Posts Tagged ‘reports’

Reflections On WCRI’s Recent Virtual Annual Conference: In A Word, It Was Excellent

Tuesday, March 30th, 2021

COVID-19 impact analysis

Last year, the Workers’ Compensation Research Institute held its Annual conference in Boston at the Westin Hotel on 5 and 6 March. The ballroom was full. COVID-19 was talked about in the conference and on the breaks, but it was too new to be on the Agenda. Everyone was doing elbow bumps instead of hand shaking. Four days after the conference wrapped, Governor Charley Baker declared a Massachusetts State of Emergency. The WCRI conference was likely the last one held in the City before everything shut down.

At that time, per the Johns Hopkins University COVID-19 Dashboard, the nation had seen ~139,000 cases and 2,425 deaths. In Massachusetts, where the conference was held, there had been 4,955 cases and 48 deaths.

The following month, the National Council on Compensation Insurance (NCCI) issued a Research Brief titled, COVID-19 and Workers’ Compensation: Modeling Potential Impacts. 

NCCI’s analysis projected a best case scenario, in which loss costs would increase $2 billion, and a worst case scenario, in which they would increase $81.5 billion, or 250% more than then current total loss costs. Willis Towers Watson also released a scenario-based analysis that suggested pretty much the same thing.

Also in April, the California Workers’ Compensation Insurance Rating Bureau (WCIRB) projected loss costs if conclusive (rebuttable) presumptions were provided to front line workers, something Governor Gavin Newsom actually did through Executive Order one month later, so the “if” became a “done.” The WCIRB report concluded costs would range “from $2.2 billion to $33.6 billion with an approximate mid-range estimate of $11.2 billion, or 61% of the annual estimated cost of the total workers’ compensation system prior to the impact of the pandemic.

A year later, at this week’s virtual annual conference, WCRI Economist Olesya Fomenko, Ph.D., reported results from her analysis of workers’ compensation claims in WCRI study states for Q1 and Q2, 2020. This period, ending 30 June, encompassed the pandemic’s first of what has been up to now three surges.*

Her data and presentation slides are preliminary, but more than likely will stand up to future scrutiny. Her findings confirmed what most students of COVID-19 were intuitively thinking. To wit, it does not appear that, at least through the study period of two quarters, COVID-19 would deal a death blow to the workers’ compensation industry. Claims in her analysis of 27 study states are plentiful, but relatively inexpensive. There is wide variation in the geographic distribution of claims, probably because COVID-19 surged at different times in different states. New York is not among the WCRI study states, but during the period of Fomenko’s analysis, it was the state with more COVID problems than any other. A lot more.

During the study period, Massachusetts, Connecticut and New Jersey had the most reported claims. Massachusetts claims were 42% of all reported claims in the study states and 59% of all lost time claims. Dr. Fomenko suggested that the presence of presumption laws, pay without prejudice (in the case of Massachusetts) and other compensability issues (in New Jersey) might is some way contribute to the high numbers in those states.

Looking at Massachusetts for a moment might be instructive.

At the top of this column we showed Massachusetts with relatively few cases as of early March, two-thirds of the way through Q1. Let’s look at Massachusetts now, at the end of Q1 a year later. The state has been hit hard, but has also rebounded. Here’s a look at the state by county:

As you can see, no county has had less than 3,000 infections, and three have had more than 10,000. But what came of those infections? How did the patients make out medically? Here is a look at cumulative cases from 9 March 2021 through yesterday, 29 March 2021.

There have been 17,130 total deaths since the beginning of the pandemic, but 97% of infected patients have recovered. Deaths are at 3%, which is less than the 5% predicted by the CDC one year ago. And this is the case for most of the country, and is one of the reasons Dr. Fomenko’s data shows claims to be relatively inexpensive.

NCCI Analysis

The WCRI studies define the concept of “early days.” So do those from the National Council on Compensation Insurance (NCCI). The point is, however, that analyses from both organizations appear to be congruent and complementary.

