RFK, Jr.: The Secretary of Health and Human Services is Dangerous to Your Health!

It can sometimes seem like the public health and medical communities are “ganging up” on Robert F. Kennedy, Jr., with ongoing criticism and attacks on his beliefs and, more important, his policies. The rebuttal is that this man, whose thinking is wildly unscientific and fringe, is the incredibly powerful Secretary of Health and Human Services, in charge of the second biggest department in the US government (after Defense) in budget and staff, and responsible for the diverse, varied, and highly important components of that department. These include Medicare, the health insurance system for the aged and disabled and Medicaid, the federal/state partnership that provides insurance for many low-income Americans (mostly children and their mothers in number, mostly long-term care in dollars). It also includes the Centers for Disease Control and Prevention (CDC), which studies and intervenes in both infectious and chronic disease, the Food and Drug Administration (FDA) that oversees the safety and effectiveness of our – food and drugs, the National Institutes of Health (NIH) that funds and supports most medical research, and other major agencies, including the Indian Health Service (IHS) that provides health care on Native American reservations, the Health Resources and Services Administration (HRSA) that funds community health centers and many other major service delivery and educational program, and the Substance Abuse and Mental Health Services Administration (SAMHSA) that supports addiction and mental health services. It’s a big, responsible, job.

And, so, there are a lot of things that can be screwed up. And a lot things are being screwed up. By him. In part, this may be because of his general incompetence and lack of actual knowledge about health care (knowing little about their portfolio is a common thread among those Trump has selected to lead federal departments). Kennedy is not a health professional, although he is a health “profess-er” – he professes a lot of opinions.  A lot of the screw up is the result of the DOGE-created cuts of 10,000 people from the HHS workforce in all of these agencies. Some of it is the administration’s political antipathy to programs (like Medicaid) that help people in need instead of the wealthiest in society who don’t need help at all. And no small part of it is because the beliefs that he has about health that come from fringe proponents of every bizarre remedy from ivermectin (good for worms, not for COVID) to hydrogen peroxide to Vitamin A to prevent measles, and opponents of many of the health interventions that we know really work to save lives. Let’s look at some of these.

Measles is a bad disease. It causes a great deal of morbidity. I come from a generation of children who almost all had measles – and varicella (Chicken Pox) and rubella (German measles), and mumps. Most of us survived, without even being hospitalized. But some did not. About 20% (1 in 5) people/children with measles are hospitalized, which means they are very sick. From 1-3 per 1000 die. That is a lot. Not as many as currently die from, say, being shot at school, but a lot. The thing is, though, that measles is preventable by vaccine. Per the CDC:

A vaccine became available in 1963. In the decade before, nearly all children got measles by the time they were 15 years old. It is estimated 3 to 4 million people in the United States were infected each year. Among reported measles cases each year, an estimated:

·       400 to 500 people died

·       48,000 were hospitalized

·       1,000 suffered encephalitis (swelling of the brain)

 

After the vaccine, measles went from being an endemic disease to one that was essentially eliminated. Until many people stopped vaccinating their children, based on unfounded fears of side effects, especially autism, being promoted by unscientific “experts” – like Kennedy. He has commissioned a new study on the link, to be done by discredited physician Andrew Wakefield, and thus is ignoring hundreds of studies with over 3 million children that show no link! Kennedy has also promoted using Vitamin A to prevent or mitigate measles. While in countries where there is widespread Vitamin A deficiency, this is a good strategy, there is no significant prevalence of Vitamin A in the US. And taking more to “be safe” is a bad idea since Vitamin A, a fat-soluble vitamin, accumulates and causes toxicity. So now, in addition to over 700 cases and at least 3 deaths (which suggests the number of cases is an underestimate) from measles, we have children being hospitalized for Vitamin A toxicity! And measles is only one serious condition; I have written about infections in children with Hemophilus influenza B and even worse polio (Raw milk, vaccines, and RFK, Jr: Some dates worth remembering, November 15, 2024) and was reminded of its effects on a recent episode of “Call the Midwife” which featured a man in an iron lung. Let’s not bring polio back!

Kennedy has also angered many Native American tribes, simultaneously calling for greater attention to their health status (good) and cutting the programs that benefit them, as covered by the Arizona Star (RFK Jr. says chronic disease in tribes a focus as program to do that gutted). He has also made the possibly not serious but nonetheless insulting proposal to move laid-off health workers from CDC and other HHS agencies to reservations (NY Times Kennedy’s Plan to Send Health Officials to ‘Indian Country’ Angers Native Leaders).

