Saturday, March 25, 2017

Doctors and health reform: maybe they do stand for health!

The new GOP health plan, the American Health Care Act (AHCA), aka “Trumpcare”, has crashed to defeat. The President, who pushed hard for it, looks like his greatest nightmare, a “loser”. It is worth thinking, however, about who opposed it. In Congress it was Democrats and (the few) moderate Republicans and very right-wing Republicans are against it, for different reasons. From outside government the response was pretty negative, with a 17% approval rating (amazing they could still think they could pass it!). Far-right “conservatives” thought that AHCA was too much like Obamacare in that it actually provides some federal support for some people, and  they don’t believe in the government ever helping anyone, except maybe themselves and their friends. (Oh, yes, and fabulously rich people. They deserve a lot of help.) The criticism from most of the rest of the universe (to say “the left” would be inaccurate, since it includes many quite a bit right of center, since, in fact, “Obamacare” started life as a Republican plan) was mostly because it would be a disaster for health coverage for Americans. Projections by the Congressional Budget Office (CBO) were that 24 million people would lose their health insurance, that access to care would be more and more limited, especially for the middle class and poor, and that costs would rise for patients exponentially. Also that the public health and preventive health infrastructure would be gutted and many of our advances in those areas lost.

The main “positive” in the CBO’s projection was that it would reduce the federal deficit by $337 billion over 10 years. This was only because it shifted costs to others, to states and employers and individuals. Those who could not pay with money would pay with their health and sometimes their lives. While, as I have pointed out (‘We have a bill! The GOP's plan to cut taxes on the rich and health care for the rest of us, March 16, 2017) many would have lost their insurance because of cuts in subsidies through the exchanges, the biggest impact would have been through the loss of Medicaid. This is clearly explained by Dr. Daniel Derksen, a family physician and director of the University of Arizona’s Office of Rural Health in a video on MedPage Today.

Among the many groups criticizing the draconian cuts in health care (as well as taxes on the rich) are almost all of the major hospital associations (including the American Hospital Association, the Catholic Hospital Association, and others), and physicians’ groups, most notably the American Medical Association (AMA) as well as most specialty societies including the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), as well as many others. They have been joined by the major nursing organizations and by patient advocacy groups. It should not be surprising, I suppose, that most of these groups would be critical of such a devastating attack on health care for Americans, but if it isn’t, it is at least a relief. The AMA is important in part because of its major role in opposing most historical expansions of health care access by the government, including President Truman’s attempt to get a national health insurance program (where they were successful) and President Johnson’s creation of Medicare and Medicaid (where they were not).

Of course, not all health providers and certainly not all physicians opposed the AHCA’s changes. MedPage Today published quotes from a number of physicians, and some were quite supportive; Darrell S. Rigel, a dermatologist at NYU, for example, said “It looks like it is a significant improvement over the ACA [the Affordable Care Act, aka Obamacare].” The most noteworthy physician advocate for the AHCA and Trumpcare was naturally Tom Price, MD, the Secretary of Health and Human services. As I discussed before his appointment (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters, December 3, 2016), Secretary Price, as a congressman from Georgia was a leader in the Tea Party caucus and an opponent of ACA or any other program to expand health coverage to Americans. Another recent voice to both support AHCA and channel the administration and GOP’s contempt for regular people is Rep. Roger Marshall, an obstetrician from Great Bend, KS who is the Representative from Kansas’ “Big First” district. Dr. Marshall told the Washington Post that “the poor just don’t want health care”. He kind of walked back those remarks later, but his analysis is telling:

“Just like Jesus said, ‘The poor will always be with us,’ ” Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. “There is a group of people that just don’t want health care and aren’t going to take care of themselves.” He added that “morally, spiritually, socially,” the poor, including the homeless, “just don’t want health care….The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,” he told STAT, a website focused on health-care coverage. “So there’s a group of people that even with unlimited access to health care are only going to use the emergency room when their arm is chopped off or when their pneumonia is so bad they get brought [to] the ER.”

I may not be the best person to comment on his bizarre interpretation of the Gospel, but I can say that for many of us the challenges that poor people face in just getting through their lives are reasons why we need to make health care accessible, not reasons to just write them off. I also wish that I could say that, in my experience, physicians with attitudes like those of Price and Marshall are rare, but sadly they are not. To some degree, there are differences by specialty, with primary care physicians and psychiatrists more likely to support government-involved health care and even single payer plans than surgeons (including orthopedists). I am sure that at least in part this difference is driven by income; while all physicians have relatively high incomes compared to most Americans (top 10%), some specialties, including orthopedics (at the top), radiology, cardiology, surgery, and dermatology make much more; the mean reported income for orthopedists, about $467K (which seems low to me based on those I know) is about the cutoff for the top 1%. When a friend of mine (who later became a surgeon) was on his surgical rotation in medical school, he was impressed by all the talk in the surgeon’s lounge about the “Big Board” – until he found out they meant the stock market, not the board listing upcoming surgeries! And primary care doctors are not immune; when I lived in Texas one family physician regularly railed against the liberal government spending our money. One day, however, his attacks were on delays in payments to doctors from Medicare. Umm…