The lasting costs of COVID-19 to the workers’ compensation industry, aside from deaths, are going to come from permanent total and permanent partial disability awards. To that end, in October, 2020, NCCI published a Research Brief updating the Brief cited earlier in this column and titled, COVID-19 And Workers’ Compensation: Permanent Disability. These costs will be significant. NCCI’s analysis determined the average age of hospitalized COVID-19 patients at 49.5 years old. Average life expectancy allows for about 30 more years of benefits. The organization writes:

Given that severe cases are expected to have a higher likelihood of permanent disability, particularly PTD injuries, NCCI
assumed that all PTD claims would occur in this symptom grouping (infections and lung claims). Adjusting our PTD rate to between 0.0% and 1.5% to be applicable to only severe cases, we observe a PTD rate between 0% and 10% (= 1.5% / 15%) using the default Critical Care Rate from the NCCI Hypothetical Scenarios Tool.

Permanent Partial Disability cases are another matter. Here the frequency will be higher as well as the costs:

One interpretation of this assumption could be that moderate cases behave more like infection claims which tend to have a
near-zero PTD rate. If we compare the lung and infection PPD rates, we observe that lung claims have about twice the
likelihood of a PPD injury compared to infection claims. To the extent that moderate cases of COVID-19 behave like
infection claims and severe cases behave like lung claims, then a similar difference in the PPD rate may be expected. Under
this view, the Severe PPD rate would range between 40% and 50% with an implied Moderate PPD rate ranging between
20% and 25%.

With assumptions it clearly states contain wide variability, NCCI suggests the following COVI-19 benefits by injury type:

We’ll continue to follow the NCCI analyses as well as WCRI’s ongoing research.

Interview by John Ruser, PhD, with John Howard, MD, MPH, JD, LLM, MBA

John Howard is the longest serving Director of the National Institute for Occupational Safety and Health, three terms and counting. He is a legend in the field, and WCRI attendees got a good look at why during this wonderful interview by John Ruser. Howard, who has more letters after his name than there are years in elementary and high school combined, put on quite a show.

Some people are one inch wide and ten miles deep; others ten miles wide and one inch deep. Howard seems to know no inch or mile boundaries.  His subject was The Future of Work, and he made a number of highly interesting and prescient points, even going so far as to describe Aristotle’s concerns about automation in the ancient world of 350 BCE.

Asked about fears of jobs disappearing because of Artificial Intelligence and automation, Dr. Howard pointed to a study showing that in 2018 there were 60% more jobs than existed in 1940. Jobs have always gone away, but they’ve been replaced, and then some, by new jobs.

He’s concerned about a safety ergonomic vacuum employers are going to have to manage somehow. He believes employers are facing a “real challenge” adjusting to the new Work From Home paradigm.

My question is: How do employers deal with, let alone manage, workers’ compensation claims bound to occur while working in the home. You’re at your desk or dining room table working, get up for lunch, fall down the stairs and break an arm. Is that compensable? Is your employer going to make you prove it actually happened while you were actually working, and not just taking Junior out to the back forty for a little tag football?

And what responsibility does an employer have with respect to OSHA’s General Duty Clause, the one about providing a safe and healthful workplace?

If anyone can figure this stuff out, my money’s on John Howard.

Conclusion

Under trying circumstances, WCRI did an admirable job of hosting its 2021 Annual Conference. I’m told attendees gave it high marks, as well they should have. At the end of the second day, Dr. Ruser announced next year’s conference as being back in Boston’s Copley Westin Hotel on 15 and 16 March 2022. And I have a suggestion: After this ridiculously stressful year, it would be helpful and probably appreciated to devote a session to the impact of COVID-19 on employee mental health. A lot has happened in the last year to the field of Behavioral Health. It seems to have fitted in quite well to the new paradigm called Telehealth. It would be interesting to learn about that.

 

* Yesterday, CDC Director Dr. Rochelle Walensky said, “We do not have the luxury of inaction. For the health of our country, we must work together now to prevent a fourth surge. I so badly want to be done. I know you all so badly want to be done. We are just almost there, but not quite yet.” Walensky said she is now feeling a sense of “impending doom.”

