Posts Tagged ‘public health’

Will Our Debt Ceiling Crisis Put A Knife Through The Heart of America’s Public Health System?

Tuesday, May 23rd, 2023

As I have written before, 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 76.1 years¹ is 4.9 years below the OECD average of 81.

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 3.9 years; Canadiens, by 5.3 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 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 turned the health care world upside down, especially with regard to health care funding. Although CMS reported U.S. health care spending grew 10.3 percent in 2020, it slowed to 2.7 percent in 2021, reaching $4.3 trillion or $12,914 per person.  As a share of GDP, health spending accounted for 18.3 percent, down from 19.4 percent in 2020.

Less than 4% of that $4.3 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.

Our current it-would-be-farce-if-it-weren’t-so-serious debt ceiling crisis is not helping. As Devon Page wrote for the Association of State and Territorial Officials discussing the impact of the recently passed  House bill to raise the debt ceiling—H.R. 2811, or the “Limit, Save, Grow Act of 2023,” that would reduce discretionary spending by 22 percent:

If enacted, the proposed discretionary spending cuts alone would have a near-ubiquitous impact, from public school funding to public safety programs. State health agencies could see core federal funding lines—some of which are already underfunded—threatened.

At stake is nearly $17 billion in unobligated funding at the Department of Health and Human Services, with about $4 billion at CDC and $2.5 billion for the Strategic National Stockpile (SNS). This includes dollars designated for the infectious disease rapid response fund, research and development of vaccines and therapeutics, payments to hospitals and nursing homes, and genomic sequencing of COVID-19 samples to identify variants.

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, as of one week ago, 1,128,903 of us have died to prove the point.

We could have learned from that. We could have, but we didn’t.

We could have done so much better.

_______________________________

¹ This figure is from the National Vital Statistics Report, August 2022, and is for 2021. Preliminary indications are that life expectancy rebounded in 2022 by 1.07 years to 77.45.

 

 

Remembering Katrina

Monday, August 30th, 2010

If you haven’t discovered the gem that is the Boston Globe’s “Big Picture” yet, you are missing a wonderful feature. Billed as “news stories in photographs” it is a themed news essay curated by Alan Taylor. From the BP oil disaster to the floods in Pakistan, the photos add a visual narrative to breaking stories of the day.
This past week, as in many media outlets, the focus was on Katrina. With a human toll of more than 1,800 dead and an economic toll exceeding $80 billion, the 5-year anniversary merits our attention.
For many of us, the anniversary is a look back, but for many of those who experienced it first hand, Katrina is a continuing nightmare. News reports point to ongoing health problems, from mental health issues to general health problems, such as skin infections and respiratory illnesses: “A recent study published in a special issue of Environmental Toxicology and Chemistry found elevated concentrations of lead, arsenic and other toxic chemicals were present throughout New Orleans, particularly in the poorer areas of the city. It suggested that widespread cleanup efforts and demolition had stirred up airborne toxins known to cause adverse health effects.”
Many residents, particularly children, are still still experiencing severe emotional and psychological disturbances. The National Center for Disaster Preparedness at Columbia University’s Mailman School of Public Health has been conducting studies on Gulf coast residents, and recently issued a white paper in coordination with the Children’s Health Fund:

“Together, these documents indicate that although considerable progress has been made in rebuilding the local economy and infrastructure, there is still an alarming level of psychological distress and housing instability. Investigators believe that housing and community instability and the uncertainty of recovery undermine family resilience and the emotional health of children. These factors characterize what researchers are calling a failed recovery for the Gulf region’s most vulnerable population: economically disadvantaged children whose families remain displaced.”

