It's not just about the emergency. It's about restructuring society so we have the ability to deal with crises.

A recent article by Jennifer Sinco Kelleher and Terry Tang from the Associated Press, highlighted in Medscape, is called “Omicron Explosion Spurs Nationwide Breakdown of Services”, and is one of many pieces documenting how this extremely contagious (if possibly more mild) variant of COVID-19 is continuing to overwhelm not only healthcare, but almost all areas of our society:

Ambulances in Kansas speed toward hospitals then suddenly change direction because hospitals are full. Employee shortages in New York City cause delays in trash and subway services and diminish the ranks of firefighters and emergency workers. Airport officials shut down security checkpoints at the biggest terminal in Phoenix and schools across the nation struggle to find teachers for their classrooms.

It goes on. One of the major flashpoints has been whether schools should reopen, often ostensibly pitting parents (who not only are feeling overwhelmed with having to supervise their children’s online education, but often have to go back to work themselves and have no one to watch their kids) against teachers (who are reasonably terrified of contracting COVID infection – and transmitting it to their own families). Of course this is overly simplistic; parents want their children to be safe and remain non-infected, and teachers want children to be educated – often this is not only their job but their calling! Michelle Goldberg in the New York Times argues that American Federation of Teachers (AFT) President ‘Randi Weingarten Still Wants Schools Open’, as she wrote a month ago. But there are many who are determined to pander to their political bases (like Oklahoma senator Tom Cotton, whom she cites) by creating bogeymen to attack.

But it has been, in case you haven’t noticed, a very stressful two years. The schools may affect a huge number of people, but so does healthcare. Kelleher and Tang emphasize the impact on healthcare, including my old hospital, the University of Kansas in Kansas City, where

The number of COVID-19 patients at the University of Kansas Hospital rose from 40 on Dec. 1 to 139 on Friday. At the same time, more than 900 employees have been sickened with COVID-19 or are awaiting test results — 7% of the hospital's 13,500-person workforce.

Paramedics are working 80 hours a week. There are simply not enough skilled people to do the work. And it is getting worse as more and more of them get sick. The always-overtaxed staff in our healthcare facilities has become more and more overtaxed by the increase in demand and the decreased number of workers. ‘"Everybody's working 'round the clock, 12-hour shifts” says New York City’s sanitation commissioner, and it is true in many fields.

It is tempting to say that this is, in large part, a result of “chickens coming home to roost”, of two generations of cutbacks in staffing and “just in time” supplying, of corporate consolidation and downsizing and increasing profits to please investors by overworking those who are left, of rewarding this with huge salaries to the C-suite executives. Well, it is, largely. We have been though a long period of rapacious exploitation of the workforce, and it is a big part of why there was nowhere near enough “flex” in the system to accommodate the huge demands of the COVID pandemic.

The news has also featured stories about the increasing power of workers, given the current labor shortages, and a few recent strikes that have been won. This is good, but it is not enough. Many hospitals have lost staff; nurses have not only stopped coming to work but have even left the profession. Not all of them would still be there if they were being paid higher wages, but it would help. It has been interesting to see that hospitals are willing to pay agencies huge amounts of money -- $100-200 or more an hour – to get “travel nurses” (nurses who will travel from where they live to your town for the more money) but not to significantly increase salaries for full-time nurses. This is part of an overall approach that sees the pandemic as a temporary blip – we can pay these high daily rates for a while, but really do not want to increase actual salaries in the long term. Reward those doing the work? Isn’t that communism?

Indeed, this is kind of the approach that the government has been taking overall; Trump or Biden, Republican or Democrat, trying to say “this will soon pass”, we can get back to normal, we can “open up”. It pleases folks who are frustrated at being at home and being on Zoom and not eating out or clubbing or whatever to hear that. Until they get sick. It must please some of the members of the Tucson Racquet and Fitness Club, who despite a county indoor mask mandate and a request from the management continue to wear masks indoors, do not -- like the two young women who held a 45-minute maskless conversation 10 feet from my machine today. Until they get sick. Probably not until they make someone else sick, since they won’t know. The county is not enforcing the mandate and the Club and stores are afraid to; supermarket managers talk of verbal and physical assaults on their employees. The stock market really likes the idea that things will get back to normal, since “normal” has been a rising market; plus all the richest investors make money either way.

Of course, people with some jobs have been hit harder than others. Those who must be physically present at work have been unable to “phone (or Zoom) it in”. And healthcare workers, doctors, nurses, and others, have been exploited by a culture which knows that they will sacrifice much for the welfare of their patients, and is willing to push it to the max. Or more. This is not ok. There is no reason for any healthcare system to be making money (whether it is called “profit” or something else in not-for-profits) or paying its executives huge salaries while the staff is getting sick, doing double shifts, burning out. It is not just about paying people more (although often this is important); it is about a paradigm shift that recognizes that long-term commitment to those doing the work needs to be the priority. It is about having enough workforce to be able to cope with increased demand when it happens.

Reminder #1: The entire structure is geared to the goal of increasing the wealth of those who already have the most and have the most power.

Reminder #2: This is not how it should be.

Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?

Martin Shkreli, the former CEO of the drug company Turing, achieved his 15 minutes of fame (or infamy) last year through predatory pricing, raising the price of pyrimethamine, an old drug used to treat a parasitic infection in the brains of immune-compromised (usually HIV-infected) people from $13.50 to $750 a pill (Drug prices and corporate greed: there may be limits to our gullibility, September 27, 2015). Shkreli manage to further alienate people by his testimony before Congress, widely described using adjectives such as “smug” and “condescending”.  The most recent Pharma CEO to hit the news for price gouging, Heather Bresch of Mylan, seems to be trying to avoid Shkreli’s “doubling down” by making an apology, of sorts.