**The Future of Work: The Economist is presenting a discussion on 8 April, at 4 pm, EST. To reserve a place, go here.

The WCRI And Sidney Powell’s “No Reasonable Person” Nutty Defense

Tuesday, March 23rd, 2021

Interesting day today at the first 3-hour day of the Workers’ Compensation Research Institute’s virtual and strange two-day conference where all the presenters looked as if they’d really rather be in the Grand Ballroom of Boston’s Westin Hotel. I’ll have a wrap up of the two-day, six-hour conference after it ends tomorrow. But for today…

In early February, 2021, an Associated Press-NORC* poll found 65% of Republicans believed Joe Biden was not legitimately elected President of the united States. One week ago, a Monmouth University National Poll found exactly the same thing. Nothing had changed in a month and a half. Why do you suppose that is?

 

 

You don’t have to be Albert Einstein to know that since the election, in fact since well before it, authority figures in the Republican Party, including the President, insisted the only way Donald Trump could lose the election would be through massive fraud. One of the leaders of this disinformation campaign is the lady pictured here: Attorney Sidney Powell, Trump’s on-again off-again lawyer in his attempt to overturn the election result.

Powell manufactured far-fetched claim after monstrously far-fetched claim of election fraud beginning two days after the election. Powell and her team of conspiracy theorists filed more than 60 lawsuits around the country that all died in court. But that didn’t stop her and her sidekick Rudy Giuliani from sharing their bird-brained ideas from the stage of the Republican National Committee in a November press conference carried on C-Span. Neither did it stop them from doing the same dozens of times on Fox News and Fox Business, never challenged by anybody from the network.

When none of that worked, Powell went for the big time and won the Gold Medal for the craziest claim of 2021 (thus far). To wit, Smartmatic and Dominion Voting Systems conspired with Venezuela’s communist leadership, ditto with Cuba, and “likely” China to create software to fix the election for Joe Biden against Donald Trump. On 8 November on Fox Business she was interviewed by Maria Bartiromo and claimed Dominion created a secret “algorithm to calculate the votes they would need to flip. And they used the computers to flip those votes from Biden to—I mean, from Trump to Biden.”

In late January, after the Dominion Voting Systems leaders had heard this lie a few thousand times, they had enough and sued Powell, Giuliani and others for $1.3 billion for defamation. That’s billion.

Yesterday, Powell’s defense team responded to the lawsuit. It’s 90-page filing can be summarized in two words: Just kidding.

In legalese, what her lawyers said was, “no reasonable person would conclude that [Powell’s] statements were truly statements of fact.” Moreover, her high-priced defense team writes that Dominion itself “characterize(s) the statements at issue as ‘wild accusations’ and ‘outlandish claims,’” and that “Such characterization of the allegedly defamatory statements further support Defendants’ position that reasonable people would not accept such statements as fact…”

In otherwords, if the company she defamed considers the accusations off-the-chart lunacy, then nobody else could ever possibly believe them.

Finally, the Powell team claims she never knew her accusations were false. “In fact,” they write, “she believed the allegations then and she believes them now.” So, she’s not guilty; she’s just crazy.

This would all be riotously funny if it weren’t so deadly serious. Deadly, as in five people died and more than 140 were injured at the Insurrection of 6 January, a day, to quote Franklin Roosevelt, “that will live in infamy.”

But notwithstanding the Insurrection, could Sydney Powell’s defense team actually be right? Would no one believe her claims, as well as all the other ridiculous claims made by Trump apologists, because they are all so nutty? The early February AP-NORC and the mid-March Monmouth University polls, as well as the Insurrection itself, appear to give the lie to that defense. Sixty-five percent of Republicans still believe Biden cheated his way to the Oval Office. They’re getting that belief from somewhere. And unless we figure out how to disconnect this significant faction of the American public from the Big Lie, it will continue as a grotesque cancer on our society.

In the 1930s, Joseph Goebbels made famous the Big Lie.

“If you tell a lie big enough and keep repeating it, people will eventually come to believe it. The lie can be maintained only for such time as the State can shield the people from the political, economic and/or military consequences of the lie. It thus becomes vitally important for the State to use all of its powers to repress dissent, for the truth is the mortal enemy of the lie, and thus by extension, the truth is the greatest enemy of the State.”

We have seen this movie before. And it never ends well.
________________
* The National Opinion Research Center at the University of Chicago, founded in 1941 whose name is now officially NORC.

