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.

Flint, lead, medical heroes, O-rings and guns

In January, 1986, 73 seconds after lift-off, the space shuttle Challenger exploded, killing all 7 astronauts on board, including one of the first civilians to go up, New Hampshire teacher Christa McAuliffe. It was a disaster; indeed the words are now paired so that we always say “Challenger disaster”. The cause was a flaw in the design of the solid rocket boosters (“SRB”s) and in the now famous “O-rings”, flexible rubber seals, like max versions of the ones we see on a lot of home tools. It was perhaps the worst domestic disaster of its time, nine years before the 1995 domestic-terrorist white-power bombing in Oklahoma City, almost 16 years before the attack on 9/11. It was a disaster in two ways; the obvious one, the explosion, and in that it could have been prevented; NASA and the company that produced the SRBs, Morton Thiokol, knew about the problem.

Morton Thiokol engineers, and particularly one named Roger Boisjoly, had been worried about the problem for years; Boisjoly had expressed his particular concerns in 1985. Morton Thiokol managers considered telling NASA to scrap the launch, and then decided not to. After the disaster, Boisjoly testified before a commission about the problem, and about the warnings that he had sent to his bosses. In 1988 he was awarded the Award for Scientific Freedom and Responsibility by the American Association for the Advancement of Science. He was shunned and at Morton Thiokol, and resigned. He was right; Morton Thiokol and NASA were wrong, and it led to a disaster. And he was out of a job.

In 2014, Michigan Governor Rick Snyder appointed an emergency manager named Darnell Earley, for the bankrupt city of Flint. One of his cost-cutting measures was to stop buying treated Lake Huron water from the Detroit system and instead supply water from the Flint River. The river was full of corrosives, from decades of industrial discharge, and one effect was to degrade the old lead pipes in many Flint homes, dramatically increasing the lead levels in the water. And in the bodies of Flint’s children. The politics of the decision are continuing to play out, with calls for Snyder’s resignation, and it would have been corrupt and evil even if the problem had been identified and remedied earlier. It wasn’t, and thus became a disaster. Good piece on it in Rolling Stone.

Again, we have a hero, a Flint pediatrician named Mona Hanna-Attisha. Dr. Hanna-Attisha had heard that a team from Virginia Tech had found high lead levels in Flint’s water, and noted that she was seeing a rise in the number of children with high lead levels. She led a team doing “the easiest research project I have ever done”; because Medicaid requires children to be tested for lead at 1 and 2 years of age, she was able to compare the prevalence of high levels from 2013 to 2015.  The percentage of children with elevated lead levels “doubled in the whole city, and in some neighborhoods, it tripled. And it directly correlated with where the water lead levels were the highest” she noted in an interview on “Democracy Now”. She announced it at a press conference, and was immediately attacked by the powers-that-be (I call them the “PTB”); in this case both the political leaders of the state and the state health department.

Well, that evening, we were attacked. So I was called an "unfortunate researcher," that I was causing near hysteria, that I was splicing and dicing numbers, and that the state data was not consistent with my data. And as a scientist, as a researcher, as a professional, you double-check and you triple-check, and the numbers didn’t lie. And we knew that. But when the state, with a team of like 50 epidemiologists, tells you you’re wrong, you second-guess yourself. But that lasted just a short period, and we regrouped and told them why, "No, you were wrong." And after about a week and a half or two weeks, after some good conversations, they relooked at their numbers and finally said that the state’s findings were consistent with my findings.

There is a long and distinguished tradition of doctors making breakthrough discoveries that helped cure or prevent disease in thousands or millions of people. Some of the most storied are Edward Jenner, the 18^th century physician who invented the vaccine to prevent smallpox, 19^th century physicians John Snow, who discovered that the contaminated water from a particular pump in London was the cause of a cholera outbreak, Ignaz Semmelweis, who showed that doctors washing their hands could prevent deaths in post-partum women, Rudolf Virchow, the “father of social medicine”, who showed an outbreak of typhus among miners was the result of the social conditions they lived in, Louis Pasteur, Robert Koch, and Joseph Lister who proved that germs caused those diseases, and 20^th century doctor Jonas Salk, who found the vaccine against polio. Does Mona Hanna-Attisha’s work rise to this standard?

