More important than our circadian rhythm: Creating a society that is safe and has health care for all

The New York Times, in addition to covering world and local news, has a lot of “feature” type news, generally appealing to educated, urban, and often higher income people, especially in New York, who are a large percent of its readers. Obviously its Arts coverage reflects the enormous NY arts scene, but also frequently seems to be more in-depth, designed to appeal to an even smaller group. Similarly, while its health coverage often includes news and opinion pieces on the social inequities in health care, on community risks (such as gun violence), and on policy issues, it also includes pieces aimed at what might be called “individual health self improvement”, sometimes involving new(ish) research.

An example is the recent front-page piece on “Circadian Medicine”, that reports on research about following our “body clocks” to get the greatest health benefits from how we do things like eat, exercise, etc. It starts with a look at the effort to move toward permanent daylight savings time and how this affects our personal and work lives.  Of course, this is ultimately a sociocultural issue; the amount of light and dark each day is unchanged, but the question is when our particular area decides to do things. Farmers and ranchers, for example, do not work based upon the time it says on the clock. If we wanted to, we could work from 9 to 6 instead of 8 to 5 rather than changing the clocks.

What is actually more important about this piece, to me, is that it goes on to emphasize how individuals can (possibly) improve their health by choosing the correct time of day to do their health-inducing activities. It is thus yet another effort to look at what each of us can (provided we have the education, autonomy, money, and time) do to make our individual selves healthier. Maybe. Such emphasis is not wrong per se (except, of course, when it is wrong, as has been, for example, our obsession with taking vitamin supplements when we are not vitamin deficient, as see F. Perry Wilson on Medscape, “It’s official: vitamins don’t do much for health”). The real issue is that it is a distractor, in that it focuses upon something that is perhaps slightly beneficial for some people (or not) but will not have a major impact upon the health of the public or the populace, taking our attention away from focusing on the very many major serious things that do have a significant effect upon the health of the public, and that we, as a people, could do something about.

 Like what? Let’s start with some data that should be scary: Among wealthy countries, the US is the only one that has seen a leveling-off and decrease in life expectancy, as reported by “Our world in data”. I have reported on this trend several times previously (Lower life expectancy in the US: A reflection of racism, classism, and social inequity April 29, 2022, Decreasing life expectancy in the US: A result of policies fostering increasing inequity, November 29, 2019) and examined some of the various proposed explanations. Case and Deaton, among others, suggest that the increase in the death rate (particularly among less affluent whites) are “deaths of despair”, mediated through the use of substances (alcohol, tobacco, opioids and other drugs). No doubt these are major contributors, but there are also others. One that has many people very concerned, as it should, is the ubiquity of gun violence in the US. This is a major contributor to death rates in populations such as young males, where suicide and homicide are very important causes of mortality. Most of us can reel off the names associated with major episodes of mass shootings, especially school shootings like Columbine, Sandy Hook, and Uvalde, but these are the tip of the iceberg. An interactive story in the Times documents the 63 “mass shootings” (four or more people shot) in May 2022 alone, and there were 65 in June, and 25 in July -- and as of only July 8 when this was published! And this does not count the many more deaths where “only” one to three people were killed! In the wake of Buffalo and Uvalde, Congress finally passed a very weak gun law. It did break an impasse, but in the minimal amount of restriction it places on gun ownership and carrying, it reinforces the idea that “America is a gun”, as in Brian Bilston’s poem. Any other country with only one major mass shooting has reacted much more dramatically and effectively. While articles continue to appear, such as the Op-Ed of Patti Davis describing the reaction (in her) and lack of reaction (in the nation) to the shooting of her father, Ronald Reagan, 41 years ago, we still are in thrall to the gun lobby and to folks who truly believe that they are at risk if they don’t have and carry guns that they make it easy for those who are going to create major violence and death.

And what about when we get sick? We – Americans – are as a group less able to access care than people in those other countries because we don’t have universal health insurance or access. Dr. Aaron Carroll, in an Op-Ed on July 7, emphasizes the impact of health insurance deductibles, noting that it is not just the uninsured but the underinsured, for whom deductibles are a major obstacle (along with other inappropriately-designed out-of-pocket payments) who suffer from not being able to access medical care, especially in time. The numbers that he cites for deductibles, and for co-payments and co-insurance, are amazingly high, as is the impact that it has on the health of those affected. For example, “The good news is that the A.C.A. limits these [out-of-pocket expenses] in plans sold in the exchanges. The bad news is that they’re astronomical: $8,700 for an individual and $17,400 for a family,” and for people in Medicare drug plans “a simple $10 increase in cost-sharing, which many would consider a small amount of money, led to about a 23% decrease in drug consumption.”

