Pay primary care more: Kennedy may be getting this one right!

I have recently written strong criticisms of Secretary of Health and Human Services Robert F. Kennedy, Jr. and his positions on a number of issues, including most importantly vaccines (see RFK, Jr.: The Secretary of Health and Human Services is Dangerous to Your Health!). Not only is he wrong about vaccines being dangerous, he is in fact creating major danger by discouraging their use. The polio vaccine essentially eliminated a disease that was a major scourge in the US as well as the rest of the world, as did the measles vaccine. Many other vaccines protect our children – and adults – from other serious viral diseases like influenza, COVID, mumps, chicken pox, rubella, shingles, and human papillomavirus (HPV) which causes cervical cancer, as well as bacterial diseases including diphtheria, tetanus, pertussis, and Hemophilus influenza b. The last is something most people have not heard of, but early in my career was a major cause of morbidity and death in infants and young children from meningitis, pneumonia, and epiglottitis, which caused their throats to swell rapidly and choke off their breathing. Many others have articulately expressed this concern, including the pediatrician Perri Klass in the New York Times. While these diseases affected people of all social classes, they were more prevalent among the poor and minority groups such as the people I cared for at Chicago’s Cook County Hospital. Indeed, research has demonstrated tremendous benefits from vaccines on the health of children and other populations that go far beyond just the decrease in the specific diseases that they target to decreasing all-cause mortality!

Kennedy is wrong about many other things, if not all of as of such immediate potential danger as urging people to not get vaccinated. These include nonsense like suggesting that people who eat right and exercise won’t get disease, that raw (unpasteurized) milk is better for you, and that “natural” is always better (which, even if we could agree on a definition of “natural”, it isn’t). One recent example is his arguing for Coke to use “natural” cane sugar rather that high-fructose corn syrup, both of which are sugar and have calories and in large amounts are bad for you.

But there turns out to be one area where Kennedy and I seem to agree, which is the need to take concrete action to increase the number of primary care physicians. Lots of people, including politicians, healthcare providers, and health policy experts, express concern about the shortage of primary care, but have done nothing to address the real cause of this problem – that primary care physicians (and the nurse practitioners and physician’s assistants working with them) get paid a lot less than do physicians in other specialties. Kennedy appears to be doing something other than wringing his hands. On several occasions I have written about the RUC, the AMA committee that decides how to divide up the pie of Medicare dollars among specialists by deciding how much each thing doctors do is worth relative to other things that they do. (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid? July 21, 2013, Doctors' incomes and patient coverage: both need to be more equal July 26, 2014, and most recently, Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!, June 27, 2024).

Not to get too technical, there is a set amount of Medicare dollars and the RUC decides (or recommends to CMS, which almost always accepts those recommendations) how many physical exams, say, are equivalent to one gall bladder surgery, considering (theoretically) both difficulty and time. This makes a tremendous difference in physician income and, I would argue, specialty choice by medical students. And, over the years, the amount of time it takes for doctors to do some things, particularly procedures, changes. Colonoscopies used to be estimated to take an hour and a quarter, but now are routinely done in 30 minutes. Cataract surgeries take a fraction of the time that they once did. This can result in physicians billing for more procedures than the model assesses as possible in a day. In contrast, the time it takes for a physical exam, or to listen to an interpret a person’s story, hasn’t changed significantly. The composition of the RUC, according to the AMA, represents all specialties, but its membership has a low proportion of primary care doctors – five of the 32 seats. Unsurprisingly, then, specialist-performed procedures are valued more highly than cognitive work. And, very important, these rates (relative value units) do not affect only Medicare payments – virtually all insurers pay based upon Medicare rates, so it is the whole health system! Prior to this new regulation, alternative models for allocating payment have been developed, such as this 2025 publication from the National Academies of Science, Engineering, and Medicine (NASEM).

So, now, maybe, a change. The NY Times reports that, buried in an 1800-page HHS regulation, are proposed changes in the RUC methodology that would benefit primary care. This would be real action! In addition to reassessing these relative values, the action would also look at the current practice of reimbursing more for the same procedures done in a hospital than in a doctor’s office, a major way that hospitals make money. And, for those who think “of course it costs more to do something in a hospital”, this is a technicality; it simply means that the hospital owns the practice or clinic. So two, say, skin biopsies performed in similar doctor’s offices across the street from each other are now reimbursed at very different rates if one is owned by a hospital. This is absurd and inequitable, and getting rid of it makes terrific sense!