Doctors, as most people know, are like other people. Their perspectives vary widely, with most being caring and some caring mostly for themselves. My family physician colleague’s self-centered view is not so different from that of those Trump voters who are now against the AHCA because they see that their benefits are being cut; see “Trump budget cuts put struggling Americans on edge”, NY Times March 18, 2017. The authors cite a retired nurse with lung cancer whose heat was cut off in the middle of the winter; she was rescued by a heating subsidy funded by the federal government and likely to be cut. “I understand what he’s trying to do, but I think he’s just not stopping to think that there are people caught in the middle he is really going to hurt,” she said. Somehow, I suppose, she thought that the cuts would only be to other people…

So, while it is true that doctors, like others, often share the perspectives of their class, and callously disregard or rationalize opposition to ensuring health care for everyone, they often do understand the situations their patients are in and serve as advocates for them. In 2001, the AMA passed its “Declaration of Professional Responsibility: Medicine’s Contract with Humanity”.  It includes the following “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”  The AMA was on the right side of the AHCA fight. I hope that most doctors agree with, and even practice, that principle.

I hope Tom Price and Roger Marshall are aberrant exceptions.

Thursday, March 16, 2017

We have a bill! The GOP's plan to cut taxes on the rich and health care for the rest of us

Every day it gets more difficult to write about the new “American Health Care Act” (AHCA) that has been introduced in the House of Representatives by Speaker Paul Ryan because every day there is so much more news about it, and so much more criticism of it that appears in the press. Even before its introduction, the bill was attacked for being likely to significantly increase the number of uninsured Americans while providing windfall tax cuts for the wealthiest.

It did not disappoint. Consistent with predictions, the nonpartisan Congressional Budget Office (CBO) estimates that initially 14 million people will lose coverage, with the number rising to 24 million in 10 years. These estimates are discussed in detail, and clarified, in “Deciphering CBO estimates” at the Kaiser Health News site. The largest number of people who will lose coverage will do so because of the changes – but let’s call them what they are, “cuts” – to federal funding of Medicaid (discussed by the Health Affairs blog), which would shift costs to the states, most of which will be unable or unwilling to absorb these costs. The 31 states that have expanded Medicaid to all those under 138% of the federal poverty level  under the Affordable Care Act (ACA) will be faced with having to fund a lot more from their own coffers; poor people in the states that have not expanded Medicaid eligibility will continue uncovered. The other group that will lose coverage will be those who have bought subsidized insurance on the ACA-created marketplaces and who will no longer be able to afford the premiums. Yes, the new GOP plan calls for tax credits to help pay premiums, but they will be far less than under the ACA and far from enough to cover the actual cost.

This change will have the biggest impact on the older, sicker poor who are not yet eligible for Medicare (and, while I we will not address it here, the GOP leadership certainly has plans for cutting Medicare!), whose premiums will go up because of two important changes the AHCA will make. It will end the “individual mandate” of ACA, so that those who feel that they do not need health insurance can pass on buying it, which means the pool of insured will lose those healthier people and have a pool more skewed to those who are sicker and will actually use health care. This will tend to drive premiums up for them, and the AHCA also allows insurers to charge 5 times as much to older people as younger. As reported by Thomas Kaplan and Robert Pear in the NY Times on March 13, 2017
Under current law, in 2026, a single 21-year-old earning $26,500 with an insurance policy that costs $5,100 a year would get a tax credit of $3,400 and would have to pay $1,700 of the premium. Under the Republican bill, that person’s share of the cost would drop to $1,450.
By contrast, a 64-year-old earning the same amount would fare much worse. That person’s $15,300 health plan would be offset by a $13,600 tax credit under current law, leaving the consumer responsible for $1,700. Under the Republican plan, health insurers would be free to charge older people more, raising that person’s premium to $19,500. But the tax credit would be only $4,900, and that person’s share of the premium would then be $14,600.
That’s a bite! And, ironically, as pointed out by Noam Levey in the Los Angeles Times (March 12, 2017), it will hurt Trump/GOP voters more than Democratic voters, because those Trump voters – and the counties and states which went for Trump in which they live -- are more likely to be in this older, sicker, group. This group of Republican voters did not like Obamacare because the premiums, co-pays, and deductibles were going too high and the coverage was not always great, especially for the plans they could afford. Trump, and the GOP, promised them high-quality, affordable coverage. These folks believed them. They voted for them. And they are not going to get it, certainly not from the AHCA. Levey notes that “…In nearly 1,500 counties nationwide, such a person stands to lose more than $6,000 a year in federal insurance subsidies. Ninety percent of those counties backed Trump…[a]nd 68 of the 70 counties where these consumers would suffer the largest losses supported Trump in November.” What can you do. Politicians lie. This one was a whopper.