The fact that it is the Medicare drug plan (Part D) that is cited here is not coincidental; it, along with both Medicare Advantage (Part C) and the newer REACH (formerly DCE) program implemented by CMS (the Center for Medicare and Medicaid Services) are the portions of the Medicare program focused on providing profit to investor-owned companies rather than health care to American seniors. A recent report by the Urban Institute on Geographic Predictors of Medical Debt, in Health Justice Monitor, shows, unsurprisingly, that those areas with the highest concentration of poor, uninsured and underinsured people, and people with chronic diseases have the highest level of debt. And the lowest level? Those areas with the highest concentrations of people over 65. This, of course, is the only part of the general US civilian population that has essentially universal health insurance, despite the efforts of the programs above to decrease or dilute it. Although this seems worth mentioning, the Urban Institute did not; maybe they thought it was obvious.

But in this country nothing is obvious to most people and needs to be pointed out.  This includes our legislators, federal and state, to whom often the only thing that seems obvious is who is contributing to them. With all respect, we need to be focusing less upon our body clocks and circadian rhythm and more on the things that made a real difference in our nation’s health.

We need to decrease the availability of semi-automatic guns with high-capacity magazines. We need government policy focused upon creating well-paid, good-benefit jobs that will decrease “deaths of despair” rather than maximizing corporate profit. And we need high-quality universal coverage and access to health care for all our people. What we do not need are more programs like Medicare Advantage, Medicare Part D, and REACH that channel public tax dollars to private enterprises as profit.

What we do need, we needed long ago, and we need it now.

Fake news, fake facts, and fake science: making stuff up to justify hurting people and the planet

The flood of “fake news” threatens serious damage to our society as surely as floods have recently destroyed much of the Caribbean and coastal US or fires have burned up much of Northern California. While it is President Trump (whom I call the #Trumpenik, from the Yiddish “trombenik”, a lazy person or ne'er-do-well; a boastful loudmouth) who uses the term most often, in fact it is he and his allies who create most of the falsehoods. A central and terrifying one is the denial by the President and his EPA of global warming, certainly linked to the increase in horrific storms and fires, and the counter-scientific efforts of his administration to make it worse by increasing the burning of fossil fuels and refusing efforts to contain climate change despite the fact that it is “Trump country” that is supplying much of our nation’s alternative energy. 

Key to this fake news is the use of “fake facts” to support reactionary political agendas. While these agendas are mostly about making more money for the richest people and corporations rather than the middle and working-class Americans who support them, they also exploit a bizarre antipathy toward science among a good hunk of our population. (One explanation is that science sometimes reveals facts that are incompatible with pre-existing beliefs, so we reject them. However, the Catholic Church finally got over its opposition to Galileo, so maybe there is, eventually, hope.) Indeed, these people don't oppose all scientific facts, but rather those that make them uncomfortable despite being true. This is suggested by the efforts to manufacture false “scientific” facts to buttress social agendas. A prominent example is the use of “fetal pain syndrome” to justify efforts to limit access to abortion, particularly in the second trimester. The flaw here, of course, is that the evidence for fetal pain is slim to none, certainly before the third trimester, as shown is several reviews of the literature, and discussed at length in this article in Popular Science. LiveScience.com notes that “The American College of Obstetricians and Gynecologists (ACOG) said it considers the case to be closed as to whether a fetus can feel pain at that stage [20 weeks] in development.” Of course, while the number of people who would change their positions on the availability of second-trimester abortion if they believed that the fetus experienced pain during the procedure would be small to minimal, it provides a convenient, if false, cover for efforts to restrict access, including a House bill that passed just this month in Congress.

This use of fake facts and junk science has recently been expanded beyond restricting abortion to efforts to limit access to contraception for women. Let’s get this completely straight: access to contraception has been a terrific thing. It has given women – and men – much greater control of their reproduction, dramatically reduced the incidence of unintentional pregnancy (although this still remains far too high), and, duh!, even reduced the incidence of abortion. While the decision to use contraception should and does remain up to the individuals involved, it needs to be easily available to them. Thus access is critical. For many – including but not limited to teens – access is, instead, very limited, and there are ongoing efforts in Congress and in many states to further restrict it. Particularly onerous and vile is the effort of the Trump administration to roll back the ACA’s mandate for insurers to cover birth control, pandering to the religious right.

