Sunday, February 19, 2017

"Hidden Figures": Racism, sexism, anti-science, public health and cancer

I recently saw the wonderful film “Hidden Figures”, which tells the story of the African-American women who worked as “computers” (when the word meant “people who do computations”) on the NASA program that sent men (and later some women) into space. The focus was on three of the most significant of these women, Katherine Goble Johnson, Dorothy Vaughan, and Mary Jackson. Ms. Johnson (played by Taraji P. Henson) is a gifted mathematician who calculated the trajectories of many of the early space flights (including, as portrayed in the movie, John Glenn’s orbital flight in February, 1962) and the later Apollo 11 moon landing in July, 1969. Ms. Vaughan (played by Octavia Spencer) became an early and leading computer programmer, a supervisor at NASA. Ms. Jackson (played by Janelle MonĂ¡e) was the first African-American female engineer at NASA. All of these women, and no doubt many others, were critical to the NASA space program.
             
All of them, as the film documents, were “firsts”. Among many such firsts, Katherine Johnson (then Coleman) was one of the first African-Americans and first African-American woman to desegregate the graduate school of West Virginia University. Dorothy Vaughan was one of the first programmers and first African-American woman supervisor at NASA. Mary Jackson became NASA’s first African-American woman engineer, after winning a court case that allowed her to desegregate Hampton High School to attend night classes. When asked in the film by a white supervisor if she would still want to be an engineer if she were a white man, she says that is she were “I would already be an engineer!” She also gives a terrific speech to the judge in her desegregation case about the significance and importance being a “first”.

“Hidden Figures” portrays and does not downplay the blatant and overt racism and sexism that existed in that period, legally in the Jim Crow South where the film takes place at the NASA Langley facility in Hampton, VA, in 1961, after Brown vs. Board of Education but before the Civil Rights Act of 1964. There are separate drinking fountains, and a separate coffee pot for Ms. Johnson, and as graphically depicted in the film, a half-mile run for her to go to the only “colored women’s” rest room to relieve herself! The laws in the South came down, but racism – and sexism – there and in the rest of the country are hardly things of the past.

But this is not a movie-review blog; it is about medicine and public health and social justice. The social justice aspect should be obvious, but let me start the discussion of health and medicine with science. Clearly, science was at the forefront of NASA’s mission, and the film depicts how the need for “best and the brightest” overcame even the structural racism of the American South for these women. On a larger scale, though, the idea that science was the future, that knowledge and education and learning and discovery were critical to America and the world, are also implicit, scarcely discussed in the film (save for a few inspiration speeches, such as President John Kennedy’s). In 1957 Sputnik, the first satellite, was launched by the Soviet Union, in April 1961 cosmonaut Yuri Gagarin orbited the earth and a month later Alan Shepard was the first American to so suborbital flight. Glenn’s 1962 orbital flight was only 7 years before the Apollo 11 landed on the moon!

I was alive then, a fairly young child for Sputnik, older for Gagarin and Shepard and Glenn, and just graduated from college for Neil Armstrong’s “a small step for a man, a giant leap for mankind” speech. I was a part of (maybe at the time I thought “victim of”) President Kennedy’s physical fitness program, doing pushups and sit-ups and chin-ups so we could “beat the Russians”. I was also a student, learning and excited by science. I was impressed by the space program, but not as dedicated a devotee as many others. Perhaps this was because I was not enough of a science geek, but perhaps it was also in part because it seemed natural, the advancement of knowledge and science was natural, progress was natural. Maybe I was less awestruck than older people in the same way that more recent generations have been less impressed by the technology of computers and cell phones. But we all (I thought) believed that science, and learning, and advancement were what the future was about. We had come through “the war” (WWII), and Americans had jobs, and their children were going to school, and while there were still fights to be waged for racial and gender and economic justice, the outcome was, we knew, unquestionable progress.

But maybe not any more. While we built the Interstate Highway system in the 1950s, while we were able to go from suborbital flight to a man on the moon in 8 years in the ‘60s, now we are in an era where many Americans – including many of our leaders – deny the incontrovertible facts of man-made global warming and climate change. An era in which science and scientists and not to be trusted, where, when facts challenge our beliefs, we make up “alternate facts”, where education and knowledge, rather than things to be sought after and admired are seen as “elitist”, where the only persistent “good” is the enrichment of the already richest, whatever the cost to the rest of us and to the planet. On April 23, 2011 (“Cabaret" and "Inherit the Wind": Will we again reap what is being sowed?) I wrote of how the play “Inherit the Wind”, written in the late 1950s, was meant as an allegory for McCarthyism, since the “ignorance” that denied evolution in 1920 Tennessee was no longer an issue; evolution was fact. And yet 50 years later it was still being questioned. We see the same, today, for all aspects of science and knowledge; this is a real test given by a “Christian” school!

But what about medicine and health? Is that not still the New Frontier? We may have abandoned even the shuttle program with manned spaceflight, and the launches from Cape Canaveral may be all private satellites out to make a profit (or spy on us), but isn’t NIH our new NASA? Didn’t President Obama promise a campaign to defeat cancer in the same way President Kennedy declared our intention to get to the moon? Well, maybe. NIH’s budget is not only stagnant, but its funding overwhelmingly goes to very basic research and to find “bullets” to kill cancer, as if it were a disease rather than scores of diseases, almost all different. But there is far, far less funding to prevent cancer, not only to find the causes of these diseases, but to even eliminate the causes when we know them. Where is the funding for public health? Sure, there are some victories. Smoking, the major cause of death for decades (and, although it is a cause of many cancers, more of the deaths it causes is from increased heart disease and chronic lung disease than cancer), is down, but the fight against it has been a long and hard one and is not over. Other environmental causes of cancer such as air, water, and soil pollution are minimally addressed, because, like smoking bans, they might decrease the profits for some businesses and the wealth of the wealthiest.

“Hidden Figures” has some brave acts by its white characters. John Glenn (Glen Powell) refuses to fly unless Katherine Johnson rechecks the calculations (and thus she gets her job back). Al Harrison (Kevin Costner), the NASA chief, takes a crowbar to the “Colored Women’s Restroom” sign when he discovers that it is traveling to far-off segregated restrooms that are taking Ms. Johnson away from her job. Yes, these can be seen as self-serving (helping them to get their jobs done) but they are also, in the context, heroic. I was recently sent copies of archives of mimeographed newsletters from civil rights groups based in southern Brooklyn, where I grew up; one of them contains an article from 1965 about young African-American women being denied membership in a “cabana club” (in the NORTH! In Brooklyn, NY! In 1965!), until the singer  Julius LaRosa shows up asks the folks picketing outside why they are there, says “I don’t perform in segregated places”, and intervenes.