The diffusion of medical services to people and communities is primarily driven not by the health needs of the populations in different areas but by the potential to make the most money for health care providers. These are largely, and increasingly, hospitals and health systems, as well as enormous insurance-company and private-equity owned practices rather than individual or small group physician-owned practices. So, we get enormous hospital campuses and medical facilities in major cities and wealthy suburbs and little or nothing in poor neighborhoods and rural areas. This should change. The only reason for decisions about what healthcare services to provide and where to provide them should be the health needs of people, and not on how much profit can be made.

The new HHS regulation will be a big step in this direction if it redirects Medicare (and thus all insurer) funds to primary care, and does not preferentially favor hospital-owned practices. To the extent that he is responsible for it, Kennedy should be congratulated. However, while it is a big step, it is not a solution. The next, necessary, step is a universal health insurance program where every single person is covered and covered by the same system, and where establishment (and closure) of health facilities, and the services that they provide or do not, is entirely based on the health needs of the people. Of course, there will be a lot of resistance – highly paid specialists will resist the proposed HHS reimbursement changes, and the institutionalized powerful insurance companies and other big players who are making lots of money from “healthcare” will oppose more comprehensive changes. Indeed, they already are, with highly funded social media campaigns against universal health care.

We are glad for this first step, but we need to keep fighting to get a comprehensive health program – like those of every other wealthy country!

"It was the best of times, it was the worst of times": Threats to the public's health from Medicaid cuts, MAHA, and others

“It was the best of times, it was the worst of times…” begins Dickens’ “A Tale of Two Cities”, and people have used that phrase to describe all kinds of times in the 150+ years since it was published in 1859. But maybe not today. In some ways, I guess, it could be the best of times for some privileged people in wealthy countries; never in history have so many people been able to enjoy things like enough food to eat, shelter, air that is breathable, water that is clean, heat in the winter, A/C in the summer, travel for long distances by plane, for many distances by private car, etc., etc. In every way, often ones that seem to us to be mundane, a lot of us enjoy a standard of living that could not be imagined even by the wealthy of Dickens’ time or earlier. Of course, that is only for some of us in the world, it is likely the majority in wealthy countries, even those working people living paycheck to paycheck.

But even in those wealthy countries we see too many who do not enjoy those benefits, who are living on the streets, who sleep in shelters or sewer grates or parks, who are freezing in winter and roasting in summer, who do not have enough to eat, who cannot get basic health care for their needs, and often have additional needs related to mental health or alcohol or drug use. We see children being abused and neglected by parents who do not have the wherewithal or support they need. We are, some of us, outraged and angry, some of us at them, and others of us at the system in which they live. Because we have a society that actively chooses to make the lives of many people worse so that the most privileged can have more.

And, once we leave wealthy countries such as the US, it becomes phenomenally worse. The number of people starving or suffering in wars and armed conflicts is incredible. Gaza is one obvious example, and it is horrific – the government of Israel using the all too real fact of centuries of oppression and anti-Semitism to destroy another people, the Palestinians, killing tens of thousands, displacing millions from their homes, destroying what infrastructure they had stingily allowed to be built – this is not wrongly called genocide. And there is Somalia and South Sudan and Ukraine in wars, and whole continents of people whose best days are the ones on which they get something to eat.

So, is it the worst of times? The policies being followed by the US government under President Trump and the bootlicking GOP Congress and the Supreme Court to which he appointed a disproportionate number of members, are leading us steadily downhill in virtually every part of the public arena. But the fact that they keep getting worse indicates that we have not yet reached bottom, we are not yet in the Europe of the late 1930s and 1940s even. But it does keep getting worse, in the US and across the world. It hits on so many fronts – the economy, basic human rights, climate, war – that it is difficult to even keep up.