Well, it may not in terms of the total lives saved, although it is worth noting that, like the work noted above, it is about public health, about populations, not individual interventions, and thus has a great impact on so many (despite the fact that in the US at least 95% of all “health spending” is on individual medical care, not public health). But she is heroic in that she stood for the truth and for the health of the children in defiance of the powerful who were trying to minimize or cover up the problem, and who tried for a while the “best defense is a good offense” strategy of attacking her, shamefully. Indeed, this is what it takes to be a hero, to not only do something important that has an impact on many, but even more to do it when you have to stand against the establishment, the PTB, the powers-that-be. This takes a great deal of courage, as well as commitment.

In Kansas, the legislature legalized concealed-carry of guns a couple of years ago, but exempted schools and hospitals until July 2017. As that date approaches in 18 months, there is little indication that the exemption will be extended, and there is great concern. A recent survey found that 70% of faculty and staff at the 6 state Regents universities oppose the law. Faculty are worried about telling students that they are failing them while they sit in their offices armed; doctors worry that if a crazy person pulls a gun in clinic, several others will draw down and make it more dangerous, police worry that they won’t even know who created the original threat. The data shows that there is a real risk of more homicide with more access and carriage of guns; “natural studies” of homicides showed a marked increase after Missouri eliminated its permit laws in 2007 and decrease after Connecticut tightened its laws after Sandy Hook.[1] [2] Moreover, 60% of gun deaths are suicides, and these are also dramatically decreased by making guns less easily accessible.[3]  Doctors and researchers need to speak out about the public health implications of easier access to guns. Luckily, many are; others are worried that perhaps the notoriously-vindictive Kansas legislature may respond by cutting funding for the university. These people will not become heroes, but they may keep their jobs and their funding.

Being a whistleblower is not easy. It is not a way to have a calm, peaceful life. Some folks have made a lot of money and retired far from those they blew the whistle on, but many more I know of are, like Roger Boisjoly, are shunned, forced out of their jobs, threatened, and may even suffer PTSD. It is not easy to take on the PTB. Better to work in their interests; for his great work as emergency manager in Flint, Darrell Earley has just been named emergency head of the Detroit Public Schools!

The full impact of the Flint lead-poisoning disaster is not yet known, because the full impact of these elevated lead levels on the brains and bones of Flint’s largely poor and African-American children will take years to take their toll. Even then, and even if, because they are treated the damage is limited, we will never know what kid who grew up seemingly ok and normal might otherwise have been brilliant.

She might have become a doctor, maybe even a heroic one like Dr. Hanna-Attisha.

---

[1] Rudolph, KE et al., Association Between Connecticut’s Permit-to-Purchase Handgun Law and Homicides Am J Public Health. 2015;105:e49–e54. doi:10.2105/AJPH.2015.302703

[2] Webster D, et al., Effects of the Repeal of Missouri’s Handgun Purchaser Licensing Law on Homicides, Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 91, No. 2, doi:10.1007/s11524-014-9865-8

[3]  Crifasi CK et al., Effects of changes in permit-to-purchase handgun laws in Connecticut

and Missouri on suicide rates, Preventive Medicine 79 (2015) 43–49

Medicaid expansion: Is there something the matter with Kansas?

One of the key parts of the Affordable Care Act’s (ACA) effort to cover most Americans was the expansion of Medicaid to cover everyone under 138% of the federal poverty level (FPL). The Supreme Court decision in 2012 (National Federation of Independent Business v. Sebelius) found in favor of the “individual mandate”, allowing the law to go forward, but found against the ability of the federal government to withhold all Medicaid funding from states that did not expand Medicaid. This decision did not prevent the federal government from creating an incentive for states to expand Medicaid, which it did; for the first 4 years the federal share of cost of expansion would be 100%, dropping to 90% thereafter. This is quite a financial incentive, and as of December 15, 2015, 31 states have expanded Medicaid, 4 are considering it, and 16 are not, depicted on this map from the Kaiser Family Foundation (KFF).