John Kennedy said we should go into space not because it was easy but because it was hard. Maybe we shouldn’t do things just because they are hard, but we need to not deny what we don’t completely understand just because it is easy. We need science and we need progress and we need public health. People may not know everything themselves that environmental scientists and scholars and mathematicians and physicists and doctors and public health workers know, but they should be proud of those who do, and encourage and support them. We need more girls and minorities to enter the STEM fields, as in programs such as that in NYC documented in the February 17 New York Times.  We need more Katherine Johnsons, and Dorothy Vaughans, and Mary Jacksons, and the love and respect for learning and truth that they stood for.

We even need more Julius LaRosas.







Thursday, February 9, 2017

"There's a sucker born every minute": False and inflated health claims

There is,” in a phrase rightly or wrongly attributed to P.T. Barnum, “a sucker born every minute.” To Barnum, and to countless others before and since, this was a business opportunity. They can get rich off us because we want stuff to be true even when every input from our senses should show us that it isn’t; we want magical, easy cures and money-making schemes, even when we know that they only work for the scheme’s designers, not the suckers who take the bait. Betsy DeVos, the recently approved Secretary of Education, who knows nothing about education and devalues public education (I could go on, but that’s another story…) is the beneficiary of such desires. She is in the position that she is in because of her great wealth which has bought her great influence, and that great wealth, at least the portion from her husband’s side, derives from the Ponzi scheme known as Amway. It is clear that Amway was in fact the path to wealth that it was claimed to be, for the DeVoses anyway.

The persistent and widespread greed of people despite evidence that the odds are stacked way against them is testimony to either optimism or stupidity, or some of both. It is one of the oldest memes in literature, from the alchemists who would turn lead into gold (or Rumpelstiltskin who would weave it) to Faust who would sell his soul to the devil (and maybe so did guitarist Robert Johnson) to Ralph Kramden (and his cartoon successor Fred Flintstone) and George “Kingfish” Stevens, doubly oppressed and vulnerable, being poor and black. And the outcome is always the same, the little guy gets screwed.

We could go on and on with this theme. The temptation to tie it to the election and reign of Donald Trump is enormous; people want something to be true (that they’ll get good jobs back, that their streets will be safe, that they can have all the health care they want and need without paying for it when they don’t need it, whatever) and Trump promised it all, and of course he is not and will not deliver, but many still love him. If you want a good article about this, try Matt Taibbi in Rolling Stone, The end of facts in the Trump era”. But, after all, this blog is about public health and medicine, and there is no shortage of examples in those fields. After all, con men and grifters, whether low level hucksters, Amway merchants, or Wall Street bankers are all regularly called “snake oil salesmen”, and what was snake oil but a promise of better health? And the liniment sold by these folks might have worked a bit since it had red pepper, a bit like current capsaicin. When they were convicted it was because their oil did not come from snakes, not because it was a fraudulent cure.

You’d think that people would wonder why, if there is a miracle easy (and sometimes even relatively cheap) cure for all their ills that everyone else hasn’t benefited from it. Ah, but that is part of the attraction – being in the know about something everyone else isn’t. Is that not the way that inside traders work? Isn’t that how they fix sporting events, how your brother-in-law knows that this 100-1 shot will come in at Santa Anita? Is that not how Arnold Rothstein got rich? So, sure, it’s done in health. Watch daytime television sometime. It is mostly about medicine, from Dr. Oz (a font of misinformation), to an electric scooter you can get FREE (or at no cost to you, other than as a taxpayer paying into Medicare), or a miracle drug that will allow you to have even better relief from your arthritis or asthma or will keep your blood from clotting even better than warfarin, at only 1000 times the price, and at great potential risk to your immune system.

The hucksters present not only misinformation about individual medical care, but also public health. The most obvious, and likely most serious, current issue is that of vaccines. Despite there being no evidence linking vaccines to autism, and strong evidence showing there is no link, the myth persists. The price will likely be serious outbreaks of vaccine-preventable diseases, especially measles, as discussed by Peter J. Hoetz in his NY Times Op-Ed “How the anti-vaxxers are winning”, February 7, 2017. Water fluoridation suffers from similar myths. Public health may be even more susceptible to such hype than medical care, since so many of its benefits are things (like measles, or tooth decay) that don’t happen, rather than those that do. We rarely wake up saying “Gee, I’m glad I don’t have cholera today because we have clean water”; indeed, we mostly worry about water quality when something specifically bad is happening, like lead poisoning in Flint. People are susceptible to liars and charlatans who tell them things that they want to believe, as well as things that seem to make sense, but as I tell students, something that seems to make sense is called a research question; only when the study is done will we know if it is true.

But it is not only the more obvious (to the discerning, anyway) scams. Mainstream medicine does it often. Every new discovery, every potential ameliorant (if not cure) is trumpeted by both the companies that manufacture it and, at an earlier stage, the university for which they work. Of course, most of these discoveries are scarcely the magic breakthroughs that they are initially claimed to be. That is the nature of science; things are learned and knowledge grows incrementally. But a new discovery by a scientist at your university is worth a lot of publicity! Maybe it is a cure for Alzheimers! Or at least a step in that direction! Certainly worth millions of dollars more in NIH funding! There is nothing wrong in incremental discoveries; the problem is when they are hyped as the Holy Grail. Indeed, on July 16, 2010, I wrote about Rosiglitazone and the "Holy Grail", and how disappointed diabetes advocates were that Avandia® was being taken off the market just because it caused heart disease, because it did lower blood sugar! (A diabetes advocate noted that lowering blood sugar was the “Holy Grail”.) This story is a terrific example of the peskiness caused by the human body being an integral organism; something that is very good for one condition may still cause big problems. And so, maybe we should wait before we hype it too much. On the other hand, what an opportunity we have to get big publicity before that happens…

A recent example involves using low-dose CT screening for lung cancer. The US Preventive Services Task Force recommends it (as a “B” recommendation) for men 55-80 years old with a history of smoking. This “B” recommendation is worth a lot to the CT manufacturers and radiologists who read them, since the ACA requires insurers to cover USPSTF “A” and “B” recommendations. But a big Veterans Administration study just published in JAMA shows that it is not quite as good as previously thought. “Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer.” Does this mean that it is a bad idea to get screened? Not necessarily; if I had a patient with a significant smoking history, I would discuss the risks inherent in getting this procedure but prepare them for the probability that even a positive test would likely not mean they had cancer, and that they might have to undergo more procedures with some risk to find out. The point is not that this is a bad idea, but it is not some amazing breakthrough, as touted.

Just because you want to get rich quick, or avoid needle sticks, or find the magic cure for your arthritis or cancer that has been denied you, and someone is selling something that claims to do it, doesn’t make it true. If you think so, I’ve got a couple of bridges to sell you.