 

What Is The Real Reason Republicans Oppose The American Rescue Plan?

Friday, March 5th, 2021

At this moment, the Senate is debating the American Rescue Plan, the Biden administration’s $1.9 trillion stimulus proposal currently enjoying deep and wide bipartisan popularity across the country. Consequently, of course, not a single Republican senator will vote for it.

Why is this?

The Federal Reserve, not what you’d call a radically socialist organization, the Treasury Department, and nearly all reputable economists back the plan. A highly credible Morning Consult / Politico National Tracking Poll, with a 2% margin of error, conducted two weeks ago from 19 through 22 February, reported 66% of all registered voters considered stimulating the economy a “Top Priority,” and 76% of registered voters support the $1.9 trillion plan. And the icing on the cake — 60% of died-in-the-wool Republicans support it.*

Additionally, 63% of small business owners support the $1.9 trillion stimulus plan, according to the Q1 2021 CNBC|SurveyMonkey Small Business Survey, including 46% of Republican entrepreneurs.

With that kind of support, what possible reasons could congressional Republicans have for doing “everything we can to fight it,” as Mitch McConnell proclaimed this week?

There are a few reasons, and, is so often the case in political argument, most of them are nothing more than sound bites.

For example, Republicans claim the proposal is “replete” with giveaways having nothing to do with the pandemic. They object to the plan’s $350 billion aimed at helping cities and states, most notably the $10 billion (less than 1% of the entire plan) to shore up pension plans or lower future taxes.

Let’s look a little more closely at Republican opposition to city and state aid. No municipality — red or blue — has designed its fiscal affairs to withstand a simultaneous public-health crisis and economic lockdown. Unlike the federal government, states and cities cannot print or borrow money at near-zero interest rates. Most are constitutionally required to balance their budgets. When a pandemic annihilates their sales and income tax revenues — while dramatically increasing their Medicaid and health-care outlays — states have little choice but to lay off public-sector workers, cut social services, and/or raise taxes. All of those measures would make our current economic woes worse. There is no economic theory to support a stimulus strategy that combines massive stimulus at the federal level and simultaneous austerity at every lower level of government. If you believe that governments can improve economic welfare by filling in shortfalls in private incomes and consumer demand, then forcing state governments to reduce employment and spending is economically indefensible.

In the face of this, there is no coherent theoretical argument behind the GOP’s opposition to fiscal aid for states. But that hasn’t stopped it from trying. Unfortunately, every strata of our nation’s economy, from business, small and large, to the public sector’s 20.2 million federal , state, county and city employees, to nuclear families and single Moms, to you and me — all are in need.

On the other hand, I’d be interested in knowing just how much economic need our elected representatives and senators are experiencing at this moment. Would you?

*To be precise, this is the exact wording of the question in the Tracking Poll. It can be found on page 229 of the 368 page report: “Would you support or oppose a $1.9 trillion coronavirus relief package that provides up to $1,400 in direct payments to Americans making less than $75,000 a year, $350 billion in emergency funding for state and local governments, funding to support K-12 and higher education to re-open, and extends increased unemployment benefits until September 2021?”

The Second Impeachment of Donald Trump Approaches

Wednesday, February 3rd, 2021

Next Tuesday, the 9th of February, the Senate will begin the second impeachment trial of Donald Trump. With ten Republican Representatives voting in the affirmative, the House impeached the former president for inciting insurrection on 6 January, an insurrection that has resulted in the deaths of five people.

Trump supporters in Congress and around the country have viciously attacked the ten House Republicans who voted for impeachment. Wyoming Representative Liz Cheney, the third most powerful Republican in the House, has come under particular fire. Die-hard Trump disciples have petitioned Minority Leader Kevin McCarthy to remove her from her leadership post. That group is reported to have more than 100 signatories to its petition. The entire caucus will meet about this later today. It could happen that when the dust settles tonight, Liz Cheney, who, with Leader McCarthy’s approval, gave voice to her conscience, could become the only person to this point punished for anything that happened on the 6th of January. I make this point to illustrate just how far the devolution of Congress has progressed.