Bresch’s company, unquestionably with her active involvement, raised the price of Epi-Pen®, a self-injectable form of epinephrine that is sold to prevent people from dying from severe allergic (anaphylactic) reactions to a variety of substance, from peanuts to bee stings, from about $100 to $600 for a 2-pack. Two things: first, such pens are lifesavers. As a physician, when I tried to figure out what I needed to pack in an emergency first-aid kit for camping, it was #1. It was the only thing I could think of that actually could keep someone from dying in the woods. Second, epinephrine is an old, cheap drug. As ABC news reported, a doctor in Canada showed how a physician can prescribe a whole vial, plus small syringe and needle, for under $10, and a person can easily inject themselves, just under the skin. The “value” of the Epi-Pen is that it is self-injecting, but hard to even justify the $100. Or the somewhat higher cost of a generic (Mylan, indeed is a generic company.) Bresch, the daughter of a US Senator, was awarded an MBA by West Virginia University despite not finishing the coursework (which led to the resignation of the president). She protested that she wasn’t being predatory like Shkreli, and offered to sell the drug at a 50% discount, only $300! That is still a lot. I have a friend whose daughter is allergic to peanuts; both her day care centers require her to have a 2-pack of Epi-Pen®, with prescription (thus can’t do the epinephrine bottle) – this could cut her outlay from $1200 to $600. Of course, she will spend it to potentially save her daughter’s life, the key point that Mylan and Ms. Bresch understood when they raised the price. At more or less the same time, Ms. Bresch raised her own salary from a paltry less-than-$2 million a year to $18 million. I guess the rise in the price of Epi-Pen® funded that. MAD Magazine® used to do satire but its recent coverage of Epi-Pen® is almost investigative reporting (see picture).

Could it get worse? Sure, why not? Bresch’s father, Senator (and former Governor) Joe Manchin of West Virginia may or may not have been helpful to Mylan (it is, after all, a West Virginia company), but many politicians have been tied to helping drug companies make lots of money. Bill Moyers covers the role of Billy Tauzin, a former Congressman from Louisiana who chaired the House Energy and Commerce Committee when Congress passed the Medicare drug plan (Medicare Part D) under President G. W. Bush. That legislation prohibited Medicare from using its clout to negotiate lower drug prices. Tauzin left Congress in 2005 and became chief lobbyist for the Pharmaceutical Research and Manufacturers of America (PhRMA), converting his well-paid (by campaign donations) service while in Congress to a MUCH better-paid job lobbying his former colleagues. He is credited with having a major impact on the ACA, passed in 2010, ensuring its Pharma-friendly characteristics. And, to be sure, Tauzin, who left PhRMA after 5 years, was scarcely alone in pushing pharmaceutical industry interests in Congress, or in receiving big donations, as the Moyers piece documents. Congress appears to buy the idea that Pharma needs high prices for doing research and development (despite the fact that they spend many times their R&D budgets on marketing, and much of the basic research is done with government funding at universities) and that other countries’ restrictions on the prices of their drugs require them to charge Americans more. Of course, the real reason that pharmaceutical companies charge so much in the US is that they can get it. Whose interests is Congress working in when it does this? Not the American peoples’…

I recently discussed the fact that some large insurers (Aetna, United, Humana)  are leaving the health insurance exchange marketplace in some parts of the country because they are losing money (or, perhaps, just not making enough) because too many sick people and not enough healthy people are signing up, turning the insurance model on its head.  Although the ACA contains an individual mandate, lots of people with less money and/or fewer health needs are not signing up and paying the penalties, which are much less costly (if they are even “caught”). Of course, the ACA did not include a “public option”, which would have been much less costly, specifically to offer these insurers a competition-free field. This is discussed in detail by Princeton health economist Uwe Reinhardt in a JAMA Forum on August 25, 2016 “Why Are Private Health Insurers Losing Money on Obamacare?”. The reason comes down to the same one that has always been true, and that I discussed a number of years ago (October 20, 2009, Red, Blue, and Purple: The Math of Health Care Spending) – a small minority of people account for most health care costs. I have attached a graph from Reinhardt’s piece that makes the same point. And, although he explains the reason insurers lose money, Reinhardt does not excuse it. "If health care costs in the United States were lower, most people would probably agree that ill, low-income citizens should receive the needed health care that is available to better-off individuals. The problem is that our health system is in danger of pricing kindness out of our souls."

So we have both the greed of pharmaceutical companies and the greed of insurers. As discussed in many recent articles in the popular press, the bottom line is that the health benefit to Americans is at best a side effect of complex plans engineered to make profit. This perverted approach, almost unique to the US, has marginalized, bankrupted, and caused illness and death in many. This system doesn’t work for people. A fairly well-off couple caught in the bind of insurance costs is profiled by AP in its “The Big Story: “Without a subsidy, couple faces higher insurance premiums”. The husband notes the failure of our system to ensure that people’s health is a greater priority than corporate profit:  "Ultimately, it's clear that health care is not something that can be efficiently provided by the private sector. The rest of the Western world has figured out that health care is a right and is intrinsically a government, public-sector activity.”

Don McCanne, in his Quote of the Day,  provided that link on August 22. And then, on August 23, a profound and direct commentary from the editors of the Des Moines Register, “Editorial: Government should not rely on private insurers”:

“Americans’ access to health insurance should not depend on the profit margins, business dealings, or mergers of for-profit companies. Not in Medicare. Not in Medicaid. And not in exchanges created by health reform law. Instead of funneling tax dollars to private companies, government is better equipped to administer insurance. It is not beholden to stockholders. It does not seek to turn a profit. And it will not abandon the responsibility of providing health coverage to Americans.”

Professor Reinhardt and those editors are right. Our souls are certainly in jeopardy. And so are our pocketbooks. And so is our health.