Friday, January 13, 2017

"The Child is the father of the man: family physicians' screening for adverse childhood experiences

"The Child is the Father of the Man: Family Physicians’ Screening for Adverse Childhood Experiences", my editorial accompanying an excellent article on Adverse Childhood Experiences (ACEs) in the latest issue of "Family Medicine", at 
http://www.stfm.org/FamilyMedicine/Vol49Issue1/Freeman5

Saturday, January 7, 2017

What do the American people want in a healthcare plan? Not what Trump, Price and the GOP will give them

Readers of this blog are probably aware that I am a member of Physicians for a National Health Program (PNHP) and, like that organization, support the creation of a single-payer health system in the US. Sometimes referred to as a Canadian-type health system, or as in Sen. Bernie Sanders’ presidential campaign, “Medicare for All”, it is pretty easy to understand, and is a system that has worked not only in Canada but, in modified forms, in most developed countries in the world. The key feature of such a system is that it is one program that covers everyone in the country, “Everybody In, Nobody Out” in the title of the book by the late Quentin Young, MD, a former President and executive director of PNHP and a “tiger for social justice” in the words of his Chicago Sun-Times obituary.

Such a system would replace the bewildering, dazzling, complex, confusing mess of the current US health care system, with its hundreds of different private insurance policies with widely varying benefits, premiums, and coverage, as well as the federal programs of Medicare, federal-state partnerships like Medicaid and the ACA’s health insurance exchanges, and of course that persistent, pesky mass of 30 million or so uninsured. And the underinsured, who are effectively uninsured, because they buy the only policy that they feel that they can afford only to find out when they need it that it, surprise, doesn’t cover what they need!

Much of the defense of the ACA has been based on the fact that an insurance pool must have healthy as well as sick people. This is a core tenet of insurance, which would otherwise be unaffordable. Life insurance cannot work if it only covers people on their deathbeds; car insurance cannot work if it only is purchased at the time of an accident, homeowner’s insurance cannot work if it is only bought by people in the midst of a fire. If this were how insurance worked, there would be no need for it, for the premiums would be basically the same as paying for the cost of the services. To have it otherwise, as insurance, requires a pool of money contributed by folks, whether directly or through their taxes, who are not immediately benefiting to cover those who need it. In fact, though, understandably but impossibly, people want coverage for when they are sick, but don’t want to pay when they are not. People may not want to pay a lot when they are healthy (or think that they are) but they want coverage for their sick parents, or newborn with health problems, or when they are diagnosed with cancer, or when their adolescents are in a car wreck. These are things that don’t happen to most of us most of the time but happen to enough of us over our lives that we know enough to fear or expect it. A national single-payer system gets rid of this problem, by having the largest possible risk pool.

But the people of the US did not elect Bernie Sanders, and he did not even get the Democratic nomination. We elected (OK, the Constitutional unfairness of the Electoral College elected) Donald Trump, whose positions may be erratic and change frequently, but whose appointments to Cabinet-level posts are remarkably consistent. Most are from the most right wing of the Republican Party, not unlike we would have expected from Ted Cruz. Despite a campaign that attacked Wall Street and the support Hillary Clinton received from the financial sector, he has appointed many Wall Streeters, including several former (and current) folks from Goldman Sachs -- most recently, their lawyer whose wife still works for them, to head the SEC. Foxes guarding the henhouse abound; climate change deniers will head the EPA and Department of Energy. And in the same vein, we have, for Health and Human Services nominee, Rep. Tom Price, the orthopedic surgeon from Georgia about whom I wrote recently (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters”, December 3, 2016).

Rep. Price certainly does not stand for a single-payer national health system. Nor does he stand for ensuring health care for the vulnerable, whether poor, elderly, rural, or sick, as demonstrated in an excellent piece in the New England Journal of Medicine by Sherry A. Glied and Richard Frank, Care for the vulnerable vs. cash for the powerful – Trump’s pick for HHS”. It notes that he “…favors converting Medicare to a premium-support system and changing the structure of Medicaid to a block grant,” which would mean that not only Medicaid, and the coverage people have received under ACA, but even Medicare which has protected seniors for 50 years, would be under threat. The article contains information about his positions on other issues, including favoring greater access to armor-piercing bullets, opposing regulations on cigars and on tobacco as a drug, opposing the reauthorization of the Violence Against Women Act and laws prohibiting discrimination against LGBT people. In terms of ensuring health coverage he is as mean as they come:
His voting record shows long-standing opposition to policies aimed at improving access to care for the most vulnerable Americans. In 2007–2008, during the presidency of George W. Bush, he was one of only 47 representatives to vote against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act, which improved coverage for mental health care in private insurance plans. He also voted against funding for combating AIDS, malaria, and tuberculosis; against expansion of the State Children’s Health Insurance Program; and in favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments.

But he is the President-elect’s health guy, and we might think that the folks who voted for Mr. Trump will get what they wanted. Except they probably won’t, other than that small slice of voters representing the wealthiest providers, insurers, drug manufacturers, corporate executives, and pundits (like the Wall St. Journal’s Kim Strassel). The health situation in the US is bad, particularly for lower income whites, whose mortality rate has, remarkably, as reported by the Commonwealth Fund, been static rather than decreasing or in some cases (low income women) increasing. These are many of the same folks who voted for Donald Trump, and are presumably looking for a solution. The Kaiser Foundation recently conducted focus groups among Trump voters in states have been hard hit by job losses and were key swing states in the election – Ohio, Michigan, and Pennsylvania. The participants either had Medicaid or were covered by ACA. The results are summarized by an op-ed in the New York Times by Kaiser’s CEO, Drew Altman, “The health care plan Trump voters really want”, January 5, 2017.
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.

That’s what they want. That’s what I want. It is what I believe a single-payer system would deliver. But it sure isn’t what they are going to get from Tom Price, or from whatever “replacement” the Republicans come up with for ACA.

And that’s more than a shame.  It’s a scandal.

Saturday, December 31, 2016

"Inconvenient truth", science, politics and USPSTF

There are a lot of things that we can expect to be different in a Trump administration, not only than in the Obama administration but even compared to that of G.W. Bush (my previous gold standard for irrational and right-wing policies). Many of these are important, and dangerous, but are arguably political, such as the change in our relationships with other countries (Russia, China, Europe, Israel). However disastrous these policies will be for people in the world (say, Syria) and even possibly destroy the world (nuclear weapons), they proceed from a different political perspective. Also arguably political will be the domestic changes, in the rights of LGBT citizens (such as marriage, use of restrooms), and access to reproductive health services for women, not only abortion but even contraception. The impact on people will be horrific, but it derives from a different perspective (admittedly one that completely devalues huge numbers of people; majorities in the case of women and non-wealthy people).

There will be other changes, however, that proceed from a rejection of science, or of what Al Gore calls “inconvenient truth”. Clearly the biggest one is the one that Mr. Gore was speaking of, global warming, because this will eventually destroy the planet. Maybe later, as we have already been so slow in implementing limits on warming. Maybe sooner, if his climate change deniers have their way. The title of Mr. Gore’s film has several meanings; it is “inconvenient” for all of us to try to find ways to use fossil fuels less rapaciously, but it is a financial issue for others. I am not talking about the coal miners who will lose their jobs; that is going to happen anyway. I am talking about the Captains of Industry, who, unlike the miners, will never be anywhere close to poor but have the possibility of making fewer billions if we seriously address global warming. Oh, the horror!