Neither of the Kansas City area states, Kansas and Missouri, are in the expansion group, and thus a significant portion of their population remains uncovered. Like the other 14, control of their legislatures (and in Kansas, of the governor’s office) is in the hands of very conservative Republicans ideologically hostile to ACA. However, this is a problem not only for the poor people left without insurance and their advocates (like many of the healthcare foundations), but also the states’ hospitals, who continue to have to provide care for these people without reimbursement. To some degree it is also a problem for the state’s business community because more than half of the this group of people are employed, mainly in small businesses that cannot afford to buy private health insurance. It also decreases, in the opinion of many Chambers of Commerce, the state’s ability to attract new business and jobs.

On January 5, 2016, I attended a forum on expanding KanCare (Kansas’ privatized Medicaid program) sponsored by many of these business organizations (6 Chambers of Commerce), hospitals, physician provider organizations, and healthcare foundations (see list of sponsors on KC COC site). The event, held in Overland Park in the Kansas City area, followed a similar one held in Wichita in November, 2015.  It began with a presentation by Dave Kerr, a Republican former president of the Kansas State Senate, detailing how Medicaid expansion would bring in at least 10 times what the state would have to spend. After this were two panels, one consisting of 5 KS legislators (3 Republican, 2 Democratic; 3 senators, 2 representatives), and the other of 5 healthcare experts.

Prominently included in the second group was the president of the Indiana Hospital Association, Doug Leonard, who presented how his state had effectively expanded Medicaid. The presumption of the sponsors of the event was that this would resonate in Kansas, because Indiana is also a conservative state with a very conservative governor (Mike Pence) who had mandated the expansion based on certain principles of individual responsibility and fiscal neutrality. Indiana’s plan is one of 4 (those with asterisks on the map) that were developed with federal waivers. In its first year, it has enrolled 220,000 people into its Medicaid program, and, largely because it is paying providers at Medicare rates, increased by 1,000 those who accept Medicaid. It is paid for by a combination of increased cigarette taxes and levies on hospitals.

Unsurprisingly, this resonated well with most of the attendees and speakers, although support was not universal. Sen. Jim Denning (R., Overland Park), who is considered a health policy leader in the state senate (apparently he works for a group of private ophthalmologists), indicated that Indiana’s program would not pay for itself after the first year and would have to tap into the state general fund. The moderator asked Mr. Leonard, who drily indicated that perhaps Sen. Denning had information that Indiana did not have. When the moderator asked Sen. Denning the source of his information, he indicated “the Forbes article”. Mr. Leonard responded that, first of all, it was not an article but a blog post in Forbes, and second that the state had responded point-by-point to its incorrect assertions.  

Sen. Denning’s credibility as a source of facts was already questionable, as he had previously asserted that Medicaid expansion would affect only those between 100% and 138% of the FPL as those below 100% were already eligible for KanCare (not true; in Kansas, adults actually must be actual below about 33% of FPL, in addition to being a a special group like mothers of dependent children or disabled, to be eligible for KanCare) and that those between 100% and 138% of FPL could buy subsidized “silver” plan coverage on the exchanges for about $2.50 a month (not true; those below 138% of FPL are not eligible to buy coverage on the exchanges at all). I do not know if he misspoke or whether he believes those assertions to be true. If the latter, it is not clear whether whether those misconceptions in part inform his opposition to KanCare expansion (and thus could be changed by the facts) or if his ideological opposition informs his willingness to believe such incorrect information. However, he is a leader in the state senate, and so he is probably accurate when he asserts that the KS legislature will not expand KanCare. Other legislators on the panel, including the Republicans, indicated that such expansion would require leadership from KS Governor Sam Brownback, which the governor has not indicated will be forthcoming. One, Sen. Jeff King (R., Independence) is from the town whose hospital recently closed, at least in part because it could not count on KanCare expansion; he indicated that his father, who had had 2 heart attacks, was now 25 miles, not ¾ of a mile, from the closest hospital.