On the Senate side of the building, Trump’s latest lot of lawyers yesterday filed a 15 page initial brief that bases their defense of the former president on two major points. First, Trump did nothing wrong either before or during his 6 January rally in DC; he was simply exercising his First Amendment rights. Second, they contend it is unconstitutional to impeach Trump, because he is no longer in office and therefore cannot be “removed,” a view that is shared by most Senate Republicans ( there is also a third defense position – the Bill of Attainder defense – that is altogether too wacky to go into).

With respect to the first defense, the question before the Senators is whether Trump’s oratory was advocacy or incitement. The U.S. Supreme Court explained in Brandenburg v. Ohio (1969) that “the constitutional guarantees of free speech and free press do not permit a State to forbid or proscribe advocacy of the use of force or of law violation except where such advocacy is directed to inciting or producing imminent lawless action and is likely to incite or produce such action.”  The Court’s ruling in Brandenburg meant that KKK leader Clarence Brandenburg’s statements such as “it’s possible that there might have to be some revengeance taken” did not amount to criminal syndicalism under Ohio law.

In addition to the “incitement to lawless action” charge, there is the “clear and present danger” test. In applying the clear and present danger test in Schenck v. United States (1919)Justice Oliver Wendell Holmes, Jr., observed: “The question in every case is whether the words used are used in such circumstances and are of such a nature as to create a clear and present danger that they will bring about the substantive evils that Congress has a right to prevent.” Holmes cited the example of a person who falsely shouts “Fire!” in a crowded theatre, causing a panic. The impeachment prosecutors will doubtless advocate that Trump really did, metaphorically, shout “fire” on 6 January, causing his followers to panic and storm the Capitol.

Regardless, the House Trial Managers are going to have great difficulty in convincing people who do not want to be convinced, in fact, refuse to be convinced, that Trump’s words at his rally on 6 January presented a clear and present danger to incitement to lawless action. This, despite the video and myriad recordings showing Trump egging on his followers to “fight” and “be strong,” because he “won in a landslide” and “the election was stolen” from him.

The Trump defense team’s second claim, that impeaching an out of office president is unconstitutional, will be equally difficult to counteract, even though the Congressional Research Service (the best research agency you’ve probably never heard of), at the request of House members, published a study on 15 January that showed clearly the precedence and constitutionality of such an action. The study, which is quite the civics history lesson, should be required reading for every high-school student.

In the study, Legislative Attorneys Jared P. Cole and Todd Garvey meticulously analyze this issue and write:

The Constitution does not directly address whether Congress may impeach and try a former President for actions taken while in office. Though the text is open to debate, it appears that most scholars who have closely examined the question have concluded that Congress has authority to extend the impeachment process to officials who are no longer in office. As an initial matter, a number of scholars have argued that the delegates at the Constitutional Convention appeared to accept that former officials may be impeached for conduct that occurred while in office. This understanding also tracks with certain state constitutions predating the Constitution, which allowed for impeachments of officials after they left office.

They also note:

Scholars have noted that if impeachment does not extend to officials who are no longer in office, then an important aspect of the impeachment punishment is lost. If impeachment does not apply to former officials, then Congress could never bar an official from holding office in the future as long as that individual resigns first. According to one scholar, it is “essential” for Congress to have authority to impeach and convict former officials in order to apply the punishment of disqualification; otherwise Congress’s jurisdiction would depend on the whims of the individual who engaged in misconduct. Another scholar notes that the grave nature of the disqualification punishment indicates that it should apply independently of the need for removal.

Some Trump defenders point to the Richard Nixon case. When Nixon resigned on 9 August 1974, the House of Representatives had already drawn up articles of impeachment. After his resignation, the House did not send the articles to the Senate for trial. Less than a month later, President Ford granted Nixon a full pardon, thereby ending the case. The Trump defenders claim not impeaching Nixon proves their case that a president cannot be impeached after leaving office. What they fail to mention is that Nixon had already served two terms as president and was barred from running again by the 22nd Amendment. The whole purpose of impeaching someone after leaving office is first, to set an example, and second, to disqualify them from future office. Donald Trump, if not impeached and convicted, is free to run again for President in 2024.