While of course the destruction of the environment is a health issue, there are also more prosaic health results from those who will try to make policies, or pass legislation, that benefits themselves or their friends and contributors at the expense of truth. Certainly we have seen this regarding reproductive health for years, especially at the state level, where laws restricting women’s access to abortion (targeted regulation of abortion providers, or TRAP, laws) have been based on what might be generously called phony science, or, more correctly, lies. These have included fetal pain syndrome, need for facilities appropriate for major surgery, need for admitting privileges for doctors doing abortions, excessive waiting periods,  and other made-up justifications for doing what legislators really wanted to do – restrict access to abortion. In Florida, a law was passed forbidding doctors from asking their patients if they had a gun in the home, meaning they couldn’t even have a discussion about how to keep them safe from their children accessing them.

So now we have the probability that Congress will be restructuring the membership of the US Preventive Services Task Force (USPSTF) to include more specialists on a body largely made up of primary care doctors and epidemiologists. The goal of the USPSTF is to dispassionately and objectively evaluate the evidence for the effectiveness of tests and procedures aimed at preventing disease. It gives ratings in easy to understand letters (A,B,C,D,I ) that are not based upon the opinions of the task force members but on the actual data. Unfortunately, this doesn’t always make providers happy; if you provide a service (say, mammography for breast cancer screening) on which you make money, then a recommendation that says it doesn’t need to be done quite so often hits you where it hurts – in the pocketbook. So you might come out against it. And while advocacy groups may not have the same direct financial interest (although if you are such an advocacy group, contributions are usually closely related to how serious how many people think a problem is), it may challenge your long-held beliefs. And then, if you find some doctors who agree with you (for example, those whose income may be decreased) you are more confident you were right.

But the goals of USPSTF recommendations is to synthesize the existing data and base their recommendations on that, not to reach “compromise” between those who want something done more (because they are “true believers” and/or have a financial stake in it) and those who believe it is unnecessary cost with little or no benefit and potential risk. This is why it is not necessary to include specialists on these panels because of their “expertise”. Other scientists can interpret the data accurately; a panel reviewing the data on, say, the frequency with which mammography should be performed in a particular population does not need mammography radiologists and breast surgeons to understand the research. This is not to say that such specialists are inherently biased and shouldn’t be on USPSTF; they could be as objectively good scientists as others. But it is to say that the reason being put forward for them being added to the panel – that they are ‘experts’ in the topic – is wrong. They should not bring their experiences and expertise to ‘balance’ the data. They should be guided by it.

It is not necessarily true that expert specialists are purposely obtuse, that they will advocate for recommendations that will make them more money. It is also true that their perspective is skewed by the populations that they see. Specialists see people with a disease, which is a selected population. Screening is, by definition, testing people who are asymptomatic and are statistically unlikely to have the disease. Therefore different standards are applied for screening asymptomatic people (say, all adult women between 50-75 by mammography) and for following up people previously diagnosed with breasts cancer, or those who are at higher risk (defined as a first-degree relative, mother or sister, with breast cancer, not a great-aunt). And, of course, doctors are not necessarily above advocating for laws to keep their incomes up. When, about 20 years ago, the federal Agency for Health Research and Quality (AHRQ) recommended against a specific type of spine surgery because it didn’t help, was risky, and cost a lot, groups of spine surgeons tried to get that agency defunded! Oh, yes, and AHRQ continues to be threatened with funding cuts because special interest groups don’t like their findings!  With the ACA requiring insurers pay for any USPSTF recommendation with an “A” or “B” rating, the political pressure is on to get such recommendations, whether the data supports them or not. On the positive side, the American Academy of Family Physicians (AAFP) has come out against such stacking of the USPSTF.

Once, when I lived in a good-sized condominium, I was one of the few families with children, and it seemed like they and their friends were often harassed for violation of (sometimes) condo rules and (more often) an individual’s belief of what should be a rule. Even the rules, however, were often, in my opinion, unreasonable; I thought the condo association rules should protect our investment and our safety, but should not be just anything 51% of the owners wanted. On the positive side, while they may have inconvenienced me and my family, they did not try to overrule natural law or science. The same cannot be said for current federal, state, and local efforts to make a law about anything they want to be true. They cannot make global warming disappear by a law, but they can make it illegal! And they can violate the rights and human dignity of our people. And stack federal agencies with anti-science people or at least turn what should be scientifically-driven decisions into a political negotiation.


This is going to be a long battle. Those with money and power are entitled and feel that it is their right to stack the deck. Happy New Year!

Tuesday, December 20, 2016

Opioids and other pharmaceuticals are the tip of the iceberg: It's the profit, stupid!

The NPR program “Fresh Air”, with Terry Gross, had Anna Lembke, MD as a guest on December 15, 2016. Dr. Lembke is the author of the recent book “Drug Dealer, MD”, in which she apparently (per the discussion on air; I have not read it) implicates physicians and pharmaceutical companies in the widely discussed “opioid epidemic”. Dr. Lembke is a Stanford psychiatrist and director of the addiction medicine fellowship there, and she is able to articulately describe what is known and what is not about the neurological impact of opiates and opioids on the brain. One important point she makes is that continued use of opioids causes tolerance and a need for higher doses; in addition she describes how chronic use of opioids causes a pain syndrome of its own (decreased tolerance to pain) in some people, and how weaning them off opioids can actually decrease or eliminate their pain.

Her key issue, however, is that the epidemic of opioid use was orchestrated by the pharmaceutical manufacturers of opioid analgesics, who heavily promoted them, created the perception among doctors and the public that physicians were heartlessly undertreating the pain that their patients were in, and hooked in (mostly) well-meaning doctors to become, in essence, their pushers (“Drug Dealer, MD”) while they made huge profits. And continue to do so. And, as the reaction to this epidemic begins to form, continues to promote new syndromes that require treatment with their drugs.

An example of this is “OIC”, opioid-induced constipation, which made its first big appearance during the Super Bowl of 2016. The commercial left it a vaguely mysterious ailment, but it is a real one. Of course, the commercial was a prelude to an advertising campaign, in this case for Movantik ®, a partial opioid antagonist manufactured by a collaboration between AstraZeneca and Daiichi Sankyo designed to treat this condition. Constipation, in fact, is the only side effect of opioids that does not decrease with continued use, so as a person uses higher and higher doses of the opioids to try to control their pain, their constipation gets worse and worse, sometimes requiring surgery and occasionally death from a ruptured colon. My reaction, while understanding we would soon see a drug for this condition promoted, was that it was a cynical and disturbing attempt to “normalize” opioid addiction. “Oh, you have this problem? Well, it’s not just you! LOTS of people have OIC!” It turns out that I was not the only one with this reaction; Ahiza Garcia on in a piece on CNN Money called “Super Bowl drug ad sparks big backlash”, quotes Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing: "It's very disturbing to see an ad like that. It's normalizing the chronic use of opioids, which aren't demonstrated to be safe over the long term.”

