Lies and cowardice screwing almost everybody's health care coverage

There is usually more than one way to look at a situation. Often referred to as “point of view”, it is good to consider this, particularly in personal relationships, as the way you see things might not be the way the other person does. In the Trump years most of us have become more aware of a different basis for disagreement, not based on different interpretation of the facts but upon different facts. This is not just a difference in emphasis-- you and I both believe X and Y are true, but I think X is more important than Y and you think Y is more important than X.

We are in a situation in which a large portion of the population believes lies are facts, believes that things that are not true are true. Of course, this has always been the case, like when most folks thought that the Earth was flat, or that the sun and stars revolved around the Earth. These were definitively disproved, we know the truth, and yet there are other just as ridiculously incorrect beliefs (and, here, I except, for brevity, religion) that many people still cleave to. Heck, there are still flat earthers! I doubt that most of the leaders of the Republican Party or members of the administration in Washington – or even Fox News commentators -- actually believe most of these falsehoods (except Donald Trump, who seems too demented or stupid or isolated or all three to know), but they find them convenient ways of keeping the public’s attention focused away from what they are doing to benefit themselves and their buddies. This could be called the “Wizard of Oz” technique, and misdirection is a core part of most magic acts, but it is also a core component of fascist tyrannies.

These outright lies in the Era of Trump are incredible, both in number and the real impact on people. In the area of health, the focus of this blog, they have been amazing in terms of their scope and impact. Vaccines, among the few actual preventive things that medicine can do, have been attacked and criticized and completely wrongly said to cause worse problems than they solve. Not to put too fine a point on it, this is pure evil coming from RFK, Jr. and his team of loons. Yes, there are individual people who should not get one or more individual vaccines, because of a serious prior allergic reaction, or even worse a rare effect like Guillain-Barre, but for the vast, vast majority of children and adults vaccines are all good. They basically eliminated smallpox from the world, and essentially eliminated terrible killers like measles in this country – until a new movement endorsed by the Secretary of HHS brought them back. Your measles as a kid wasn’t too bad? Neither was mine. But lots of kids got sick. A bunch died. You never had measles because you’re too young? Because even your parents are too young? And you all had vaccinations? Sadly, maybe you’ll see it in your children. Mumps made people deaf and infertile, meningococcus dead or brain damaged, H influenza the same. Polio made people dead or paralyzed, in wheelchairs or in iron lungs. When I was a medical resident, we saw H influenza meningitis and epiglottitis, meningococcal disease, even some measles and polio. All eliminated by vaccines. Until we stop using them.

    

Smallpox                                Measles               Polio (in iron lung)

There are many, many other health disasters promulgated (it seems on purpose) by this administration. Eliminating or cutting back infectious disease surveillance – cyclospora, E. coli, salmonella -- anyone? Enjoying that? How about animal diseases? And funding for medical research – being heavily cut back especially for researchers that the administration doesn’t like.

But one HUGE area is health insurance, financial coverage for our medical care. I have written about the terrible US health care non-system which is designed to make money for private corporations (insurance companies, big hospitals and health systems, Pharma) instead of being designed to deliver the best actual health care for our people, and how it needs to be replaced by a system of covering everyone, as in every other wealthy country – improved Medicare for All. People need financial coverage because all those big corporations are owned by investors who demand ever-increasing profits, so the costs of the overall system (highest in the world by far), and to individuals, keeps going up.

Under the current administration, the opposite is happening. In a recent editorial in the NY Times, the cuts to coverage are enumerated and documented. The most dramatic of these are cuts to the Medicaid program and the subsidies for purchasing individual insurance on the marketplace created by the Affordable Care Act (ACA, “Obamacare”). The Medicaid cuts target the most vulnerable and needy, the poor and disabled, and the cuts to the ACA subsidies means that the poor-but-not-quite-poor-enough-to-qualify-for-Medicaid population that was finally insured through ACA will lose it. (If you want to know how poor you must be to qualify for Medicaid, you can look it up by state, but it is always very poor. When you look it up, remember that while many states tie eligibility to about 135% of the Federal poverty level, many others have much lower qualifying incomes.) This is really bad because it is going to kill people, is going to strain many physicians and hospital systems – especially those that cannot afford it, like rural hospitals – and create a lot of misery.