Looking back to look ahead
It’s no mystery why FEMA would designate September as National Preparedness Month. Between the man-made disaster of 9-11 and nature’s twin-wallop of Katrina and Rita, it’s certainly been a month fraught with peril, at least in terms of the last decade. In particular, FEMA is calling on businesses to be ready with disaster plans, and offers resources for that purpose.
A crisis by its very nature is unpredictable and random. But from a risk management point of view, it’s important for businesses to examine past events so that lessons learned can become part of planning for future crises with an eye to minimizing losses and disruption.
Perhaps one of the best articles we’ve seen on this theme is Crisis Management of Human Resources: Lessons From Hurricanes Katrina and Rita. This article discusses the three phases of crisis management: planning and preparation; immediate event response; and post crisis, or recovery. It cites specific companies and the way they problem-solved aspects of the Katrina crisis, and points to the importance of putting some plans in place: having and circulating an alternative emergency communication systems plan; keeping contact information and next-of-kin data current; maintaining communications with employees during an emergency; having updated policies and procedures for compensation and benefit continuation; making resources such as EAP services available to employees; and having flexible and alternative work arrangements.

Swine Flu Meets Workers Comp

Monday, April 27th, 2009

It’s only Monday morning and many of us are just refocusing after a weekend of gardening, football drafts, NBA playoffs, baseball (Ellsbury steals home!), so we are probably not quite ready to think about the unthinkable: a potential swine flu pandemic, originating in Mexico and already active in several major American cities.
Here is the official government announcement (which appears to circumvent potential panic by burying the bad news in gov-speak):

As a consequence of confirmed cases of Swine Influenza A (swH1N1) in California, Texas, Kansas, and New York, on this date and after consultation with public health officials as necessary, I, Charles E. Johnson, Acting Secretary of the U.S. Department of Health and Human Services, pursuant to the authority vested in me under section 319 of the Public Health Service Act, 42 U.S.C. § 247d, do hereby determine that a public health emergency exists nationwide involving Swine Influenza A that affects or has significant potential to affect national security.

[Where, oh where, do they learn to write like that?]
As is our custom, we focus on the implications for workers comp. Back in 2005 we blogged the ramifications of smallpox exposure from the comp perspective. The smallpox exposure – a result of the terrorism scare – proved to be a false alarm. The swine flu, unfortunately, appears to be all too real.
The Comp Dimension
It’s not difficult to isolate the kinds of activities that might expose an individual to the Swine flu. Many of these exposures are prevalent in the world of work:
: travel
: frequenting congested areas (travel terminals, public transportation, classrooms, etc.)
: touching anything handled by strangers
: eating out
: meeting business colleagues from around the country and around the world
In order for the flu to be a compensable event under comp, certain requirements must be met:
: the individual must be “in the course and scope of employment” when exposed to the virus
: the exposure must arise out of work (as opposed to being a totally random event)
: work itself must put the individual in harm’s way
An individual commuting to work via public transportation might have high risk exposure, but flu caught on a subway or bus would not normally be covered by comp. But if the exposure stems from company-provided transportation (for example, a van), the subsequent illness might well be compensable.
If one worker in a closed environment brings the flu to work, co-workers who succomb to the virus can make a good case that the illness is work related. The initiator, however, would not have a compensable claim, unless he/she could demonstrate a definitive work-related exposure.
Health workers are on the front lines of any pandemic. Even though it might be impossible to prove that they actually caught the virus at work, any and all cases of Swine Flu are likely be compensable.
If you fly on an airplane on company business and the person next to you is sneezing and coughing, your exposure is work-related and the subsequent illness is likely to be compensable. If you are flying to visit Aunt Martha, you are on your own.
The comp system is not well equipt to deal with illness. It’s usually very difficult, if not impossible, to determine exactly when an individual actually caught the virus. With state laws varying in their assumptions of compensability, with a multitude of insurance carriers and third party administrators making compensability determinations, we will see a crazy quilt of decisions regarding the compensability of swine flu.
There is a lot of money at stake in these compensability decisions. For mild cases, the issue is moot. It’s the more severe cases – prolonged illness and even death – that raise the greatest concerns. While thus far the fatalities have been limited to residents of Mexico, if the feared pandemic occurs, there will be prolonged illness and even fatalities in the states. Then the crucial decisions regarding compensability will directly impact the future cost of workers comp insurance.
What is to be Done?
So how should employers handle flu exposures? For a start, educate employees on prevention. The above government website has some helpful hints – and they are actually written in plain English; unfortunately, they are only written in English.
Any employee showing up at work with flu symptoms should be sent home immediately. And if any employee appears to come down with the flu while “in the course and scope” of employment, employers should report the illness to the insurer/TPA, so that a proper compensability determination can be made. As in all things comp, it is usually a mistake for the employer to make assumptions about compensability. When in doubt, report the illness and let the experts determine what to do.
As the world lurches from one crisis (economic) to another (pandemic), it is all too clear that we have fulfilled the Chinese (?) curse: “May you live in interesting times.” We do, indeed.