Let me end on a hypothetical question. Suppose a President commits an impeachable action on the 19th of January; say it is discovered a week later that he or she had been colluding with a foreign power for personal gain at the expense of our nation. If the action is committed while in office, but not discovered until after he or she flies off in Marine 1, what is to be done about it? It is almost sacred theology that a President cannot be criminally charged for actions committed while in office (See the Mueller Report). How else is the miscreant punished other than impeachment?

I have no illusions about the Senate convicting Donald Trump of “high crimes and misdemeanors,” although I think he is guilty as charged. Further, I think he is responsible more than anyone else for the deaths that happened during and after the storming of the Capitol.

It is dispiriting for me to have to conclude that, rather than suffering one day of punishment for any of it, he will just live in the lap of luxury for the rest of his horrid life, the same mass of stunted protoplasm he has always been.

 

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.

Shameful Leaders Play Chicken With The Economy Hanging In The Balance

Monday, November 9th, 2020

Today, the Bureau of Labor Statistics announced productivity, output and earnings data for Q3, 2020. This follows its announcement three days ago that the nation’s unemployment rate in October had fallen to 6.9%, the 6th consecutive month it has dropped.

While the drop in the unemployment rate is certainly good news, the long-term unemployed (those jobless for 27 weeks or more) increased by 1.2 million to 3.6 million, accounting for 32.5 percent of the total unemployed. Further, the country has seen only half of the 22 million people who lost jobs due to the pandemic return to the workforce.

Regarding today’s announcement, while productivity and output rose 43.5% and 38.6%, respectively, real earnings, a very important number, dropped 9.1% in Q3.

Most of the relief bills passed earlier in the pandemic have expired, including the $2.2 trillion CARES Act, which provided for additional unemployment benefits of up to $600 a week for many individuals.

The Federal Reserve, led by Chairman Jerome Powell, as well as the nation’s leading economists, have been arguing for months that we need a second relief package. Powell maintains that businesses, cities and states, and the unemployed are in dire need of help. On 6 October, in a speech to the National Association for Business Economics, he said the unemployment rate would be closer to 11% were it not for misclassification of idle workers and for people leaving the workforce. He warned the group that without additional support, the economy could slip into a downward spiral “as weakness feeds on weakness.”

Powell and his colleagues at the Federal Reserve say we need a new relief package NOW, and we need it to be BIG. Personally, I am not optimistic about that. I’m no economist, but I have friends who are, and they are not optimistic, either, at least not in the short term. And, although the 74 million (and increasing) Americans who voted for Joe Biden are happy Donald Trump has been handed his walking papers, we remain a house divided now more than ever. Some of us are euphoric, some in denial, others in despair, still others angry beyond words. It will take time and a lot of compassion for healing to even begin. But time is something many of our neighbors in horrific economic difficulties through no fault of their own simply don’t have.

In the next few days and weeks we’ll discover if our elected leaders can get out of the way of their ego-driven lust for power and display enough moral fiber, presuming they have some, to help the businesses, cities, states, and millions of our fellow citizens who hang by their fingertips over the edge of an economic abyss.

 

COVID-19 Analysis from Jennifer Christian, M.D., M.P.H.

Monday, September 21st, 2020

I have written before of my great admiration for Dr. Jennifer Christian and for her Work Fitness and Disability Roundtable (WFDRoundtable@groups.io). The Roundtable is a mainstay for clinicians and other health care professionals.

I thought this morning’s Roundtable post by Jennifer to be particularly thoughtful and thought-provoking, so I asked her if she would allow us to republish the post in its entirety here at the Insider. She very kindly gave permission.

I think Jennifer is one of those brilliant three or four folks I’m lucky enough to know who think around corners. Her mind makes intuitive leaps where others (like mine) plod along.

Here is Jennifer’s post:

How many people have some pre-existing immunity to COVID-19

There is growing uncertainty about what this fall and winter is going to look like with regard to the COVID-19 pandemic.  Are we going to have a second, and possibly even bigger wave of worldwide infections — or is the biggest part of this pandemic over and done with once each geographic area has had its first wave?

A new review from the British Medical Journal says researchers may have been paying too much attention to antibodies and too little attention to a second part of the human immune system that protects against and reacts to infections:  T cells.   More on this in a moment…..