Beyond Sen. Denning, there were other concerns about the forum. Every panel member was white, and other than one state senator, Laura Kelly (D., Topeka), every one was man. Women gave the opening and closing remarks, but there were no people of color who spoke. This was obvious, but not the only important way in which the speakers (at least) and probably audience differed from the average person. One reason was that there were a lot of business leaders, because they have clout. They do, however, have a limited – and not always accurate – view of the rest of the people in this country. They seem to think that support for expansion of KanCare (and other social programs) is important until people get good jobs and get these benefits from their work (they referred a lot, disparagingly, to the “able bodied unemployed”). But where are the jobs? Job creation is supposed to be a high priority of the governor and legislature, and is the stated reason for the dramatic tax cuts of 2012 (indeed, rich people are now renamed “job creators”) but not only has job growth been slow, but it is mostly in lousy jobs – poorly paid and without benefits (eg., health insurance!). There was a great deal of talk about “retraining”, but there simply are not enough “good” jobs to employ everyone no matter how retrained they are. Their myopia may be because many well-to-do people have contact with others who are like them; in their neighborhoods, work, and country clubs. They have little insight into the real issues confronting those in the bottom 80%, not to mention 50% or 10%. I doubt they even know what the numbers are, but this article from CNN Money, with its neat interactive graph, should help; the median household (not individual) income in the US is $52,000.

I see lots of both poor and “regular” people as a doctor in the clinic and in the hospital. I live in a neighborhood that is mostly, well, working class. I see my neighbors, adults and children, on the streets when I walk my dogs. They’re trying, but it is not easy for them. Jobs are scarce, and many of those  that  they can get involve the sort of physical labor that takes its toll on their bodies and leaves them prematurely disabled. Lack of health insurance exacerbates their problems. A major recent NY Times/Kaiser Family Foundation study, reported by the NY Times, finds “Even Insured can face crushing medical debt”. Those business leaders who may think that $200K a year (for a household, most with two earners) is “middle class” should know it puts that household in the top 5% (and, for goodness sakes, in many parts of the country households making $200K are still struggling!). It would be good for them to meet with some regular folks and find out about their lives. I applaud the work that the various healthcare foundations in Kansas, many of whom co-sponsored this event, are doing. But our leaders, political, business, and otherwise, need a little reality check to leaven the ideology.

There are a lot of things that impact on whether a person is healthy besides access to health care (the social determinants of health: housing, warmth, food, education, safety, etc.). But access to health care helps. 

Tax policy, drug companies and the public's health

Tax policy is complicated. You have to figure out who to tax and how much, and how much revenue it will bring in and what you (the government) needs to spend the money on and figure out how to match it up. People of different political stripes differ with regard to how much money to spend on what, and also who to tax. For example, is it better to have more graduated income tax (a “progressive” tax, where the more you make the higher percent you pay on the incremental amount), or more “regressive” tax where everyone, regardless of income pays the same amount, like a sales tax, or a “proportional tax” where everyone pays the same percent but not the same amount, like some variations of “flat tax”?

In Kansas, for example, our Governor and Legislature have made that decision. Faced with enormous budget deficits as a result of 2012 massive tax cuts on corporations and wealthy individuals, and unable to make it all up with one-time fixes such as raiding the state highway fund (hope those corporations don’t need to transport goods on our roads), they have gone for big sales tax increases. This is because, to them, the 2012 tax cuts are sacrosanct, because they believe that this will stimulate the economy and create jobs. They believe this even though such a strategy has not worked so far in Kansas and has in fact not worked anywhere. They even brought in Arthur Laffer, the trickle-down guru economist, to address the legislature. Nonetheless, owners of “S” corporations (usually small businesses, like lawyer’s offices, or the few remaining private practice doctors’ offices) do not pay state tax on the income they make from being the owners. Their employees -- nurses and secretaries and legal assistants – do, along with the new higher sales taxes. The Governor and Legistlature have other plans as well; faced by a State Supreme Court decision to increase public school funding by a half-billion dollars or so that they don’t have (vide supra), they are thinking about not funding the State Supreme Court. Could be a solution, if they can get around the constitutional issue.