A Note to Fellow Immigrants

Friday, March 3rd, 2006

Franklin Roosevelt may or may not have begun an address to the Daughters of the American Revolution with the memorable line, “Fellow Immigrants.” (A curmudgeonly blogger says a reporter made up the quote.) If Roosevelt didn’t say it, he should have. It’s a great line and perhaps more compelling than ever. The current debate over illegal immigrants – as fractious and divisive as the debate over abortion – has created a fault line that runs through every aspect of our culture.
In an excellent article in the New York Times (registration required) by Nina Bernstein, we read about the effect on access to health care that well publicized “throw them out” legislative initiatives have had on undocumented immigrants. Not surprisingly, these immigrants are sensitive to anti-immigration sentiments. For example, knowing that identity requirements are tightening, Chinese immigrant workers in New York City are shying away from the conventional health system (which in many cases is not exactly welcoming) and relying more on traditional herbal remedies. Bernstein writes of the sad demise of Ming Qiang Zhao, a 52 year old restaurant worker who could not afford to continue treatment for his nasal cancer. He relied on street remedies until he finally collapsed in a coma. The system which discouraged him from securing ongoing treatment readily admitted him on an emergency basis: a very expensive proposition ($5,400 day) involving several near-bankrupt hospitals. Unable to decipher the effect of the herbal remedies that he had been taking, the doctors treated him as best they could until Ming died.
Who cares?
Beyond the humanitarian issues, beyond the inflammatory rhetoric seeking to toss the illegals out, is the reality of having a two-tier health care system. In the system that most of us subscribe to, treatment is readily available, pharmacology is the best in the world, and minor ailments are treated with respect and concern. In the parallel universe of undocumented immigrants, there are bootleg remedies and unlicensed practitioners – until you collapse and are taken by ambulance to an emergency room.
The public health implications of this two-tiered system are alarming. Bernstein quotes James Tallon, president of the United Hospital Fund: “Anything that keeps anyone away from the health system makes no sense at all. It takes one epidemic to change everyone’s attitudes about this.” (We’ve already blogged the terrifying conjunction of avian flu and illegal workers in the poultry industry.)
The debate over what to do about illegal immigration impacts every one of us. I highly recommend that Insider readers track the current debate in Washington through Peter Rousmaniere’s working immigrants blog, which is devoted solely to immigration-related issues.
Public Policy Parameters
The immigration issue is complex. There are no easy solutions. The problem is going to test us in ways that we can hardly envision. It brings to mind something that Roosevelt definitely did say: “When you get to the end of your rope, tie a knot and hang on. “I would hope to see the debate over immigration guided by a few basic assumptions:
– It’s neither feasible nor desirable to deport 11+ million undocumented people and their families.
– Undocumented workers are an important part of our economy. If they disappeared tomorrow, we would all suffer the consequences.
– It’s counter-productive to cut off immigrant access to the health care system. You don’t want people treated by quacks. Somehow, we must open health care to everyone residing in our borders. It’s the right thing to do and it’s in our own selfish interests to do it.
– No matter what people think about illegal immigration, we must develop some kind of fundamental accommodation, some way of making every immigrant visible, so that these people are able to engage in the mainstream culture on a basic level.
– As we figure out ways to accommodate undocumented workers, the cost of doing business will definitely go up. When the protective umbrella of fair labor laws and fundamental benefits begins to cover workers who are currently “off the books,” the cost of labor will rise.
– You can build walls to keep people out, but walls tend to become prisons for people on both sides.
There are undoubtedly many more assumptions could be added to this list. Insider readers should jump in on the discussion. This problem is not going away. And how we address it as a nation has powerful implications for all of us.