Of course the greed and anti-social behavior of pharmaceutical manufacturers is neither new nor is it going away. Their efforts to use doctors and exploit the public as much as they can possibly get away with in pursuit of exorbitant profits continues to generate news, and occasionally, reaction by states. We have all heard about the huge price increase in Daraprim ® by Martin Shkreli and Turing (Drug prices and corporate greed: there may be limits to our gullibility, September 27, 2015) and Epi-Pen® by Heather Bresch and Mylan (Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016) and maybe thought that this publicity would rein in further abuses. But not so. Reuters just reported in “US states sue Mylan, Teva, others for fixing drug prices” that “Twenty states filed a lawsuit Thursday against Mylan NV (MYL.O), Teva Pharmaceuticals (TEVA.TA) and four other generic drug makers, saying they conspired…on pricing of two common generic drugs, according to a copy of the complaint.” Lest you think that this conspiracy is just preventing these companies from being undercut by each other, we are talking fantastic price increases for common and necessary drugs. “The drugs involved in Thursday's lawsuit include the delayed-release version of a common antibiotic, doxycycline hyclate; and glyburide, an older drug used to treat diabetes. Doxycycline, for example, rose from $20 for 500 tablets to $1,849 between October 2013 and May 2014, according to Senator Amy Klobuchar, a Minnesota Democrat who had been pressing for action on high drug prices.” In case you missed it, this is a 9245% increase in the price of doxycycline! And it may well be up to the states to bring such legal action, since there is little reason to think that the federal government, led by President-elect Trump and his corporate cabinet, along with the Republican-dominated Congress, will be doing anything about it.

Which, of course, is the core problem, and has been for a long time. Corporate profit has become the be all and end all of US policy. Anything that increases corporate profit is seen as good. This certainly includes subterfuge, cheating, exploitation, and corruption. While this has long been the case, it is likely to increase under the Trump administration, with its depressing panoply of corporate exploiters and climate change deniers. We are likely to see not only tolerance of encouragement and celebration of such outrageous excesses. Of course, it is fine to make a profit, but that profit should be reasonable and honest; it should not be highway robbery, generated by dishonesty, exploitation, and trampling others.

The pharmaceutical company activities cited about are the result of an attitude that “if we can make some money honestly, look how much more we can make if we are corrupt!” that pervades virtually every industry, from fossil fuels (see Rex Tillerson, the Exxon CEO who is Trump’s nominee for Secretary of State) to financial services. After campaigning against Goldman Sachs, the largest investment bank, and its ties to Hillary Clinton (“I know the guys at Goldman Sachs. They have total, total control over [Cruz]," Trump said. "Just like they have total control over Hillary Clinton"), Trump has named at least four current and past Goldman execs to cabinet-level positions, including its #2, Gary Cohn, as director of the National Economic Council. And, should anyone harbor any illusion that the survival of Goldman in the face of the collapse of rivals Bear Stearns, Merrill Lynch, and Lehman Brothers has anything to do with their being more honest or less evil, less likely to have indulged in “the Big Short” and transferred all their toxic investments to their own clients, read the recent piece by Matt Taibbi in Rolling Stone, The Vampire Squid occupies Trump’s White House”.

Speaking of Rex Tillerson, his close ties to Russia and Vladimir Putin are seen (by the President-elect) as major qualifications for Secretary of State. In this context, the New York Times Op-Ed by Andrew Rosenthal from December 15, 2016, “To understand Trump, learn Russian”. Rosenthal notes that Russian has two words for “truth”:
The word for truth in Russian that most Americans know is “pravda” — the truth that seems evident on the surface. It’s subjective and infinitely malleable....But the real truth, the underlying, cosmic, unshakable truth of things is called “istina” in Russian. You can fiddle with the pravda all you want, but you can’t change the istina.

The pravda will change a lot with the new administration. Fossil fuel extraction is all good, climate change is a hoax, public education is bad, getting rid of the ACA will improve access to healthcare, immigrants are the problem, Putin is good, and gays and transgender people have no rights. That putting foxes in charge of the henhouse makes sense, and that having corporate titans in direct rather than indirect control of government will benefit us all. But the growth in the gap between the wealthiest and the rest of the people has grown under both Republican and Democratic administrations and anger at it was actually one of the drivers of the vote for Trump.


The istina, though, is that making the wealthiest wealthier and destroying the earth in the process is not the answer. Attention to the common good, for all of us, is the only thing that will move us forward, as a society and as a world.

Sunday, December 11, 2016

The urban-rural divide and the health of people in both settings

I recently wrote about the impact of the massive vote for Donald Trump by “white working class” voters and how it will have repercussions for their health, as well as that of others, if the policies advocated by the Republican majority (as exemplified by Secretary of HHS nominee Rep. Tom Price) are implemented. And there is little doubt that they will be implemented, but slowly, so people are less aware of what is being done to them. As Medicare is increasingly privatized, as vouchers that cannot cover the cost of health insurance for those with chronic disease are implemented, “Medicare for all” will increasingly seem a poor idea. And people’s health will suffer. I wrote about the cynicism of the AMA and the AAMC in endorsing Mr. Price; they are doing more than “kissing the ring”, as a colleague suggested. They are lauding the fact that one of “theirs”, a doctor, will be in this role, not an insurance executive. But if anyone had a doubt about whether having an “MD” at the end of your name guarantees a concern for people’s health, Mr. Price is the poster child for “not so”.

The other big divide demonstrated by the election is urban-rural, and this one is also real. A majority of the people in the US are jammed into small geographic areas, urban islands. Maps that portray “red states” and “blue states” seem to be an ocean of red because of physical size; think New Jersey  (population about 9 million, with 8700 square miles, more than 1000 people/sq mi) vs. Montana (just over 1 million, in 147,000 square miles, less than 7 people/sq mi). The contrast is even greater if we look at counties; most of the population of even “blue” states is concentrated in a few urban counties, although, conversely, there are many “blue” seas and islands in “red” states, cities like Houston, Dallas, San Antonio, St. Louis, Kansas City, etc. The media has recently been awash in articles about the way that our Electoral College system advantages rural areas; because of the 2-Senate-seat-per-state rule, a Wyoming voter has 5 times the clout of a Californian. See, for example, Steven Johnson’s “Why blue states are the real Tea Party” in the NY Times, December 4, 2016. He points out that at the time of the writing of the Constitution, the urban northern states were in debt while the southern states were solvent – largely through the magic of the free labor of slavery. Now cities are the engines of our economy; they are where ambitious and educated young people go, leaving rural areas increasing older and poorer (as well as whiter).