While on many of these issues, such as opposition to vaccines, Kennedy is simply wrong (and dangerous, see the recent NY Times article The many ways Kennedy is already undermining vaccines), on others it is less clearcut, which is why his opinions get traction. For example, he advocates strongly for the importance of diet and exercise to health. Those are generally are good. Most people should get more exercise and eat more healthful foods (and fewer unhealthful ones). But that is not a panacea. A healthful diet will not prevent measles – or COVID or smallpox or Hemophilus influenza B infections or cancer – although having good general underlying health will likely make one relatively able to weather such conditions better. Kennedy employs many logical fallacies in his pronouncements, including setting up “straw men” to knock down, using misdirection to keep you from looking at what he is saying, data-dumping to overload you, appeal to (false) authority (like Wakefield), and others. Some of these are discussed in the NY Times piece, From ‘Data Dumping’ to ‘Webbing’: How Robert F. Kennedy Jr. Sells Misleading Ideas and by Dr. Jessica Knurick. “Your Local Epidemiologist”, Katelyn Jetelina, discusses the Progress on Make America Healthy Again (MAHA), his signature plan. It has made a lot of progress, although it has been in reverse, making America less healthy. For more on his strategy, check out Paul Offit, MD, of the American Council and Science and Health, who describes the RFK Jr. Playbook. And, of course, he has traded on his family name and the reputations of his father and uncle John, who would (like most of his surviving family) be outraged by his positions.

Kennedy’s ideas and actions are both unscientific and damaging to the public’s health, leading the American Public Health Association (APHA) to call on him to resign or be fired in a statement enumerating many of his most damaging actions and dangerous pronouncements. All the “charges” it lists are accurate, and serious, and he should be gone. He is a real danger to our health. But the things he has championed, his hypocrisy and sleight of hand, and the false relativism he promotes that is dangerous, would unfortunately not be likely to be better with any HHS Secretary nominated by the current President. Most of Trump’s Cabinet and other senior-level picks have been unqualified, uninterested, and incompetent at best, and evil at worst. It has been said that their only “qualification” needs to be obsequious loyalty to Donald Trump, but a serious commitment to ruining the lives of as many American people as possible also seems to be important.

And, of course, that is the intention.

Hospital charge variation and Medicare equipment fraud: two forms of gaming the "non-system"

There has been extensive coverage of the recently published report from the Center for Medicare and Medicaid Services (CMS) that revealed dramatic differences in the prices charged for medical services between hospitals, not only between regions but also within the same city. “Hospital Billing Varies Wildly, Government Data Shows”, in the NY Times May 8, 2013, reports that “A hospital in Livingston, N.J., charged $70,712 on average to implant a pacemaker, while a hospital in nearby Rahway, N.J., charged $101,945…In Saint Augustine, Fla., one hospital typically billed nearly $40,000 to remove a gallbladder using minimally invasive surgery, while one in Orange Park, Fla., charged $91,00. …In one hospital in Dallas, the average bill for treating simple pneumonia was $14,610, while another there charged over $38,000.” 

Bloomberg News notes that treatment of psychoses ‘showed the greatest price discrepancies, with the most expensive hospital charging $144,523, more than 52 times its cheapest peer,’ and the ‘most common procedure in the data, treatment of simple pneumonia and lung inflammation with complications, had prices ranging from $5,093 to as much as $124,051.’” The Kansas City Star reports, in “New data reveal puzzling differences in hospital charges”, that “… the hip replacement surgery that one hospital in Ada, Okla., charges at $5,304 cost $223,373 at a hospital in Monterey Park, Calif.,” and giving a local example, “In Kansas City, charges for that surgery range from $24,874 at Truman Medical Center Lakewood to $66,268 at the University of Kansas Hospital.”  Among the many other news sources covering this are Wall Street Journal (“Data shine light on hospital bills”), USA Today, AP,  Los Angeles Times, Washington Post, and others.  The LA Times article notes that the data call “into question medical billing practices just as U.S. officials try to rein in rising costs.”

But, of course, this information should come as no surprise; it confirms something not only well-known by hospitals and physicians for a very long time, but repeated reports by investigative journalists over the last several years. These have included  Atul Gawande’s article, “The Cost Conundrum” in The New Yorker June 1, 2009 (my blog coverage in Medicare Costs: "All Politics are Local", June 11, 2009) and Steven Brill’s February 2013 Time magazine piece “Bitter Pill: Why Medical Bills are Killing Us”, which I discussed in Squeezing the needy: a truly flawed financing system for healthcare, March 2, 2013. Hospitals’ “charge masters” list “list prices” for any number of procedures and equipment which, as noted above, vary wildly. Although Medicare performed the study, in fact Medicare does not pay those prices or anything close to them; it sets its own payment schedule for these procedures which does not vary much between hospitals. However, as Gawande makes clear in “The Cost Conundrum”, there is a second problem arising from the fact that some hospitals seem to do – and bill Medicare for – a far larger number of procedures than are done by other hospitals caring for similar populations.

