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.

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.

Dark Times for Public Health and Healthcare: Will the insurance industry fix itself?

It’s an exciting time for both health care and public health! Anything goes, and almost anything is, or will in the near future! On the public health front, we have the nomination by President-elect Trump of Robert Kennedy, Jr. to the post of Secretary of Health and Human Services. Kennedy has long been what is generously called a “vaccine skeptic” and his lawyer, Aaron Siri, has sued the Food and Drug Administration to revoke the approval of the polio vaccine. Although the NY Times article says ‘Like Mr. Kennedy, Mr. Siri insists he does not want to take vaccines away from anyone who wants them. “You want to get the vaccine — it’s America, a free country." This is disingenuous. If the FDA approval is revoked, nobody will be able to get it.

I have written recently about the importance of vaccines, especially polio and measles, in preventing disease and death (Raw milk, vaccines, and RFK, Jr: Some dates worth remembering, Nov 15, 2024). A series of letters to the Times in response to the Siri article make clear the risk. Read them; they address the science, the controlled trials of polio vaccine, the experience of those who were doctors and children during previous polio epidemics, and touchingly, the experience of dancer Tanaquil LeClerq, wife of choreographer George Balanchine (short answer: no vaccine, polio, and paralysis). In regard to other vaccines, we can read in the Times ‘Tiny Coffins: Measles Is Killing Thousands of Children in Congo’ and imagine it happening in the US as a result of Kennedy’s anti-vaccine actions. Kennedy calls his movement “health freedom” and says that he will give infectious diseases a “break” (whatever that means), but in fact, as described by Gregg Gonsalves in The Nation, RFK Jr. Is Giving Infectious Diseases a Promotional Tour.

I posted on Facebook that I have heard people say “kids get too many shots”, and asked “then which preventable disease do you want your child to die of?” One comment I got from a colleague was that the problem was not that kids get too many shots, but that too many kids get shot! The most recent killings, in a Christian school in Madison, WI (15-Year-Old Girl Identified as the Shooter in a Wisconsin School) were at least the 323^rd this year in the US! THIS is an epidemic, the extent of which people in most other countries cannot imagine, and, like many of us, wonder what will be done about it. Sadly, the answer is going to be very little, if anything; we may be closing out the statistics for deaths from school shootings in 2024, but nothing suggests that 2025 will be any better.

On the healthcare front, things are not getting better. The anger at the health insurance industry exposed by the shooting of UnitedHealthcare CEO Brian Thompson was deep, broad and well-justified, as I wrote in Murder of a Health Insurance CEO: People HATE the companies and the people who run them (Dec 8, 2024). Study after study continues to appear providing evidence that more and more people have inadequate, unaffordable, or no health insurance. The Commonwealth Fund recently published a report that shows Hispanic/Latino Adults Lack Adequate, Affordable Health Insurance Coverage,

and that this led to their having real trouble accessing health care. The breadth of this lack goes far beyond Latinos.

Maybe we can come up with a solution! I think I have already indicated several – mainly instituting a single-payer universal national health insurance program. Or, until we do, capping the amount of out-of-pocket costs a person can have to a reasonable number ($1000?). And limiting the profits of health insurers, or the ways in which health care providers (e.g., hospitals mainly, but also nursing homes, doctors, etc.) act to make money, whether technically profit or “non-profit”, at the expense of people’s health.

Others have entered this discussion. In a remarkable Op-Ed essay in the NY Times on Dec 13, UnitedHealth Group’s CEO Andrew Witty (Brian Thompson’s boss, who makes more than $20M a year) wrote The Health Care System Is Flawed. Let’s Fix It. Unfortunately, what is remarkable about this article is that the Times chose to run it at all, since it makes no significant suggestion on how to “fix” it, certainly none that would threaten UnitedHealth’s profits. It mostly displays the Times’ complicity in an effort to focus away from the righteous fury of the American people with the health insurance industry.

USA Today reports on Seven reasons why Americans pay more for health care than any other nation, and it gets most of them right. (Reason 1: Lack of price limits, Reason 2: Hospitals and doctors get paid for services, not outcomes, Reason 3: Specialists get paid much more ‒ and want to keep it that way, Reason 4: Administrative costs inflate health spending, Reason 5: Health care pricing is a mystery, Reason 6: Americans pay far more for prescription drugs than people in other wealthy nations, Reason 7: Private Equity.) There are a few others, but it is a good list. Despite that, however, it doesn’t come up with a meaningful, comprehensive solution to them, or any of them. Indeed, it ends up quoting the Witty piece referenced above, "We know the health system does not work as well as it should, and we understand people’s frustrations with it,” rather than having any kind of answer. Like, say, universal non-profit health insurance, limits on hospital system (and physician) incomes, and banning private equity and other for-profit players from the health system!

Maybe it is asking a lot for insurance companies, largely the perpetrators of this massive scam that is bleeding the entire US economy, to come up with a “solution”. But USA Today, Commonwealth Fund, and others that do such a good job of identifying the problem should be able to take the simple next step to recommending the fix. In what is to me an amazingly open (if entirely disgusting and reprehensible) acknowledgment of their agenda, CNBC reported back in April 2018 that Goldman Sachs, the huge investment bank (Jamie Dimon, CEO) raised the question (discussing biotech research) ‘Is curing patients a sustainable business model?’.

!!??