But we need to remember that there is tremendous need in rural America, as there is in the inner city. Rural areas are poor, and underserved both medically and in terms of social services (as well as, of course, in the other things you’d expect – access to groceries, for example). Those rural areas that are located in “red” states are even worse off, because those states spend far less on health care and social services in the first place so that their more isolated communities are in the worst shape. And yet, as Johnson points out, they get far more federal aid for tax dollar contributed: New Jersey receives $0.61 on the dollar while Wyoming gets $1.11. The Trump campaign, and the Republican Party, strongly appealed to voters in these areas, but Trump and his proposed cabinet all live and work in cities; they are not rural billionaires. Tom Price is a suburban doctor; he does not deliver care to the rural poor, as do Rural Health Clinics.

So there is tremendous need in rural communities, but their political clout, which is both unfair and anti-democratic, is not being used to actually help the people there, but rather to limit positive policies in urban areas. The North Carolina “bathroom law”, to force people to use the restrooms of the gender of their birth, was a reaction to the city of Charlotte (a blue “lake”) making it legal for people to use the restroom of their current gender. The most well-publicized efforts currently are threats by Trump and his people to forbid cities from declaring themselves “sanctuaries” for immigrants (see NY Times debate on whether sanctuary cities have a right to defy Trump, December 1, 2016; “yes” by Cesar Vargas and “no” by Jan C. Ting). These cities are trying to exert their local control over such important issues, while states (generally supported by rural populations that do not actually have to deal with these problems) try to restrict their ability to do so. These hypocrites are against government regulation when it comes to their rights to carry guns or graze their cattle on public land (things they want to do), but are all for it when it comes to things important to others, like deciding who can marry, where one can go to the bathroom, whether people can get an abortion or even contraception. “Those who deny freedom to others,” said Abraham Lincoln, “deserve it not for themselves”, which I first learned as a young stamp collector; it appears at the 4 cent American Credo stamp.

If the selective interpretation of what “freedom” means is not enough, if rampant discrimination and bigotry is not enough, there are other, health related, concerns that go with this divide. For example, federal funds for HIV care go to the area where patients are from. However, a large percentage of gay HIV patients leave those areas for the cities where they are more accepted. Thus the cost of providing that care is borne by the cities, while the money flows to the rural areas where services are not available – and often the victims themselves are not welcome.

A recent article published in Science Direct by Jason Beckfield and Clare Bambra, “Shorter lives in stingier states: Social policy shortcomings help explain the US mortality disadvantage” demonstrates that the lack of social services in the US leads to shorter lives than in other Organization for Economic Cooperation and Development (OECD) countries, i.e., the rich countries. The “highlights” of their study are that:
• The US combines a laggard welfare state with shorter life expectancy compared to the OECD.
• Fixed-effects models show associations between life expectancy and social policy generosity.
• US life expectancy would be 3.77 years longer if the US welfare state were just average
In this article “state” refers to nation-states, comparing the US to other OECD countries, but similar differences can be seen among the US states, again depending upon their social services, including public health and access to health care. This is supported by a new study from the Commonwealth Fund which finds that “adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs”. A third of U.S. adults “went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs”, as compared to as few as 7-8% in other countries. They were also the “most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.”

This is not good for our country, not good for our health, and not good for our lives. And as far as we can see, the new administration’s plans are not to fix it but to make it worse.

Saturday, December 3, 2016

Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters

The election of Donald Trump as President continues to be extensively analyzed. It demonstrates major divisions among our populace. One of those that has been discussed a lot is that the “white working class” that voted for him by a 2:1 margin will suffer a lot from the policies likely to be implemented by his administration. Not more, and probably less, than minority people, but a lot.

Healthcare and health insurance is one of those areas, as discussed by me in several recent posts and by Paul Krugman in the New York Times, December 2, 2016, “Seduced and betrayed by Donald Trump”. He notes that anger about their health care coverage, and in particular the dramatic increases in premiums under the ACA exchanges, drove many people to choose Mr. Trump’s promise to replace it with “something terrific”. Of course, he never specified what that would be, for the same reason that the Republicans in Congress have never been specific, which is that any replacement plan that does not move “left” toward a more universal coverage plan such as the single-payer advocated by Senator Bernie Sanders (and me) will be much worse for most people, including most Trump voters, who will either lose or have to pay a lot more (if they can!) for their health insurance coverage. Repealing Obamacare means that many of the 13 million newly insured (a majority white, for the record) who received insurance under the exchange will not get rate cuts, but rather they will get no coverage. Certainly not those who need the insurance most, because they have pre-existing conditions that insurance companies were mandated by ACA to cover. As Krugman puts it, “we’re probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.” This is made clear in the Times article on December 3, 2016 “GOP plans immediate repeal of health law, then a delay” by Robert Pear, Jennifer Steinhauer and Thomas Kaplan. The reason is because the only plan they have will yank health insurance coverage for so many people, and despite their vociferous opposition and multiple votes to repeal ACA, they do not want to do that, at least right away.

The best evidence for their long term plan to, basically, remove health insurance coverage from many Americans including their base of support is the appointment of Rep. Tom Price (R, GA) as HHS Secretary. Mr. Price has been a leader of the Tea Party movement and a major Congressional figure calling for the repeal of Obamacare. His solution is not completely fleshed out, but does include eliminating guaranteed issue, community rating, and federal support for the exchanges. He is a fan of vouchers, an idea advocated for decades by conservative think tanks, and which, I guarantee (and this is far more of a certainty than Mr. Trump’s promises), can NEVER work, especially over the long term. Vouchers will never cover the cost of a decent insurance policy; people with health problems will naturally be the first to seek coverage, and faced by the adverse selection insurers will raise the premiums, co-pays, and deductibles for them. If there are problems with this under Obamacare, vouchers will make those look pale by comparison. And by getting out of the running-the-infrastructure business, the government will ensure that it never gets better.

Price, a wealthy orthopedist from suburban Atlanta, does not really care. He represents rich doctors who want to be able to charge whatever they want to be able to charge, and care only for the people who have insurance good enough to pay it. Sorry, Trump voters with not much money, chronic disease, and difficulty paying even ACA premiums, that isn’t you. And when you get to an age that you can get Medicare, finally having federally-supported coverage, Mr. Price has another answer for you – privatize Medicare! Make it subject to the same market forces that have made health care and health insurance so unaffordable and unavailable to younger folks affect the elderly too! The ACA has modified the egregiously negative impact of private sector health insurance for the under-65 group; the crumbum Price wants to both reverse that benefit and extend the damage to seniors too.

When Lyndon Johnson signed the Medicare law at the Truman Library in 1965, presenting Harry and Bess Truman with cards #1 and #2, he quoted the former President from nearly 20 years earlier: "Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection." LBJ then added that “There are more than 18 million Americans [in 1965; way more now] over the age of 65. Most of them have low incomes. Most of them are threatened by illness and medical expenses that they cannot afford. And through this new law, Mr. President [referring to Mr. Truman], every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”

This is what Tom Price and his colleagues want to reverse. The AMA, with its shameful history of actually having blocked Truman’s health plan, and unsuccessful opposition to Medicare, is endorsing him. The Association of American Medical Colleges (AAMC) is endorsing him as well. The American Academy of Family Physicians (AAFP) more tepidly expresses optimism. Presumably these are political decisions, to maintain access. After all, in the ongoing battles between insurers and providers (patients are rarely a real player), at least he is a provider. But many others, including Physicians for a National Health Program (PNHP) and Common Dreams, as well as the medical students of Future Docs, have appropriately condemned Price and these organizations endorsing him.