A terrific piece by Aaron Carroll on October 10, 2017 in the NY Times, “Doubtful science behind arguments to restrict birth control access”, details and refutes the bogus claims made by those who want, bizarrely, to do so. These include the idea that access to contraception has not reduced unintended pregnancy (it absolutely and most assuredly has, and greater availability would further reduce it). The Trump (and at the time, Tom Price-led) Department of Health and Human Services used cherry-picked and archaic data to support its tortured argument. Carroll notes that “In 2011, the unintended pregnancy rate hit a 30-year low. And the teenage pregnancy rate and teenage birthrate right now are at record lows in the United States. This is largely explained by the use of reliable and highly effective contraception.”

HHS also argues that there are health risks, especially from hormonal contraceptives. There are, of course, but there are health risks and side effects from any drug treatment, and the risk of harm from the treatment has to be weighed against the probability of benefit. Ironically, in the care of hormonal contraception, the most significant side effects (both symptoms and even blood clots) are similar to (if generally less severe than) those from the condition contraception is designed to prevent – pregnancy. That is, not using contraception because of concern about these side effects and then getting pregnant increases the risk of these adverse events!

The bugbear for religious conservatives in this debate is their fear that contraceptive availability will increase people – especially teens -- having sex, but for the rest of us the concern is how this would impact the unintended pregnancy rate. Carroll cites a “2016 study in The New England Journal of Medicine showed that the unintended pregnancy rate among women who earn less than the federal poverty line was two to three times the national average in 2011. An earlier study showed that in the years before, that rate was up to five times higher.” From a cost point of view, the study’s author, Jeffrey Peipert, notes that “Every dollar of public funding invested in family planning saves taxpayers at least $3.74 in pregnancy-related costs.” For women (and their partners), especially those who are low-income or teens, the direct cost for contraception is sometimes prohibitive, especially for the most effect type of contraception, long-acting reversible contraception (LARC), IUDs and hormonal implants, that have a high one-time up-front cost. It is the programs to make these more affordable and available are exactly the ones being targeted for major cuts. And, in the “adding insult to injury” department, the justification for cutting some programs is sometimes the existence of other programs, which are also being targeted for cuts!

The use of junk science, sadly but unsurprisingly, is not limited to contraception, abortion and even climate change. In a Viewpoint piece published in JAMA, October 10, 2017, “Flawed theories to explain child physical abuse”, John Leventhal documents a new trend in legal cases of child abuse. Defense attorneys bring in “medical experts” who testify that something else could have caused the child’s injuries. These include real diseases that could cause the findings but are both uncommon and can be ruled out with proper workup, real diseases that are very uncommon and unlikely to cause the findings, and essentially made-up conditions to explain the findings. Since child abuse is generally not a controversial area (nobody claims to be in favor of it!) the reasons for this seem to be mainly personal gain – such “experts” make big money for this testimony. There are not that many real experts in child trauma willing to offer absurd pseud-explanations for the injury, so there will be fewer of you willing to testify in defense of the perpetrators, so you again stand to make a lot more money.

In any case, the use of fake or fraudulent science and fake facts to support political agendas is one of the many bad things growing in the fertile “don’t try to tell me the facts” environment in Trumpian politics. The administration is now allied with “traditional” Republicans to facilitate rape of the planet in pursuit of gains for the wealthiest, and with “populists” in pursuit of social repression. There is some irony in that these advocates for “freedom” (e.g., from gun control) are so intent on denying it to others (e.g., gays, women, poor people, children), but apparently this is a long-standing US tradition (see: slavery), which inspired Abraham Lincoln’s famous quote “Those who deny freedom to others deserve it not for themselves,” There is also irony in the pursuit of the cloak of (fake) scientific facts to facilitate an anti-scientific agenda.

But the irony is not nearly sufficient satisfaction to mitigate the terror.  

Insurance coverage and access to care in the US

In the New York Times’ “Upshot” of October 24, 2016, Dr. Aaron E. Carroll discusses “Why the U.S. Still Trails Many Wealthy Nations in Access to Care”. He notes the increase in insurance coverage of the American people since Obamacare, but also that insurance coverage is not the same as access to care. He cites the most recent Commonwealth Fund survey of international health systems to demonstrate that, compared to most of the other ten wealthy countries that were studied, Americans have greater difficulty getting an appointment and being seen. (Canada is worse than the US in many of these measures, but not all; see discussion below.) Indeed, he also notes that when the populations of these countries are divided up between above-average and below-average incomes, the folks with below-average income in most of these other countries have better access than the above-average in the US.