So why do they have these charges and why do they vary so widely? They vary because different amounts of “fixed costs”, the expenses that hospitals have that are not for the individual patient (staff, building maintenance, equipment, etc.) are loaded into these charges, as are more or less profit. They are high because there are occasional payers (fewer all the time) who do link their payments to charges, such as Worker’s Compensation. While Reuters quotes HHS Secretary Kathleen Sebelius as saying "When consumers easily compare the prices of goods and services, (providers) have strong incentives to keep those prices low. But even basic information about health premiums and hospital charges has long been hidden from consumers. These rates can vary dramatically in ways that can't be easily explained," it is not clear that posting the prices, or having smaller differences, would be of much help to most people. 

Large health insurers, like CMS, do not pay the posted “charges”; although they pay more than Medicare or Medicaid, their payments to hospitals are usually tied to Medicare charges as a multiple (e.g., they might pay 2 times Medicare). Of course, the group that most clearly gets screwed are people with no insurance at all, who are in fact billed for the entire list charge. They are, also of course, very unlikely to be able to pay any significant portion of those charges (minus the rare sheik or hedge fund manager who might show up). Therefore, the difference between owing $24,874 to Truman Medical Center Lakewood or $66,268 to the University of Kansas Hospital for hip replacement surgery may be largely theoretical to them, but in the meantime, it can, and frequently does, absorb their life savings, ruin their credit, and throw them into bankruptcy. And there are “middle class” uninsured families who might be able to pay off $24,874 over a few years, but for whom $66,268 is more than they could pay in a lifetime. (Fortunately, most hospitals, including I know the University of Kansas Hospital, do develop payment plans for patients, which, if they make payments that are agreed on can preserve their credit.)

Meanwhile, in “Medicare anti-fraud effort has Missouri roots” (Kansas City Star May 7, 2013), Lindsey Wise, the paper’s Washington correspondent, describes how the concerns of a St. Louis physician that she was receiving requests from medical device sellers for approval of medical equipment that she hadn’t ordered, and that it turns out her patients hadn’t requested, led her senator, Claire McCaskill, to hold federal hearings. As noted by Sen. McCaskill, “Most Americans have seen ads on TV or received calls or letters promising medical equipment ‘at little or no cost to you,’”  but, as she adds, “there is always a cost to you, because it is paid for by federal tax dollars.”  Both Dr. Kennedy’s patients and others testifying before McCaskill’s committee said they often receive several calls per day from device retailers. Investigations of two companies that had faxed unsolicited requests to Dr. Kennedy discovered, respectively, a 68% and 92% “error rate”, a euphemism for what may well be fraud.

Why mention these two separate issues, Medicare fraud by medical device companies and huge charge disparities among hospitals for the same procedures, in the same blog post? While definitely different – the device sellers, at least those who are guilty of such practices (“Please don’t convict the entire industry,” says the executive director a trade association that represents medical equipment companies), are unscrupulous and perhaps committing fraud, while the hospitals are not – they share they key characteristic of seeking profit by “gaming” the system. Medicare pays for medically necessary equipment (including scooters, oxygen, diabetes monitors, etc.) for patients who need them, and some companies selling them do aggressive direct-to-consumer marketing (as do pharmaceutical companies), to try to increase their sales. Hospitals post exorbitant “prices” for their services that bear little relationship to the cost of providing them (as proven by the wide variation) in hopes that the occasional payer will pay them, or at least pay a percentage of them (unlike Medicare’s fixed reimbursement). What they have in common is the exploitation of a nonsensical non-system of health care in which profit is pursued by taking advantage of its intrinsic disorganization.

For medical supplies, while Sen. McCaskill’s committee discovered many cases where patients did not want the equipment physicians were asked to approve, there are many others cases in which the patient is convinced that it would be good to have, say, a scooter that they don’t have to pay for --  even when the doctor thinks it is not necessary or might even be harmful (for example, when a person who doesn’t exercise because of their weight gets a scooter and does even less activity and thus gains more weight). Fraud is fraud, should be investigated, and it appears that it is being done.

For hospital charges, however, the solution is different. It would be to have a national payment system that, possibly with regional differences based on the cost of labor and other variables, pays a fixed amount for services, as does Medicare – a single payer system. It probably needs fixes (Medicare may currently pay too little, requiring private insurers to subsidize that care; certainly the law should allow the uninsured to be billed at no more than Medicare would pay), but a little rationality would go a long way.