Mr. Price will be joined by Seema Verma, who will head the Center for Medicare and Medicaid Services (CMS). Verma helped Mike Pence design the Indiana version of Medicaid expansion. On the plus side, that state did expand Medicaid, helping people more than those states that did not. On the minus side, the requirement that everyone covered has to pay meant at least 1/3 of those who would have been eligible did not sign up. I guess she is the moderate!

Mr. Trump’s cabinet picks are, so far, a panoply of people who are either right-wing ideologues who wish to destroy everything that has been done to help the American people at least back to the Great Society and maybe to the New Deal, or are billionaires who speak for the corporate financial ruling class that he attacked so effectively during his campaign, or both. An example of the latter is anti-public education billionaire Betsy DeVos to head the Department of Education. Myron Ebell, a noted climate-change denier, will head EPA. Steven Mnuchin, a leading Goldman Sachs banker, will be Treasury Secretary. Senator Jeff Sessions (R, AL), denied a judgeship because of his racist beliefs and practices will be Attorney General. Trump's nominee for Commerce Secretary, Wilbur Ross, according to Money, alone has 10 times the net worth of the entire cabinet of President George W. Bush. Talk about foxes guarding the henhouse! Compared to these folks, naming El Chapo to head the DEA, as suggested in a New Yorker satire by Andy Borowitz, would be a moderate pick.

The future of not only public health, but also your individual private health, now and when you get to retirement age, is in great jeopardy. But, then, so is everything else that helps people. Not to mention the earth, since global warming is likely to accelerate during a Trump administration. There is an endless string of battles before us.

And we must join every one.

Thursday, November 17, 2016

The Trump Election, the ACA and health care in America: Not with a bang but a whimper

As you may have already heard, Donald J. Trump won the election and will be the next President. “The media”, from the mainstream to the left, have moved from excoriating him as a candidate with outrageous personal characteristics and terrifying policy proposals, to excoriating him as President-elect, with less emphasis on his personal characteristics and more on what future policy is likely to be. There is special and valid emphasis on the people who are his main advisors, right wing zealots like Steve Bannon, and the hawkish, sometimes completely out of touch with reality, group. 

There are many  post-hoc analyses of why Clinton lost – I recommend Naomi Klein’s discussion of neoliberalism -- and what the most scary aspects of a Trump presidency are. Regarding the latter the always-terrific Noam Chomsky’s interview on Truthout, firmly identifies global warming and climate change as the greatest threat to the continuation of the world. He emphasizes this threat by noting that 40% of Americans are not concerned about the long-term impact of global warming because they believe that Christ will return and the rapture will occur in the next several decades.

There will, certainly be many other major threats, some of which, like nuclear war, could end the world. After the election, I was reminded that T.S. Eliot wrote in The Hollow Men, “this is the way the world ends, not with a bang but a whimper,” and yet the bang is not out of the question. In less apocalyptic, but just as serious terms, many people in America, whole populations, have real reason to be fearful. Obviously Muslims and “illegal immigrants” have been the victims of the most direct attacks by the President-elect and his advisors, and have a great deal to fear, but the list goes on to include Latinos who are here legally, citizens, members of other groups based on race/ethnicity (African-Americans) or other characteristics (LGBT). It includes women who may seek not only abortions but effective and available contraceptive care – and their partners. It affects all of us who value justice, diversity, peace, civil rights and civil liberties, opportunity, and freedom. We may see some irony in the last two, as they were clarion calls by many Trump supporters, but it has always been clear that for much of this group “freedom” was the freedom to do what they want (carry guns, practice their religion, etc.) and not any concept that would apply to everyone (be safe, have reproductive rights, practice their religion). Opportunity was always about the opportunity of some people to get ahead and not lose ground.

Many Trump supporters, but of course not those who are or will be in leadership in his administration, will be among those who suffer, because income and wealth will be major drivers of suffering, as they always have been. This is not to minimize the impact of race; as Dr. Camara Jones analyzes in her discussions of the “social determinants of equity”, class may be the final mediator of social, and especially health, disadvantage, but it does not explain why there are so many Black and other minority people in the lower class. Yes, surveys have shown that the bulk of Trump voters were white people in the “middle class” ($50,000-$90,000) range, but there were also many lower income whites. Indeed, while conservative ideologues in the Republican party railed against the ACA because it actually provided benefits to people in a “socialist” way, most voters who were hostile to it were motivated by (in addition to racism; it was after all “Obamacare”, named for our African-American President) the fact that premiums were going up to unaffordable levels, and the coverage that they received, when they got sick, was inadequate.

Of course, to be concerned about your premiums and deductibles and co-pays going up under the health insurance exchanges, you have to be covered by them. And, if we didn’t have “Obamacare”, you wouldn’t be covered at all, especially if you have a “pre-existing condition” or have to be paying a lot more if you could. Trump recently seem to be recognizing this, noting that there are popular as well as unpopular aspects of the ACA, and that junking the whole thing, as Republicans have voted to do dozens of times, might be a bad move. The things people like about ACA are that they can get coverage, that they can’t be denied coverage for a pre-existing condition, that there is “community rating” which means that they can’t be charged an especially high premium because they are sick, and that children can stay on their parents’ policies until 26. What they don’t like is high and increasing premiums, high deductibles, high co-pays, discovering the insurance that they could afford is lousy and doesn’t cover what they need and, in many cases, community rating, which means that if you are young and healthy you pay more.

Trump, in characteristic fashion, promises us we will only get rid of the bad parts, and keep the good parts, so the results will be terrific! Too bad President Obama didn’t think of that. Or me. Or that it isn’t possible within the constraints of the ACA. The ACA was designed to deal in insurance companies and their profits to a more-inclusive national health plan. This was the quid pro quo: we’ll do community rating and insure everyone regardless of pre-existing condition, you have to make everyone buy insurance (the “individual mandate”). But lots of healthy, and especially young, people are not buying insurance, gambling that they will stay healthy. If they get “caught” (and most don’t) the penalty is far less than the cost of the insurance. So they win. Until they lose. Of course, many who buy insurance get the lowest cost policy they can and then they really lose. And if they buy better coverage the insurance companies get mad. Much analysis of the history of ACA and its roots, as well as speculation about its future, is covered by Himmelstein and Woolhandler in this PNHP post.

And it doesn’t come at a good time. The Commonwealth Fund just released a report showing that Americans have more challenges in receiving needed health care than in 10 other rich countries. Well, it hasn’t been a good time for a while. This report just shows, basically, the same thing that Commonwealth and others have been reporting for years.