What is the reason for this? Many of Congress’ and Washington’s leading “conservatives” say that they believe that the role of government should be as close to zero as possible, and certainly think that the government has no business being involved in the insurance marketplace to ensure that people without resources have health coverage; to them, the AHCA is too much like the ACA in that it actually makes some effort to help some people, if weakly. There are a few of these “conservatives”, in and out of Congress, who really believe this and act on such beliefs. Uniformly, they are not poor, are not close to poor, and are not likely to be negatively affected. There is a much larger contingent that only believe government should not help most people. They support legislation that benefits rich people, like the AHCA, which uses the money it will save (and the CBO says that it will reduce the deficit over 10 years by $337 billion) to give tax cuts, not evenly distributed, but very much skewed to the highest incomes. This is where the [mean] rich people come in; they fund the Congresspersons, and this is what they want. Rep. Michael Burgess (R, TX), Chairman of the Energy and Commerce subcommittee on health, is quoted in the Times on March 11 (“The GOP’s high-risk strategy for health law repeal”) as saying “If you ask someone to give up something, there will be resentment,” and he is correct. That it is regular people who are being asked to give up something by Mr. Burgess and his colleagues, so that his rich patrons can save even more on their taxes, is something he doesn’t focus on.

One of the most iconic differences between ACA and AHCA focuses on equity: the subsidies (and tax credits for those who paid taxes) under ACA were tiered to income. The tax credits that replace subsidies under AHCA are tiered to age. Of course, as I have noted, older people are more likely to be sick, but they are not all of the same need; some older people have lots of money, and some have none. The same is true for younger people, including those with medical need. In any case, the tax credits in AHCA will not, as demonstrated above, be sufficient for those without significant other resources to buy health coverage, even if they are in the more-highly-subsidized older group. The Times’ Alan Rappeport reports on March 16, “One certainty in health bill: tax cuts for the wealthy”, with 40% of the cuts going to the top 1%, and the bill providing the necessary basis for further tax cuts for the rich. Rappeport quotes Mike Mulvaney, the White House budget director: “We promised at the outset that we were going to repeal all of the taxes. Who cares if someone else benefits?” Well, maybe the people who will suffer for their benefit? The same issue of the Times contains a brief and informative piece by Mr. Pear, “Putting Republicans’ plan on the Obamacare scale”, examining the criticisms of ACA and how the AHCA solves them (or not).

President Trump apparently feels conflicted; he promised the repeal of ACA, and the Congress wants to do that. He also knows that any plan that comes out that does this will be called “Trumpcare”, just as the ACA was called “Obamacare”. Enough Republican senators are concerned that the House’s AHCA will make it too hard for too many people to afford insurance that they might vote against it, so “Mr. Trump was left to strike a balance between siding with House Republicans while also distancing himself from the details, with top aides conceding that the legislation needed modifications before it could pass the full Congress,” (”G.O.P. Senators Suggest Changes for Health Care Bill Offered by HouseNY Times, March 14).

For the rest of us, it is an impending disaster.

Saturday, March 4, 2017

Will the GOP "solve" access to health care? No, unless you can redefine "access"!

An editorial in the New York Times on February 20, 2017 (“Ryancare: You can pay more for less!”) does a very good job of concisely demonstrating what the new Republican plan is likely to do to access to health care, the cost of health insurance, and what it covers. The key to House Speaker Paul Ryan’s plan for replacement of Obamacare involves “…flat tax credits unrelated to income, that could be applied to the purchase of insurance” (Paul Krugman, “Death and tax cuts”, NY Times February 24, 2016). As Krugman makes clear, the credits would be insufficient for low and middle income families to buy insurance, but would be a small benefit to high income households. The obvious result would be the loss of health insurance for millions of Americans who gained it through either the ACA exchanges and accompanying subsidies or through Medicaid expansion.

Giving tax credits or deductions is a long-standing Republican strategy that pretends to be equitable but in reality always benefits the financially better off. Ivanka Trump (the President’s daughter who is not, it should be observed, elected or even appointed to anything) has her pet project, tax deductions for childcare. Again, this sounds good, especially to the more well-off, two-income couples who would benefit (but don’t get your hopes up; the $500 billion tab makes it unlikely to pass even with the First Daughter’s support), but would be of less benefit to the poor. The one thing that is certain about Republican and Trump policy is that it will benefit the better-off; the problem with such deductions, from their point of view, is that it is costly and doesn’t benefit a narrow enough slice of the highest income individuals and corporations (sorry, Ivanka).