The Federal Government also has to deal with such issues. In the last 50 years our income tax policy has become less progressive, with a top rate of 35% rather than 90% when I was taking civics in junior high school. (Please note that this is not a flat tax of 90% on all of top-earners’ income, but on the marginal amount above the next lower tax rate; everyone paid the same percent on earnings up to each next bracket.) Also in that civics class, we saw that corporate income tax made up more income for the feds than personal tax. Not any more. Corporations are getting away with paying very low taxes, and with the new “global economy” taking more and more of their profits abroad, where they can avoid paying tax until they are re-patriated. To encourage them to do so, the Congress is considering legislation to create a “tax holiday”; this is where corporations are rewarded for bringing their profits home by paying a lower tax rate on them. This has been done before, and been amazingly unsuccessful. So let’s try it again. Like Kansas, why learn from experience? Why not, for example, tax those international earnings? After all, if they are creating jobs, it is not in the US.

Also like Kansas, the US has a problem with roads and other infrastructure, and the Federal Government funds much of the cost of repairs, which are unfortunately not being done. A study by the Center for Effective Government, “Burning our Bridges” notes that “To modernize our infrastructure, the American Society of Civil Engineers estimated it would cost $3.6 trillion by 2020. They warned that if we fail to make these investments, American citizens and businesses will face costs of $1.8 trillion a year in travel delays, water leaks, and power failures.” How has Congress responded? It's slashed infrastructure spending to the lowest levels since the post-WWII era.

 

 But where could we get the money? Is the amount of money not being paid by US corporations on international earnings that big? Well, there is $2.1 trillion in untaxed international income, so that could be a chunk of change. About half of it is held by 26 corporations. Apple has the most, and GE is #2. The enormously profitable pharmaceutical industry (I have previously noted that it is, each year, either #1 or, well, #1 in profit among US industries) has about $82 billion among its 7 largest companies. Given that the report is called “Burning our Bridges”, it is of interest to note that this is enough money to pay for all US bridge repair and maintenance needs.

I guess this is where the public health and medical part of this post comes in. Let’s just think about that. We have drug companies charging “whatever the market will bear” for their products; for some of the recent recombinant DNA treatments for autoimmune diseases, Hepatitis C, and cancer this can range into 5 digits (before the decimal point) a month. They try every trick in the book to keep their prices high and patents in place to prevent generic competition. Some I have addressed before include changing the formulation of the drug -- the FDA mandated elimination of fluorocarbons as propellants in inhalers was a bonanza because changing to non-fluorocarbon propellants was a “new formulation” allowing them to extend their patents. Or taking drugs used by, but not previously tested and approved for use by, children and testing them (when already, via practice, shown to be safe) in children, also extending their patents. Or in some the most offensive practices, testing drugs that have been used for generations and patenting them, thus jacking up their prices. The prime example is the gout treatment colchicine, formerly available for about 10 cents a pill and now available for $355 for 60 (about $5.20 a pill!).

In Canada, there are price controls on drugs, so they cost less. Thus pharmaceutical manufacturers try to block import (and Internet sale) of drugs from Canada. The Medicare drug benefit, (Part D) passed in the GW Bush administration, forbid Medicare from using its purchasing clout to negotiate lower prices. The new Trans-Pacific Partnership (TPP) pushed through by the Obama administration will offer more protections; corporations will be able to sue governments to ensure their profits, not in real courts but in specialized TPP pro-business “courts”. I wonder how long the price restrictions on drugs in Canada and elsewhere, not to mention the manufacture of affordable generic equivalents of high-priced HIV drugs in Brazil, India, and Thailand, will continue?

I personally am rooting for the success of the Brownback tax cuts to create jobs in Kansas. Not because I think they were good or even close to moral, or even because I think that they have a prayer of being successful, but as long as they are in place it would be nice to see some new jobs. It’s not going to happen with this state government. TPP passed, and there is no meaningful effort to either tax the international profits of pharmaceutical and other corporations, or to force drug manufacturers to make their products affordable in the US.

In their recent paper “Fantasy paradigms of health inequalities: Utopian thinking?”, Alex Scott-Samuel and Kathleen Smith note that "In a capitalist society, where liberal macroeconomic policies position virtually all economic activity – including unhealthy activity – as beneficial, there is an inbuilt incentive to ‘blame the victim’ rather than to tackle the corporate and economic causes of the problem."[1] We prefer not to regulate unhealthy activity (when we have done so, such as with making cars safer and limiting smoking, it took intensive, long-term campaigns by public health advocates), and we allow corporations such as drug companies to profiteer from our trying to repair the damage to our health. And we also let them not pay taxes, which we really need.