But first, a reminder.  We are in the middle of the first large-scale pandemic with a new and highly contagious respiratory pathogen since the field of immunology was born!   Immunology is still quite young compared to other specialty areas in biological science and medicine.  It was only in the mid-20th century that advances in cell biology started making it possible to study the detailed processes that make up the immune response in detail.  That has led to much deeper understanding of the mechanisms by which vaccines work, to the development of the first cancer chemotherapy agents that selectively killed rapidly-proliferating immune cells, and to the development of immune-modulating drugs, which enable the transplantation of organs by muting the body’s natural rejection of foreign tissues.

The appearance of HIV/AIDS in the 1980’s again precipitated huge leaps in funding for research to increase our understanding of the immune system, which in turn highlighted the function of T cells and other previously unrecognized aspects of it.   However, in comparison to other bodily systems and organs, our knowledge of the human immune system is still primitive — it’s obvious there is much left to learn — and some of what we don’t know may seem very basic!

If you’re an immunologist, virologist, epidemiologist — or a public health officer trying to figure out how to protect and guide your local population — this is the overwhelming challenge of a lifetime.  Personally, I hope that the media and the general public will remember that this pandemic has attacked our society at the very edge of what is known.  All of those professionals are working at a feverish pace to observe carefully, assemble enough data to be confident they have enough to detect a real pattern if it’s actually there, make sense of what they are seeing, and then figure out the implications for action.  Let’s agree to be forgiving of the fact that “the facts” have not all been revealed to us yet, and “the scientists” simply don’t yet know everything we wish they did.

Back to the T cell story.   Researchers have shown that people with the most severe cases of COVID-19 (the ones in ICU and who are most likely to die) often have low T cell levels.  But some other puzzling data has appeared. For example:

  • some countries — and especially some areas within those countries that had bad initial outbreaks — have not seen widespread new infections despite having relaxed protective restrictions; and,
  • blood tests in a noticeable fraction of people with no record of exposure to SARS-CoV-2 virus show some of the T cells reacting weakly to it anyway — indicating a potentially partial immune response.

This has led scientists to start wondering whether we really know enough about the human immune system’s ability to develop partial T cell “cross-reactivity” to families of closely-related viruses and whether that might predictably and reliably reduce the severity of illness or even reduce the likelihood of getting ill at all when a new-but-related virus appears.   And, that, of course, raises some possibilities that need to be investigated:

  1. Does cross-reactivity explain why some geographic areas that had first pandemic peaks are not seeing second ones — because the people who got sick had no immunity and were more susceptible, and most of the remaining ones have some limited immunity which is protecting them?
  2. Does cross-reactivity explain some of the disparity between people who get deathly sick from COVID-19 and people who are exposed to the virus but never get infected, or, if they do, remain asymptomatic or have only mild illness?  Note that there are two  possibilities:  Cross-reactivity could be making the illness worse or it might be making it less severe — we don’t know yet.
  3. How could cross-reactivity be protective if it develops after prior exposure to coronaviruses, because children are the least likely to get a severe case of the disease and adults are the most susceptible to severe COVID-19 illness and death?  (Children have not had a lifetime of colds, and thus less opportunity to be exposed to coronavirus and develop partial-immunity to SARS-CoV-2)

In short, my best advice as of 21 September 2020 is:

  1. Stay tuned for further developments in the factual realm – both changes in case counts and new research results;
  2. Hope for the best but prepare for the worst as autumn approaches and we all retreat indoors.

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?”

 

A Puzzlement Before The WCRI’s Annual Conference

Tuesday, March 3rd, 2020

Thoughts and questions before heading to the Workers’ Compensation Research Institute’s (WCRI) annual conference this week in Boston.

Despite the erstwhile efforts of certain folks to put a big lid on scientific data and bury it all deep in the ground, the U.S. Bureau of Labor Statistics (BLS) continues to publish interesting and compellingly thought-provoking work. Take the paradox of union membership and earnings, for example.

Beginning of the paradox: Non-union wage and salary workers earn only 81% of what union members earn. Union workers in 2019 earned an average of $1,095 per week, as opposed to $892 for non-union workers, a difference of $203 per week, which, if you’re doing the math, is $10,556 per year.