As summarized in MedPage’s Washington Watch Policy Papers on ACA Repeal: Many Question, Few Answers, no one, outside the Republicans pushing it, has any belief that the Ryan plan will provide coverage for most of the people who gained coverage from the components of the ACA, not to mention those who remained uninsured even with ACA in place, mostly poor people in states that did not expand Medicaid and undocumented people, as well as those who risked the penalties for violating the individual mandate rather than buy health insurance that they felt they could not afford. The first two groups are completely left out of any “replacement” plan (and of course undocumented people were never part of Obamacare). None of these plans will in any way benefit the middle and lower income people who voted for Trump in part because they wanted to get rid of Obamacare, which was costing them too much, and get the terrific, affordable health care coverage that the President promised them in the campaign. It is not going to happen, and people are beginning to understand that; CNBC reports that Obamacare is getting more popular in the first month of Trump’s presidency.

All that has been revealed so far about the content of a Republican “plan” indicates that it will cover fewer people than the ACA currently does. Some of this has to do with the mechanism of funding, with “tax credits” replacing direct subsidies for lower-income people. There is even a debate among Republican lawmakers about whether those tax credits should be “refundable” or not; if they are, then people will get the amount designated for the tax credit even if that amount is greater than the amount they would have owed in Federal income tax. Thus, it would be a subsidy, and thus many “conservative” (their word) Republicans oppose it. For a very large percentage of those who would be buying insurance and need help, the amount would likely be greater than the amount of Federal tax they owe. Of course, this depends upon how much the tax credit is determined to be; one thing, however, is that there is essentially no chance that it will be enough to actually purchase insurance.

Which brings up another big part of the way Republicans talk about health coverage. They use the term “access” rather than coverage, and have defined it in such a way that it is different from coverage; people, they say, will have the option of buying health coverage, not be forced to, the way that the ACA’s individual mandate did. This requires a conscious effort to ignore the crucial “ability to pay for it” as part of access, and makes the idea of “option” insincere. Something is not an option if you cannot afford it. Sen. Bernie Sanders said, in a good takedown of this use of “access”, that he had access to purchase a $10 million house; he just didn’t have the money to do it!

Insurance companies are a big part of the problem for ACA. The absence of a “public option”, not to mention a single-payer plan, meant that the law had to build in a way for insurance companies to be able to make money. To be able to profit, they have to either be able to charge a lot for coverage (or deny it altogether) for sick people, which was the pre-ACA status quo, or have a large pool of healthy low-cost people buying insurance. Thus, especially given ACA’s elimination of their ability to refuse insurance to people with pre-existing conditions, the individual mandate, requiring everyone to buy insurance, was needed. Despite the mandate, though, not enough healthy people bought insurance, and there was no rate cap, so it quickly has become unaffordable for many. Of course, we could have done what other developed countries do – have either a single-payer system where we have everyone automatically in the risk pool and everyone is actually covered, or have a highly regulated system, where benefit packages and rates are set by the government and insurance companies are non-profit, so compete on customer service. We actually have examples of both in the US. Medicare is a single payer plan (and while Medicare Part A, hospital, is paid for by the Medicare trust fund, Part B, doctor and outpatient bills, require individuals to pay, with high-income  people paying a supplement), as is the military health care system and the VA. Medicare supplement (Medigap) plans are regulated with regard to benefits; there are a number of plans lettered Type A to Type N (except there is no E, H, or I) with different benefit packages. The degree of comprehensiveness does not follow the alphabet (F is the best, K probably the worst) but at least they are standardized so all Type A, C, F, or K plans offer the same benefits regardless of which company you buy from, and so you can shop based on price.

I do not think that we are going to have such a simple situation as a highly-regulated marketplace, and certainly not single payer. We are likely going to back as far away from comprehensive coverage and affordable health care as the Republican Congress and President can get away with, which means as far as the American people will allow. Of course, the American people (other than the small number of, but incredibly powerful, wealthy ideological conservatives) do not want to lose their health coverage; they just want to pay less. Or not pay until they are sick. For them, and maybe for their families. For others, maybe not so much; some studies have found that as many as 2/3 of Americans support Medicare for All, while for Dr. Paul Gordon on his “Bike Listening Tour” across the US in 2016, one of his most upsetting findings (at least among the mostly white, rural, northern people he interviewed) was people’s lack of concern for others. Or at least “the other”, folks not like them.

It’s a real shame. We could have comprehensive quality care for everyone, at a more reasonable cost. Too bad the ideologues and the greedy are in control.

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 if 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 60 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

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.

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