It's time to get serious, and hold them responsible and make them responsive.

---

[1] Scott-Samuel, A. & Smith, K. E. (2015).Fantasy paradigms of health inequalities: Utopian thinking? Social Theory & Health, advance online publication, 1 July 2015; doi: 10.1057/sth.2015.12

The Supremes and ACA: Is opposing coverage for the poor really just mean?

In the context of the historic and momentous Supreme Court decision legalizing gay marriage across the US, and its affirmation of the Fair Housing Act, the third of the “trifecta” of progressive decisions announced this week, the ruling against those who argued that the ACA forbid federal financial support of federally-sponsored rather than state-sponsored insurance exchanges, seems rather pedestrian. After all, it just decided that the intent of the ACA was to achieve what its intent was – greater insurance coverage for the American people – and this would not be invalidated by 4 poorly-chosen words in a 1,000 page bill. What is more worthy of note is that there were three Supreme Court Justices who voted against it, when it was clearly not a real issue of law but an end-run to get it invalidated on a technicality. The low point of the dissent was Justice Scalia’s juvenile characterization of the majority decision as “jiggery-pokery”, an archaic expression most recently used in the public domain in a Harry Potter movie. Of course, Scalia could make a fair Harry Potter villain; not the potent evil of Lord Voldemort, but more of a scowling, snarling Severus Snape.

But the decision has real meaning. It means that millions of Americans in the 34 states that elected to not establish state-based exchanges and thus depend upon federal ones will not lose their health insurance. That is a good thing for those people, and it is a good thing for America. It does nothing for those people who were excluded by the SCOTUS decision 3 years ago (also written by Chief Justice Roberts) that, while validating ACA, precluded requiring states to expand Medicaid. This left millions more in the states that have not done so (like mine, Kansas) without insurance.  It certainly does nothing for the millions of those without legal documentation who live here, or the many others who fall between the cracks of the law. It still leaves us without the moral, medical, social, and economic advantages that come from a truly universal health system such as any of those adopted by every other wealthy nation, which achieve better health for less cost (see graphic). But it does make us seem slightly less cruel and benighted.

Not that this will end the discussion. A small article in the New York Times of June 27, 2015 notes that “Legal challenges remain for health law”.  These include a lawsuit by House Republicans led by Speaker John Boehner maintaining ACA is invalid because it spends money not appropriated by Congress, and a series of suits by religious organizations about the law’s requirement that they cover contraception. Indeed, the whole opposition to the law has becoming akin to a religion itself; according to its opponents (obviously also including all the Republican candidates for President) it is bad as a matter of faith, even though it does so much good. Yes, it does good in costly ways, ensuring that insurance companies make their profit; it does it in arcane ways; it does it in ways which in fact cost some people more than they might have otherwise paid. But it provides several million people the opportunity to not be the Donna Atkins or Tommy Davis of the future (see Dead Man Walking: People still die from lack of health insurance, November 17, 2013).

In response to a blog in which I posted a map that shows that the vast majority of those remaining uninsured are in the states of the former Confederacy and suggested that while Southern people might not be meaner than others, the impact of their policies was (Medicaid expansion and uncovered lives: are people meaner in the South?, February 8, 2015), Bobby Cohen wrote in a comment “If meanness doesn't explain the rejection of Medicaid expansion by Southern states, what does?” Well, for many people, I suppose, it is ignorance, of the sort demonstrated by “Keep the government’s hands off my Medicare!” or what I have called the “Craig T. Nelson fallacy” (“I've been on food stamps and welfare. Anybody help me out? No. No.”!!). Or the beliefs of some of the people in southeast Kansas interviewed for Kai Wright’s excellent article “Life and Death in Brownback’s Kansas”, published in the June 22/29 issue of The Nation where it seems that “Everyone is convinced that someone else is getting a better deal, that somewhere a horde of Kansans are gaming the system and preventing the truly needy from getting help.” In a true “What’s the Matter with Kansas”[1] illustration, even the doctor at the community health clinic who is fighting hard to get care for her impoverished patients who would have otherwise had Medicaid is conflicted; Brownback, after all, is a strong anti-abortion advocate, as is she.

