next nine years, 38 states, using ACA funding, expanded their Medicaid programs. During that time, the numbers of uninsured fell to 28 million before rising to 30 million in the first half of 2020 due to policy changes to the ACA by the Trump Administration that made it harder to qualify for coverage.

There are now twelve states left that have refused to take advantage of the ACA’s provisions to expand Medicaid, a move that would significantly lower the number of uninsured people within their borders.

The states in orange are the states that have refused to accept Medicaid expansion and the significant federal dollars that go with it. The orange states are all “red” states.

The ACA was passed in 2010. We now have 404 studies in the seven year period 2014 through 2020 producing 440  findings resulting from Medicaid expansion (A number of studies looked at more than one area).

There have been five studies concluding ACA Medicaid expansion has brought negative results in two areas ―  Provider Capacity and Positive Health Outcomes; remember that; they’re the ones in orange in the chart below (Good luck finding them). This is opposed to 435 findings of positive results in eight areas. These include 25 positive findings in Provider Capacity and Positive Health Outcomes (compare to the five mentioned above). The Kaiser Family Foundation summarized the studies in this chart:

There are three overarching benefits to Medicaid expansion nearly all experts agree on:

Expanding Medicaid helps low-income families’ health and financial well-being, especially those in which someone has lost a job.

In states that expanded Medicaid under the ACA, unemployed workers experienced large gains in coverage. Further, there are spillover benefits for economic well-being: lower debt and better credit scores. Physical health and financial health are inextricably linked. Expanding Medicaid improves both for low-income families. This has been doubly so in the time of COVID.

Expanding Medicaid reduces hospitals’ uncompensated care.

I write from experience. I was once a Director at a Massachusetts major hospital system. At one meeting, I asked our CEO what the system did when an indigent person showed up in the ER very sick or injured. By law we had to take care of them. So, given that, how did the system get paid? He replied, “We charge them the most we possibly can.” I said, “But they can’t pay.” He said, “That’s right, but the state’s Uncompensated Care Pool can.” This was a big drain on Massachusetts, eye-opening to me, and an obvious wrinkle in health care policy. Medicaid expansion dramatically reduces this burden for hospitals. In Michigan, uncompensated care was cut in half after Medicaid expansion in 2014. In 2016, Dranove, Garthwaite and Ody, publishing in Health Affairs, found uncompensated care decreased at hospitals in Medicaid expansion states but not at hospitals in non-expansion states. Moreover, in April 2021, Karpman, Coughlin and Garfied found significant reductions in uncompensated care in ACA expansion states:

Reflecting a significant decline in the share and number of people who were uninsured at any point in the year, the average annual share of nonelderly individuals who had any uncompensated care costs fell by more than a third following ACA implementation, going from 7.3 percent in 2011-2013 down to 4.8 percent in 2015-2017. This change represents a decline in the number of people with uncompensated care costs from 20.2 million to 13.1 million.

Correspondingly, the aggregate annual cost of uncompensated care provided to uninsured individuals dropped by a third following implementation of the ACA’s coverage provisions, from an average of $62.8 billion per year in 2011-2013 to $42.4 billion in 2015-2017. The cost of implicitly subsidized uncompensated care—or care that had no payment source, including a non-health insurance source—dropped from $21.6 billion to $15.1 billion per year on average before and after the ACA, respectively.

Expanding Medicaid is a highly effective form of economic stimulus.

An often-overlooked benefit of Medicaid expansion is that it creates jobs. During a recession, the infusion of federal spending gives a boost to a state’s economy. Evidence from the Great Recession shows that Medicaid spending is a highly effective form of stimulus: for every $100 000 of additional federal Medicaid spending, two workers gained a year of employment.

There are other intangible benefits, but we won’t go into them here, because they’re fuzzy, and it will give naysayers a hook, albeit a painted one, on which to hang their negative opinions. Let’s just say that being able to provide health care for your family, not having to forgo necessary care for you or your child because you need that money to eat, is psychologically significant. Contrast this with a recent statement from Senator Ron Johnson (R, WI): “People decide to have families and become parents. That’s something they need to consider when they make that choice. I’ve never really felt it was society’s responsibility to take care of other people’s children.” Compassion like that is disgustingly reminiscent of Ebenezer Scrooge before the spirits arrived.

Tomorrow, we’ll dive into the reasons governors and legislatures give for rejecting ACA funding to expand Medicaid in the remaining 12 non-expansion states. Hint: There are three reasons most often cited. They are opinions only without any credible supporting data, but in those orange collared states in the map at the beginning of this column, that doesn’t seem to matter.

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.