So what can we expect, as a nation, from a Trump administration? Well, there is odds-on betting that we will get a right-wing, anti-abortion, anti-reproductive rights Supreme Court. And, if not actually a wall, major deportations and harassment of immigrants. And real anti-Muslim activity. Hate crimes are already up, per the Southern Poverty Law Center, with really bad people feeling emboldened by the Trump rhetoric; we can only hope his Justice Department will prosecute these crimes at least as aggressively as they do immigrants. We will probably get more of the same in attacks by police on minorities, and especially on policies that enrich the richest and hurt the poor. We will get little or no action on climate change. And we will not get the jobs that have been lost back, whatever the President-elect promises.
 
Protests will continue, centered as they have been in the small islands of the nation that voted Democratic – and where most of the people in the US live. We need to be sure that the losses I describe above do not come easily, that we do not keep our heads down, that we make waves.

And, in healthcare, we probably will not get single payer, although this would solve the problem and allow Donald Trump to actual give us most of the good without most of the bad. If he would only.

The Trump Election, the ACA and health care in America: Not with a bang but a whimper

As you may have already heard, Donald J. Trump won the election and will be the next President. “The media”, from the mainstream to the left, have moved from excoriating him as a candidate with outrageous personal characteristics and terrifying policy proposals, to excoriating him as President-elect, with less emphasis on his personal characteristics and more on what future policy is likely to be. There is special and valid emphasis on the people who are his main advisors, right wing zealots like Steve Bannon, and the hawkish, sometimes completely out of touch with reality, group. 

There are many  post-hoc analyses of why Clinton lost – I recommend Naomi Klein’s discussion of neoliberalism -- and what the most scary aspects of a Trump presidency are. Regarding the latter the always-terrific Noam Chomsky’s interview on Truthout, firmly identifies global warming and climate change as the greatest threat to the continuation of the world. He emphasizes this threat by noting that 40% of Americans are not concerned about the long-term impact of global warming because they believe that Christ will return and the rapture will occur in the next several decades.

There will, certainly be many other major threats, some of which, like nuclear war, could end the world. After the election, I was reminded that T.S. Eliot wrote in The Hollow Men, “this is the way the world ends, not with a bang but a whimper,” and yet the bang is not out of the question. In less apocalyptic, but just as serious terms, many people in America, whole populations, have real reason to be fearful. Obviously Muslims and “illegal immigrants” have been the victims of the most direct attacks by the President-elect and his advisors, and have a great deal to fear, but the list goes on to include Latinos who are here legally, citizens, members of other groups based on race/ethnicity (African-Americans) or other characteristics (LGBT). It includes women who may seek not only abortions but effective and available contraceptive care – and their partners. It affects all of us who value justice, diversity, peace, civil rights and civil liberties, opportunity, and freedom. We may see some irony in the last two, as they were clarion calls by many Trump supporters, but it has always been clear that for much of this group “freedom” was the freedom to do what they want (carry guns, practice their religion, etc.) and not any concept that would apply to everyone (be safe, have reproductive rights, practice their religion). Opportunity was always about the opportunity of some people to get ahead and not lose ground.

Many Trump supporters, but of course not those who are or will be in leadership in his administration, will be among those who suffer, because income and wealth will be major drivers of suffering, as they always have been. This is not to minimize the impact of race; as Dr. Camara Jones analyzes in her discussions of the “social determinants of equity”, class may be the final mediator of social, and especially health, disadvantage, but it does not explain why there are so many Black and other minority people in the lower class. Yes, surveys have shown that the bulk of Trump voters were white people in the “middle class” ($50,000-$90,000) range, but there were also many lower income whites. Indeed, while conservative ideologues in the Republican party railed against the ACA because it actually provided benefits to people in a “socialist” way, most voters who were hostile to it were motivated by (in addition to racism; it was after all “Obamacare”, named for our African-American President) the fact that premiums were going up to unaffordable levels, and the coverage that they received, when they got sick, was inadequate.

Of course, to be concerned about your premiums and deductibles and co-pays going up under the health insurance exchanges, you have to be covered by them. And, if we didn’t have “Obamacare”, you wouldn’t be covered at all, especially if you have a “pre-existing condition” or have to be paying a lot more if you could. Trump recently seem to be recognizing this, noting that there are popular as well as unpopular aspects of the ACA, and that junking the whole thing, as Republicans have voted to do dozens of times, might be a bad move. The things people like about ACA are that they can get coverage, that they can’t be denied coverage for a pre-existing condition, that there is “community rating” which means that they can’t be charged an especially high premium because they are sick, and that children can stay on their parents’ policies until 26. What they don’t like is high and increasing premiums, high deductibles, high co-pays, discovering the insurance that they could afford is lousy and doesn’t cover what they need and, in many cases, community rating, which means that if you are young and healthy you pay more.

Trump, in characteristic fashion, promises us we will only get rid of the bad parts, and keep the good parts, so the results will be terrific! Too bad President Obama didn’t think of that. Or me. Or that it isn’t possible within the constraints of the ACA. The ACA was designed to deal in insurance companies and their profits to a more-inclusive national health plan. This was the quid pro quo: we’ll do community rating and insure everyone regardless of pre-existing condition, you have to make everyone buy insurance (the “individual mandate”). But lots of healthy, and especially young, people are not buying insurance, gambling that they will stay healthy. If they get “caught” (and most don’t) the penalty is far less than the cost of the insurance. So they win. Until they lose. Of course, many who buy insurance get the lowest cost policy they can and then they really lose. And if they buy better coverage the insurance companies get mad. Much analysis of the history of ACA and its roots, as well as speculation about its future, is covered by Himmelstein and Woolhandler in this PNHP post.
And it doesn’t come at a good time. The Commonwealth Fund just released a report showing that Americans have more challenges in receiving needed health care than in 10 other rich countries. Well, it hasn’t been a good time for a while. This report just shows, basically, the same thing that Commonwealth and others have been reporting for years.

So what can we expect, as a nation, from a Trump administration? Well, there is odds-on betting that we will get a right-wing, anti-abortion, anti-reproductive rights Supreme Court. And, if not actually a wall, major deportations and harassment of immigrants. And real anti-Muslim activity. Hate crimes are already up, per the Southern Poverty Law Center, with really bad people feeling emboldened by the Trump rhetoric; we can only hope his Justice Department will prosecute these crimes at least as aggressively as they do immigrants. We will probably get more of the same in attacks by police on minorities, and especially on policies that enrich the richest and hurt the poor. We will get little or no action on climate change. And we will not get the jobs that have been lost back, whatever the President-elect promises.
 

Protests will continue, centered as they have been in the small islands of the nation that voted Democratic – and where most of the people in the US live. We need to be sure that the losses I describe above do not come easily, that we do not keep our heads down, that we make waves.


And, in healthcare, we probably will not get single payer, although this would solve the problem and allow Donald Trump to actual give us most of the good without most of the bad. If he would only.

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