All of these may explain some of the position of the leaders of this movement, but a better explanation can be found in the answer to one of the questions in “Steven Pinker’s Mind Games”, a psychology quiz on the NY Times website: “the best liar is the one who believes his own lies”. But it is hard to look at, not to mention listen to or read, the hard-core right-wing justices on the Supreme Court (who, unlike the GOP’s many presidential candidates are not even running for office) without thinking that they are, essentially, mean. They are not only against helping people when it will cost them, not altruists (another Pinker question), but even when it will save them money (again, see graphic).

I do not claim to be a legal scholar of the status of any of the Supreme Court Justices, or indeed the President. I gained some understanding from “The elusive right to health care under US law”, by Prah Ruger, Ruger, and Annas in the June 25, 2015 issue of the New England Journal of Medicine, published before any of these SCOTUS decisions were announced.[2] It’s a good and readable article which helps medical people like me understand some of the logic of court decisions. One line I found of particular interest was “American constitutionalism has championed negative liberties more than positive rights.” The idea is that the Constitution says government should not be allowed to take away our individual liberties (e.g., our guns) but not so much that we have a right to things (e.g., health care).

And yet, as pointed out by Gail Collins in “Supremes hit a high note”, this Court has “…destroyed the nation’s campaign finance laws, limited workers’ rights to challenge wage discrimination and women’s rights to control their bodies. And basically disemboweled a 50-year-old Voting Rights Act that Congress had renewed by increasingly large margins on four different occasions.” These decisions, almost all of which came out differently from those of the last 2 days only by the “swing vote” of Justice Kennedy (Chief Justice Roberts did join the majority in the decision on ACA), do not always follow this logic. It is quite an extension of the idea of liberty to say that corporations are people (the founders certainly didn’t think so) or money is speech. It is quite opposite protecting individual liberty to have laws limiting the ability of women to obtain contraception or abortion (although they can sure have guns!). Whether put forward by ignorant bigots, self-serving politicians, or sanctimonious Supreme Court Justices, the concept is most consistently “people should be allowed to do whatever they want, as long as they want the same things I do, but not what I disapprove of”. Sometimes, particularly when describing the actions of the powerful, this is described as political. But I think Dr. Cohen is right; it is essentially mean.

A phrase we commonly hear is that “mean people suck”. They do, but more important, when they have positions of power, they can do a lot of damage to others.

  

---

[1] Thomas Frank. “What’s the matter with Kansas?”. Henry Holt. 2004 [interestingly, published in the UK and Australia under the title “What’s the matter with America?”!] ISBN 0-8050-7339-6.

[2] Jennifer Prah Ruger, Ph.D., M.S.L., Theodore W. Ruger, J.D., and George J. Annas, J.D., M.P.H., The Elusive Right to Health Care under U.S. Law, N Engl J Med 2015; 372:2558-2563June 25, 2015DOI: 10.1056/NEJMhle1412262

Cost of health care increases poverty around the world, and in the US

The title of the press release from the World Bank, “New WHO and World Bank Group Report Shows that 400 Million Do Not Have Access to Essential Health Services and 6% of Population Tipped into or Pushed Further into Extreme Poverty because of Health Spending”, about says it all. Or does it? Certainly, it summarizes the core information provided by that study, and that is pretty bad. Even in a world whose population this year reached 7 billion that is a big number (nearly 6%), and remember that it is talking about “…essential health services—including family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation.” This is not coronary artery bypass surgery (as essential as that seems to those of us who need it), or knee replacement (which may make it possible for us to walk with less pain), or even tight control of our diabetes (possibly less prevalent in populations that are chronically malnourished), still less entirely elective care.