The difference in earnings for men and women is stark: Men in unions earn an average of $1,147 per week, which contrasts with non-union earnings of $986. The difference here is $161 per week, or $8,372 per year. Unionized women, on the other hand, earn less than the men, but way more than non-unionized women: $1,018 versus $792, a difference of $226 per week, or $11,752 per year.

Clearly, union members earn significantly more than non-union workers.

So, will somebody tell me why union membership has been declining for decades? Every year, God bless ’em, the brainiacs at the BLS tell us by just how much, which is the second part of the paradox.  In January, 2020, BLS published data for 2019, which showed the union membership rate for wage and salary workers to be 10.3%, down 0.2% from 2018. Of course, our workforce is made up of both private and public sector workers, and here the public sector saves the day. The union membership rate of public-sector workers, at 33.6% is more than five times higher than the 6.2% rate for private-sector workers.

Some say the reason for declining union membership is the hefty annual dues union members have to pay. Well, the most any worker will pay in dues to the International Brotherhood of Electrical Workers for 2020 is $492; for the United Auto Workers, it’s $843.84. It doesn’t seem as if sky-high dues can be the answer.

I don’t know whether WCRI, or anyone else for that matter, has studied whether there is a statistically significant difference in workers’ compensation injuries and costs between union and non-union wage and salary workers. Might be interesting to find out whether the 10.3%, in addition to earning more, has better workers’ compensation performance

Hope to see you in Boston

Low Wage Workers Pay More For Health Care Than High Wage Workers

Monday, January 21st, 2019

Anyone who can rub two brain cells together knows America spends more, much more, on health care than any other developed nation, as this chart from the Organization for Economic and Cooperative Development  (OECD) shows.

Also well established is the sad fact that in terms of health care outcomes our brethren in the OECD – Canada, England, Germany and France, for example – fare better than we.

Now, recent data published by the Bureau of Labor Statistics show lower wage workers pay more for health insurance than higher wage workers in employer provided plans.

What this means is: The employee portion of the monthly premium for family coverage paid by the lowest 10% of earners is $612, while the monthly premium for the highest 10% is $488. The lowest 10% of earners pay 25% more than the highest 10%. Similar results for single coverage.  Look at the light blue and light green bars in each of the strata in the chart. The more you make, the less you pay.

This is wacky. And terribly unfair. But wait, there’s more.

For every year in the 21st century, this has been getting worse.

From 2000 through 2018, health insurance costs for a single person in an employer-provided health plan rose 179%; family coverage rose 204%. During this same period, the Consumer Price Index was up 49%, while earnings for hourly employees grew by 48%. So, essentially, workers’ pay matched inflation, meaning real wages, wages adjusted for inflation, did not move as health care costs continued their rocket ride to the moon.

I keep thinking this cannot continue. I keep thinking Herb Stein was right: If something cannot go on forever, it will stop. And I keep being proven wrong. The fact is, up until the mid-1980s, our health care system was like a typical family home with its two bedrooms, a bath and a half and a nice little two-car garage. Today, it seems like the 1,000-room, maze-like Windsor castle where you need a map and a guide to find your way around. Vested interests litter the landscape, and any change gores somebody’s ox.

How can we possibly stop this runaway train? Many placed hope in the Affordable Care Act, but look what’s happened to that. The new generation of Democrats yearns for “Medicare For All,” but has yet to figure out how to pay for it. Others suggest “Medicaid For All,” but Medicaid is a state-based system, and every state has its own version. I’d love to see a single payer system, but, looking at the lunacy behind our current government shutdown, can you envision that cresting over the horizon, given all the work and bi-partisanship it would take? When I look at the health care horizon, I see the Four Horsemen of the Apocalypse coming over the rise.

Certainly, there are pockets of innovation and excellence around the nation, but we have no national, systemic approach to fix to the problem of extraordinary high costs, and it’s hard to imagine this congress, or any congress, doing anything about that. At more than $8 billion dollars, the health care industry spends more on lobbying than any other industry, and that’s not about to change, once again proving Mark Twain right: We have the best government money can buy.

I believe the work done in those “pockets of excellence” will gradually lead to improved health for Americans who can afford to pay for it. It’s the “can afford to pay for it” part that sickens me.