The Smallpox Conundrum

Friday, January 28th, 2005

Remember smallpox? At the height of concerns about terrorism following 9/11, the federal government proposed that health care providers and first responders get vaccinated against the disease. The lack of response, as they say, was deafening. Recently there was a privately-funded simulation of a smallpox incident in the news. Headed up by former Secretary of State Madeline Albright, the exercise — dubbed “Atlantic Storm” — posed a scenario in which terrorists spread dried smallpox at an airport in Frankfurt, Germany and a number of other locations throughout Europe and the United States. The simulation revealed a number of serious weaknesses in our current planning. As the former Polish Prime Minister, Jerzy Buzek, put it: “Fortunately, we are not prime ministers anymore. Nobody is ready.”
Here are a few facts concerning the vaccination for smallpox (for detailed information, see the CDC’s website):

  • For the most part, the vaccination is safe: the rate of adverse response to the vaccine is relatively small (1,000 serious reactions for every million vaccinated). However, given the scale of the anticipated inoculations that would be needed if all health care providers needed protection, there is cause for concern. Under rare circumstances the vaccine can lead to death.
  • After vaccination, the individual is potentially contagious, for up to three weeks (as long as the vaccination site remains open). This means that health care workers — primary targets for vaccination — might not be able to work for a significant period of time.
  • There is a portion of the general population that is at higher risk for adverse reaction to the vaccine (e.g., people with a history of eczema or acne, HIV positive individuals, burn victims, cancer patients, pregnant women). There are guidelines for screening these individuals out of a vaccination program.

The Public Policy conundrum
The smallpox vaccination program raises a number of issues involving workers compensation and other forms of insurance. In addition, there are some gray areas, where vaccinated workers and their families may face periods of disability that are not covered by insurance. Here is our take on just a few of these issues:
If employers require their employees to be vaccinated, any adverse responses would certainly be covered by workers comp, up to and including death. Even if the vaccination is “voluntary,” adverse reactions are still likely to be covered by workers comp. There is a potential “disproportionate impact” on insurers of health care facilities and ambulance services, whose workers are first in line for vaccination. This exposure is not currently contemplated in workers comp rates.
Regarding the significant portion of the general population that is at higher risk for adverse reaction to the vaccine (see above), many of these vulnerable individuals work in health care facilities, where their not being vaccinated might put them at higher risk for serious illness. If exposed to smallpox, they would be at very high risk when they are compelled to take the vaccine to stave off the illness.
As if the real risks were not enough, the considerable publicity about the dangers of the vaccine significantly increases the probability of “false positives” — people reporting what may be imaginary ailments. These “false positives” would immediately appear on the workers comp radar screen.
Here’s the crux of the problem for the health care industry: inoculated workers might not be allowed to come into contact with patients during their potentially contagious period (up to 21 days). This would apply especially to health care workers whose patients include the highly vulnerable groups mentioned above. This inability to work is not a period of “disability” but of quarantine. Workers comp would not apply. Who replaces the lost wages during this period? Is it fair to require workers to use their sick leave? What if they do not have any sick leave? Beyond that, if there is a mass inoculation of health care workers, how will hospitals staff their facilities during the quarantine period?
As if all the above weren’t enough to worry about, during the contagious period, a worker might infect family members. How would these exposures be covered?
This is not meant as a definitive summary of the smallpox policy issues. However, it is clear that any mass inoculation program will raise a number of concerns that need to be confronted head on, not as we are currently doing, with our heads buried in the sand.