We are talking about access to clean water and sanitation. We are talking about the fact that the greatest cause of death in the world is water and that most of those deaths are in children. We are talking about the absence of the most fundamental aspects of access to health, not to mention health care and medical care.  While not a focus of the World Bank report, in many places war makes it worse, adding to the lack of basic services an extraordinary need for major medical care. In his New York Times Op-Ed piece of June 21, 2015, Nicholas Kristof describes the chilling war being waged by the government of Sudan against its own people in the Nuba Mountains, with daily bombings of civilians. He describes the deaths and maiming of children, and the inadequacy of even the most committed physicians to help in the atrocious conditions that exist there. An 8-year old boy, who had just lost several siblings to the bombing, “showed extraordinary courage,” the lone doctor at the hospital remembers, “but he would scream every day from pain as his dressings were changed.” While he “persevered for weeks”, “flies were laying eggs in his wounds, and soon the burns were crawling with maggots. Dr. Catena says that he would cut out the maggots, and the next day more would return.”

Yes, most of these 400 million are not in the US, are in developing (a euphemism, perhaps) countries. But in the US there is great need also; every day in our cities we see people who have not had access to TB or HIV treatment, who have delayed care because they are uninsured and cannot afford the cost, until they are so sick that their treatment costs far more than it otherwise would have. We see women who do not come for antenatal care until very late in their pregnancies if at all, missing the chance to discover and treat relatively minor problems until they become major. Fortunately, it is uncommon in the US for them to not receive “skilled birth attendance” since the law requires hospitals to provide care when women come in in labor, but they often appear with no records of whatever prenatal care they may have had. An excellent post on the blog of Medical Care Section of the American Public Health Association (unfortunately, access is limited to APHA members), “For Medicaid enrollees, a choice: PCP or emergency department?”, by Sandhya V. Shimoga, describes the problems that Medicaid patients, particularly those newly covered by Medicaid expansion in those states that have done so, in finding primary care providers; they continue to have to use the ED instead, often (again) with conditions far worse than they would have otherwise had. This, of course, does not count the largely insured people in the US who elect not to immunize their own children, secure in the knowledge that most other people are and that they will have access to care if anything does go wrong. Which it often, by the way, does.

And then there are states like mine, Kansas, that have chosen not to expand Medicaid, so that people similar to those Shimoga describes in Oregon and California do not even have a choice. The people of this state, once proud of its education and health care, have seen their rate of uninsurance increase relative to the states which have expanded Medicaid (Kansas only state to increase number of uninsured: A how NOT to do it strategy, August 9, 2014). The “solution” backed by the Republican Party and state governors such as Kansas’ Governor Brownback, is to further decrease the number of insured people by suing on a wording issue in the Affordable Care Act (ACA, “Obamacare”) that might invalidate the federally-run insurance exchanges which have allowed low-income-but-not-desperately-poor people in states like Kansas to gain insurance coverage.

This is a bold strategy, likely to work as well as Governor Brownback’s experiment in reducing taxes on the wealthy and businesses in 2012, which left the state with an $800 million budget deficit this year (on a budget of only about $8 billion). Half was replaced with one-time funds (eg, raiding the state highway fund) and the other half, after a marathon legislative session that ended a month late, with the largest tax increase in state history. However, these were all regressive taxes, mainly a sales tax increase, that hurts the poor and middle class; the 2012 cuts stayed in place for the wealthy, so I guess in that sense it did work. Business pays less tax, and if you own your business (say, self-employed lawyers or doctors) you pay no state income tax although your employees do. Kansas spends less now than neighboring Nebraska, which has 2/3 as many people. Now if we can only get rid of those federally-sponsored exchange so even more people will be uninsured…

The World Bank report calls for universal health coverage. “The world's most disadvantaged people are missing out on even the most basic services," says one official, who adds that a “... commitment to equity is at the heart of universal health coverage.” The report said that 17% of people were pushed into poverty (<$2/day) and 6% into “extreme poverty” (<$1.25/day) by the cost of emergency health care. Few Americans make anywhere near that little, but the cost of living, and of health care, is much higher and the same trend exists here; medical expenses are the largest cause of personal bankruptcy (see Fox Business’ 2014 report).

“As more countries make commitments to universal health coverage, one of the major challenges they face is how to track progress,” says another World Bank official, commenting on the study. Of course, if a country, such as the US, does NOT make a commitment to universal health coverage, this is not a problem.

Except, of course, for the people without health care.