A major reason that Carroll cites for the poor access is the low percent of primary care physicians in the US, a fact supported by data from the Organization for Economic Cooperation and Development (OECD, the “rich countries” group). It is true. There are not enough primary care doctors -- family physicians and general internists and general pediatricians -- to meet the access needs of the people of this country. There are plenty of excellent specialists; in fact, in many major metropolitan areas there are too many of them, sometimes leading to too many interventions that both increase the cost to the system and the risk to patients. Traditional “supply and demand” economics would suggest that limits on demand would force a constraint on the number of specialists, but it hasn’t happened yet; none of them are starving. This is because, in medicine, supply often drives demand rather than vice versa. When are people finally getting enough procedures, and when does it cross into too many? People don’t understand medical care, what is “good” for them and what is “too much”, much less the cost-benefit ratio. Indeed, doctors usually do not. But they do know what they know how to do, and that it will make them money.

This is a major area that having sufficient primary care physicians would help. If everyone has a family doctor that they can trust, whose income is not tied to procedures or referrals, they can help you to understand these complex issues. But there are far from enough; less than 30% of doctors in the US are in primary care, compared to 50%+ in other wealthy countries, and that is dropping as fewer students choose primary care careers. Many reasons for this are cited by studies (the culture of academic medical centers, status, work-life balance, etc.) but the real bottom-line reason is the bottom line: primary care physicians earn way less than most other specialists. Not just a little, but often half or a third as much as the highest paid specialists. Pay for primary care is going up with demand, but 10-15% increases will not change specialty choice; between income increases for primary care and decreases for specialties (heaven forfend!) the ratio needs to be at least 70%. Specialists know this; they want primary care doctors to do all the things that they themselves are not able or don’t want to do for their patients and are not opposed to primary care salaries going up -- although of course they themselves don’t want to see their own incomes go down.

Getting the care you need is a combination of having enough providers for you to be able to find and get in to see, and adequate coverage. Insurance, as we have long seen even before Obamacare, is not all the same; there is good insurance (although hardly, any longer, great insurance) and lousy insurance, and there is no insurance that is both cheap and of high quality (although, again, there are plenty of plans that are costly and of poor quality). Premiums are the tip of the iceberg; deductibles (how much you have to pay out of pocket before your insurance kicks in), co-pays (how much you have to pay each time you access care), co-insurance (what percent of “covered” care you have to pay) also impact on out of pocket costs. As, of course, does the overall cost of care (by providers) and drugs (by drug companies), and what services are not covered by your insurance.

As an example, if you are over 65, try figuring out what plan to buy for your Medicare Drug Coverage (“Part D”). There are the monthly premiums. And the deductibles. And the co-pays. And those vary by type of drug (generic vs. brand-name, preferred vs. non-preferred), and sometimes they are by a fixed $-per-prescription amount and sometimes by a percent. And if you order by mail it is different. On the bright side, most vendors offer you a calculator into which you can put the drugs you take, and it puts it all together and tells you which is cheapest for you. Until, of course, the drugs you take change.

This is insane, of course, but only if you happen to care about what works best for actual people, and not what makes the most money for private for-profit companies like insurers. Drew Shenaman, cartoonist for the Newark Star-Ledger, in the accompanying editorial cartoon, makes it very clear what the real reason is that insurers are pulling out of Obamacare. Their interests are not our interests. Surprise!

 

So we have excellent quality medical care available in the US, if you are geographically and financially able to access it, except sometimes it is not needed and done anyway. We have too many doctors in some specialties and far too few primary care doctors, and even they are not distributed well across the US. We have insurance companies that are focused on making profits, rather than on providing access, and sell complex, difficult-to-understand products that often have a “gotcha” at the point when we are most vulnerable. While access to appointments may be a little better in the US than in Canada (but not other countries), cost to the individual is way higher in this country than in Canada; access to care has both financial and non-financial components.

Not everything can be reduced to dollars, but a lot can. The money spent on health care in this country should be spent on providing health care, not on profit for insurance companies, providers, drug companies, and the like. If private insurance is to be part of the system, it needs to be non-profit and highly regulated. There need to be more primary care doctors, and the way to make this happen is for them to get paid much closer to the same amount of money for the work that they do as other specialists. Medicare can and should lead the way on this. Physician distribution should be fixed by augmenting the incomes of doctors in rural areas, not punishing them. None of this guarantees quality care, but without it quality is a pipe dream.

Obamacare was good insofar as it went. It didn’t go far enough, and now we need to fix it.