And health and health care? The focus of this blog? Still lots of bad things, starting with the cynical, opportunistic, and dangerous policies being implemented by the Secretary of Health and Human Services (HHS), Robert F. Kennedy, Jr., the director of the Centers for Medicare and Medicaid Services (CMS), Dr. Mehmet Oz, and others in the administration, which become more and more outrageous. And, of course, the negative impact of the President’s “Big, Beautiful Bill” on those dependent on Medicare and Medicaid will be dramatic. STAT News recently reported that the Congressional Budget Office (CBO) estimates 11 million people will lose their health coverage as a result of Medicaid cuts. That is a lot of people, and only a very tiny percentage are the “boogeymen” cited by the GOP as deadbeats, adults capable of working but not seeking work. In fact, most people on Medicaid are children and their mothers, and most Medicaid dollars are spent on caring for seniors and disabled people in long-term care, and most able-bodied adults receiving Medicaid are already working, sometimes at more than one job, but making less than the standard (often 138% of the Federal Poverty Level). In my state, Arizona, that is less than $22,000 a year for a single person, and it is similar for families and in other states. The outrage is not that there are people receiving Medicaid who should be able to work, but rather that people working full-time can be paid so little that they qualify for Medicaid and other federal benefits. Many of these folks are working for high-profile (and high-profit!) corporations such as Walmart and McDonald’s, as reported by CNBC in 2020 (and probably is worse now!) Medicaid, by the way, is not a benefit paid to individuals (such as welfare or SNAP) but rather is paid to medical facilities for providing care to eligible individuals. To the extent that there is fraud, it is more likely to be on the part of those providers than the individuals. And cutting Medicaid threatens the continued existence of many of those providers, particularly rural hospitals which are, because the population that they serve has a higher percent of poor, disabled, and elderly people, more dependent upon Medicaid payments.

Medicare is also being harmed, in less obvious ways than the cuts to Medicaid, largely by encouraging the movement of Medicare recipients into private, insurance company-run plans called Medicare Advantage. I have often discussed the details (e.g., Open Enrollment Season for Medicare and Medicare Advantage: What you should know, Oct 7, 2024) but, in brief, insurance companies get paid more than Medicare spends on “traditional Medicare” (TM) recipients, and use some of it to provide benefits that are attractive, especially if you are not really sick. Of course, it is not then Medicare, but an insurance package, a PPO or HMO paid for with Medicare dollars, and the insurance company can (and often does) deny claims, as they do for their non-Medicare insurance packages, which TM does not.

And what about RFK, Jr., and his MAHA (“Make America Healthy Again”) campaign, including his disparagement of vaccines and advocacy for unproven (and sometimes proven-to-be-dangerous) treatments such as unregulated use of stem cells, and other “alternative” treatments, including saying “‘Charlatans’ Are No Reason to Block Unproven Stem Cell Treatments” even though “some methods have resulted in blindness, tumors and other injuries”? I’d say there is great cause for concern, but would also recommend reading the sympathetic and balanced discussion of MAHA supporters by Katelyn Jetelina, “Your Local Epidemiologist”. She distinguishes between leaders of the movement, like RFK, Jr., about whom she says “I don’t believe RFK Jr. is acting in good faith. His record is riddled with contradictions and falsehoods. His tactics often erode trust under the guise of restoring it. Treating him as a serious partner would be a mistake,” and the grass-roots. Many of these people feel that they are not getting accurate information (often they are not), many (appropriately) distrust Big Pharma and associate the mainstream medical and public health disciplines with it, and some are advocates for the magic benefits of “alternative” treatments such as stem cells. But a big issue that she identifies is their desire for “autonomy”, to make their own decisions on health care (where to go and what to do, what treatments to use, etc.) rather than be forced into using vaccines, or taking pharmaceuticals when they don’t want to. This is a big issue. In many areas, particularly infectious disease, individual autonomy that says “we don’t want vaccines” can lead to big disease outbreaks (like the ones we’ve recently seen of measles, which include deaths of unvaccinated children). The issue of individual autonomy vs. the public good is a longstanding tension, and of particular potency in the US.

So, what is there to say? I say do get vaccinated. Vaccines do not cause autism. Childhood vaccines, as is often stated, cause adulthood – because children do not die of polio, measles, or influenza, or epiglottitis and meningitis from H. influenza B, and hepatitis, and all the other conditions which at best cause significant suffering even when they do not lead to permanent disability or death. Vaccines are a good thing.

Swimming in polluted water, as RFK, Jr., has done is a bad idea. Taking your grandchildren along with you, as he has also done, is a really bad idea.

And yes, cutting millions of people, most of whom are hard-working, off of Medicaid, is another really bad idea.

 

 

For a balanced description of the terrible abuses that were carried out in the name of medicine and public health by Nazis, Americans, and others, see the excellent podcast “Doctors Gone Bad: Physicians, Dictatorships, and Warrior Cultures” by Dr. Martin Donohoe, part of his outstanding podcast series “Prescription for Justice”.

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.