Actually, it’s a good question. Maybe the answer is “no”. Most ethical physicians I know (and it is the vast majority who are ethical) have always said something like “I look forward to the day when we can put ourselves out of business”. Investment banks and other forms of private equity, and the insurance companies like UnitedHealth and the providers that they control, do not see this as a positive. Maybe it is refreshing to see such a stark portrayal of the problem? Or not.

But I, and I believe most Americans, would rather see diseases and the people who have them cured, and would be happy to see the profits of any of these profiteers, privateers, just plain ganevem, and the salaries of their C-suite execs and Boards, disappear.

Raw milk, vaccines, and RFK, Jr: Some dates worth remembering

Some dates worth remembering:

1862: Louis Pasteur discovers the eponymous process of pasteurization (based on work done by Lazzaro Spallanzani 100 years earlier), first used in beer and wine, but most importantly in milk. As the process is gradually introduced (the first US state required it in 1947, the federal government for interstate commerce in 1973). It took a while, but with its introduction the frequency of serious and often life-threatening infections coming from unpasteurized (= “raw”) milk, including streptococcus, typhoid, typhus, and TB, among others, dramatically decreased. Health was improved.

2024: The US President-elect, Donald Trump, announces that he will nominate Robert F. Kennedy, Jr., who advocates the drinking of unpasteurized milk, to the cabinet post of Secretary of Health and Human Services.

1952: During the last major polio epidemic in the US, a friend comes to visit our family on a Saturday to see my new baby sister. On Monday, she comes down with polio and spends the rest of her life in a wheelchair. My parents are worried about their children having been infected, more about the greater risk to 3-year-old me than the baby, as polio in infants was uncommon. I do not get clinical polio (see * below) and soon thereafter receive both the Salk (injection) and later the Sabin (oral) polio vaccines. During this decade I also come down with clinical cases of measles, mumps, German measles (rubella), and chicken pox. The last was quite unpleasant, but I didn’t die and had no significant after-effects. The vaccine against measles (and mumps and rubella) were released in 1963. The rates of these diseases, especially measles which caused the most deaths, plummet. Most measles outbreaks since have been in populations in which people did not immunize their children, notably in 2019 among Hasidic Jews in Brooklyn.

As a young doctor at a public hospital in the 1970s, one of the common and feared infections we saw in the pediatric emergency room was that caused by the bacteria Hemophilus influenza b (not the same as the virus influenza). It commonly caused ear infections, but also very serious meningitis, and, most scary to us, epiglottitis, in which the epiglottis, the piece of tissue in your throat that prevents you from breathing in food, swells very large very fast and can completely cut off a child’s breathing unless a breathing tube can be placed in time (and it is difficult with the swelling). In 1985, the vaccine against H flu b was introduced, and these infections and deaths almost disappeared. Varicella (chicken pox) vaccine was not released until 1995, and the rate of those infected (and then later infected with shingles, a resurgence of the same virus, known as Varicella-Zoster) plummeted. Before the vaccine was released, about 4 million cases of chicken pox, with over 10,000 hospitalizations and 100 deaths, occurred (mostly among children) annually in the US.

2024: The US President-elect, Donald Trump, announces that he will nominate Robert F. Kennedy, Jr., who believes all vaccines are bad and should be avoided, to the cabinet post of Secretary of Health and Human Services.

The difference between individual and public health is important, and bears repeating.  For the individual, getting a disease (infectious or not) is 0% or 100%. If something happens to “one in a million” people it is very rare (including serious reactions to vaccines, which do not, incidentally, include autism) but if you are the one, it is 100% for you. On the other hand, if something affects 99% of people, but you are in the 1%, you are lucky. Public health looks at trying to prevent (or contain, if they are infectious) diseases by looking at the impact of disease, or preventive measure (e.g., vaccines, pasteurization) on the population**. Pointing to individual exceptions (“my grandfather drank a quart of whisky and smoked two packs of cigarettes a day and lived to be 100”, or “we drank raw milk all the time and we’re healthy”) does not change that unless an subgroup that is not susceptible can be identified (e.g., biological males do not get cervical cancer – although they still should be immunized against HPV as they can transmit it). Some things may decrease the risk; those drinking raw milk direct from the cow on their farm are at lower risk of infections than those who consume it after it has been shipped and had days, or longer, to become infected. Folks who are skeptical of modern medicine often emphasize “prevention”, but this is not a magic incantation. Vaccines are one of the few things we have that actually prevent serious disease. Also avoiding foods that have a significant likelihood of being infected – tainted meat, shellfish, water infected with sewage (water remains the largest cause of death, through infant diarrhea; the main reason commercial campaigns to replace safe breastfeeding with formula that needs to be rehydrated are terrible), or raw milk.

Human progress is not unidirectional. There are often steps backwards, motivated by misinformation, financial gain, fantasies, (some people’s interpretation of) religious beliefs, political gain, and others. The appointment and confirmation of Kennedy would be a big step backward. The implementation of the policies he advocates will take us back more than a century.

There is a – very important – place for evidence and truth.

 

*Even though poliovirus infects almost everyone exposed who is susceptible, not everyone who is infected with poliovirus gets clinical polio; it is about 10%. Measles, on the other hand, also infects almost 100% of susceptible people, and virtually everyone infected gets clinical disease.

**It is worth noting that even the practice of one-on-one clinical medicine is based on applied epidemiology, the science of studying disease in populations. Why we may suspect a certain condition in a person with certain symptoms is because, in a population of people who are similar and who have these symptoms, these are the common causes. Same for treatments: we don’t say “well, the last person I saw with diabetes responded well to insulin, but you’re a different person, so let’s try digitalis.”