There are several other bad things related to health coverage that the Times does not even address. One of these is the aggressive promotion of Medicare Advantage (MA) plans for Medicare eligible people. These plans are not actually Medicare, a federal government run program, but private insurance products that use Medicare money (and gets paid more per patient than traditional Medicare, TM). On the one hand, if you get a good, comprehensive MA plan it can save you money (with TM you probably need to pay for a Medicare supplement and Part D plan as well as the Part B premium taken from your Social Security payment). But it can also have bad results because the insurance companies that run it can, and often do, deny payment for your care, just as they do for regular insurance.

Another health insurance problem the Times does not address is the fact that even in the best situations (in those states that chose to expand Medicaid and before Trump), the ACA did not cover everyone. Both this and Medicare Advantage are also areas not addressed by those making policy for the Democratic Party. It is not coincidental that the Times and that portion of the Democratic Party called (depending on where you stand) “centrist”, “moderate”, “Wall St.” or “right-wing” are similar, because both share a similar ethos. This is to be better than the GOP on a lot of social issues affecting individuals but to not threaten the basic status quo: corporate America making a lot of profit, and enriching its investors, at the expense of the rest of us, particularly but not only the poor, who get screwed out of medical care and/or bankrupted by the bills. Oh, and, by the way, if you one of the majority of people who have employer-sponsored health insurance, you’re still not safe. Costs for insurance to employers (with much or all of the increase passed on to employees) is expected to go up 11% in 2027!

The “centrist” branch of the Democratic Party does not support eliminating or strictly regulating Medicare Advantage, not to mention Improved (covering everything) and Expanded (covering everybody) Medicare for All. The same tired and inadequate reasons are given: “we can’t afford it” --- ridiculous given that every other wealthy or middle-income country does -- when what they mean is “we don’t want to alienate the billionaires who continue to support us”. They say that they need to “be moderate” because they don’t want to turn off independent voters, which results in policies that do not significantly help most regular people. Like Improved and Expanded Medicare for All (see the Jayapal House, HR 3069, and Sanders Senate, S 1506, bills) would.

We should be terrified of what the Trump Administration and GOP are doing, especially trying to disenfranchise voters before the election, and the huge cuts to our health care. But voters are not going to be excited by “Republican lite”; they need to hear about bold programs that will change their lives for the better.

Vaccines and autism: "Culture eats data for lunch"

A common saw in the business world is that “culture eats data for lunch every day”. The lesson is supposed to be that in trying to create organizational change, it is important not to assume that people do what they do simply because they are ignorant of the facts, and that these simply need to be presented to them and change will occur. This is also the case in many other areas, including public health, and it seems it is often easier to create change by presenting simple “facts” (even if they are wrong) that are easy to digest and concord with pre-existing belief systems than more complex or nuanced facts that are actually right.

Recently, in a Facebook “discussion”, I was informed of a couple of things by a friend-of-a-friend whom I do not know. One was that vaccines are bad because pharmaceutical manufacturers make lots of money on them, and they are evil. Indeed, I had acknowledged that I think that they are evil, and the “discussant” asked (rhetorically, I assume) how I could then trust them? I didn’t respond (who needs to waste time arguing with folks who will never be convinced) but it is a logical fallacy. Drug companies are evil, in that they systematically exploit every method they can to make money, and even more money, but this does not mean everything that they do or make is evil. They are happy to make lots of money selling drugs (or vaccines) that in fact work well; their evil is in hiding when they don’t work well, or have bad effects (think “Sackler” and oxycontin) and grossly overpricing them when they do. Vaccines do work, and incredibly well, some better even than others. There have been rather rare side effects (beyond local soreness or slight fever) associated with them, but the one getting the most play is their association with autism, especially measles (or measles/mumps/rubella, MMR) vaccine. They don’t cause autism as shown by many studies, some of which are cited below and all are available by searching PubMed (National Library of Medicine) or Google Scholar.

Or maybe not. The other thing that this discussant noted was that there are over 200 studies showing that it does cause autism, which was news to me. They didn’t provide the citations (it was, after all, just a Facebook post) but I presume they have them. The only other explanation I can think of is that it is a number that they heard of read somewhere and are repeating (something which most of us are, at least sometimes, guilty of). In any case, I haven’t been able to find them. I am not going to go into great detail here about the absence of a link between autism and measles vaccine, as there are already many good discussions available, two of which are a review of Vaccines and Autism by the Children’s Hospital of Philadelphia and Vaccines Don't Cause Autism. Why Do Some People Think They Do? From the Johns Hopkins Bloomberg School of Public Health. This article in StatNews also reviews the evidence. If you are interested in some of the studies done that showed no association between vaccine and autism, one big one was from Denmark that looked at over 650,000 children and was published in the Annals of Internal Medicine in 2019, Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. There are dozens of others, which have looked at over 3 million children, and are easily found on searches on either NLM or Google.

If not 200, however, there are at least 2 studies, by the same author, Andrew Wakefield, that purport to show that measles vaccine causes autism. The first, published in the Lancet in 1998, Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children, studied 12 children. It not only didn’t prove that the vaccine caused autism, but was so deeply flawed it could not have, and the Lancet retracted the paper (which you will see in a notification when you search it or follow the link above). Several of Wakefield’s co-authors removed their names from this paper. There was a second study published in 2002, using a different, but also flawed, methodology.

However, despite the vast preponderance of evidence, the Secretary of Health and Human Services, Robert F. Kennedy, Jr., is not convinced and is commissioning a new study of the link, to be done by David Geier, long associated with the movement to associate vaccines with autism, (who was not a doctor but practicing under the license of his father -- who had HIS revoked for experimenting on autistic children). I wonder what it will find?

In 2025, so far in the US, there have been almost 900 cases of measles, with 3 deaths, the most of both in many decades. Given that the mortality rate for measles is about 1/1000, it suggests an under-reporting of cases. 97% of those affected were unimmunized. This means that parents who choose to not immunize their children are risking disease and death from measles. And doing so for a “benefit” (not getting autism) that is unrelated. This is sad, but people believe what they believe for a variety of reasons, and act on those beliefs. There is also no shortage of papers studying and reporting on why this is so, e.g. Why Parents Say No to Having Their Children Vaccinated against Measles: A Systematic Review of the Social Determinants of Parental Perceptions on MMR Vaccine Hesitancy.

Historically, and today, the prevalence of measles is higher in communities of lower socioeconomic status, for a variety of reasons discussed, for example, in Measles Outbreak in Socioeconomically Diverse Sections: A Review. Of course, many diseases are more common in communities of lower socioeconomic status, for the same reasons, prominently including lack of access to health care. What is concerning about the current measles outbreak is that it is so closely tracking, in the main outbreak in West Texas and adjacent New Mexico, low levels of immunization that result from belief that vaccines are bad, not because they are inaccessible.

Taking things on faith and not on evidence is a cornerstone of most religions, but belief in things like vaccines causing autism, and other evidence-free ideas, should not be on the same order as religious beliefs. However, it may be that being used to accepting some of the most important things on faith conditions one to being willing to accept others. Also, while the autism/vaccine question is pretty specific, it is easy to accept simplistic guidelines to guide a person as to what is “good” or “bad”, without the (unfortunately ubiquitous) subtleties. One example is “natural”; things that are “natural” are good, and things that are manufactured or modified are not. So, vaccines, being manufactured, could be bad. Of course, this idea is pretty dangerous; lots of natural things are poisons, and many beneficial natural things (like plants that help with certain conditions) are actually not as good as the standardized and purified forms made by those evil pharmaceutical companies. Aspirin is derived from willow back. But how much willow bark is good for my arthritic pain? In what season? What microclimate? How much will be too much and cause stomach ulcers? If something seems too good to be true it usually is; similarly using a single touchstone (e.g. “is it natural”) it is too simple and often wrong.

I used to be very concerned with people ignoring science and good research and believing, well, what they wanted to believe, for whatever reason. Now I am even more concerned about the seeming pride that they take in not believing science, as if that were a good thing, that in not believing what the evidence shows they are asserting their loyalty to a cause and victory over an enemy.

This is the much more important thing to believe in: US mortality is high, and strongly linked to wealth! Let us work on addressing that.

 

 

 

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.