More wealth, more health: what can we do to mitigate disparities?

The Washington Post’s “Wonkblog” reviewed a report by economists discussing “The stunning — and expanding — gap in life expectancy between the rich and the poor” (Max Ehrenfreund, Sept 18, 2015). One focus of the article, which is based on a report from the National Academy of Sciences, is that (in the words of the alternative title of the Wonkblog piece that displays in the URL), “the government is spending more to help rich seniors than poor ones”. A big reason for this is that the greater life expectancy of the more well-to-do means that they collect benefits from Social Security and Medicare for longer. But, of course, the real issue is that there is such a difference in the life expectancy of rich and poor. Ehrenfreund illustrates this with two dramatic graphs:

This is a pretty significant difference. What are the reasons for it? The report (and the article based on it) indicate that while differences in “lifestyle” (smoking and obesity, mainly) account for some of the difference, it is less than 1/3. The study also alludes to the impact of “stress”. This may seem vague, non-specific, or ubiquitous: aren’t we all stressed? Don’t rich people have a lot of stress because wealth is often accompanied by great responsibility? Such interpretations sometimes leads “stress” as a factor in longevity to be discounted by many commentators. But the impact of stress on health is a real thing, and it is well documented. Many people are familiar with the old terms “Type A” and “Type B” personalities, and how being Type A (more stressed) can lead to a greater risk of disease, particularly heart attack. But the real concern is a kind of stress that is more common in poorer people. This is the continuousstress, from worrying about whether you and your family will have enough food to eat and a place to live, whether you will have a job, whether it is safe to walk down the street, whether (especially if you are a young Black man) the police are going to stop you at any moment, that has major negative health effects. The mechanisms through which this occurs are incompletely elucidated, but certainly involve the neuroendocrine system, the release of hormones that prepare the body for “fight or flight” by refocusing blood flow to muscles, increasing heart rate, etc. Such a response is very useful in an emergency, but when it is happening most or all of the time, and the body does not have the time and rest to fully recuperate, it results in real health damage. This hormonal response allows a person to run fast, from an attacker or for sport, for a short time, but if the challenge never stops, the body eventually wears out
This sort of stress on the body may be the “final common pathway” through which many of the negative life situations that poorer people are more likely to find themselves in exact their toll, but there are also other factors. People’s health, and thus their life expectancy, is to a large extent determined by their early childhood experience. The relative income of their families of origin that affects their childhood nutrition and education, their warmth in the winter, and the amount of transmitted stress that their parents felt, is also a big determinant. While this disparity at the start of life is something that can be mitigated, by some, through future success, it can never be completely erased. That is, while rich people from poor backgrounds may have better health later in life than those who stay poorer, they have on average worse health than those who started out wealthy and stayed that way. “Choose your parents wisely,” I tell my medical students, “if they are both long-lived and rich, it bodes well for your future health.” Luckily for them, the majority of medical students come from at least upper-middle-income families.
Another big determinant is education, and many studies show the correlation of higher levels of education with longer life and better health. Of course, education is highly correlated with income, both on the front end (children from higher-income families are more likely to achieve higher educational levels) and on the back end (those children from families of lower socioeconomic status who are successful have usually become so through education). In the US, income is related to education in part because our schools are largely funded by local tax bases, so that wealthier people live in better funded, and educationally better, school districts. People from other countries often have difficulty understanding that we have “good” and “bad” school districts; as one friend said “where I come from all schools are the same! No one would choose where to live based on the quality of the schools!” This concept is so alien to me that I had difficulty understanding them!
In addition, education does not take place only in school. Children from upper-income families are more likely to have educated parents, who not only encourage them to pursue educational success, but read to them and talk to them from the very beginning of their lives. These are also families in which survival needs do not displace the priority of children getting an education. In 1943, the psychologist Abraham Maslow published his hierarchy of needs; survival must come before self-actualization. This was originally conceived of for the individual, but is also true of families and communities. A similar pyramid has been developed to describe the impact of Adverse Childhood Events (ACEs). ACEs are a ways of thinking about the combination of negative impacts including hunger, homelessness, physical abuse, sexual abuse, neighborhood dangerousness, etc., that have been shown to have a lifelong negative impact. In addition to being associated with higher future rates of drug abuse and mental illness, they are associated with higher rates of just about everything bad. The Adverse Childhood Experiences studyconducted by Kaiser Permanente beginning in 1995-97 is the most significant study on this topic. It is ongoing and being replicated in many other countries.
Of course, lower income people are exposed to other risks beyond these. People living in “worse” neighborhoods have a greater likelihood of being homicide victims. Those neighborhoods are much more likely to be exposed to environmental pollutants in the air and water and even from the earth (such as toxic waste dumps). Many lower-income people work in more dangerous jobs, especially true in rural areas (farming, ranching, logging, highway construction, etc.) Indeed, the potential for “confounding” results from such exposures was the reason that Michael Marmot and his colleagues did their classic series of studies showing the direct correlation of higher socioeconomic status (class) and better health by examining people who worked for the government in the same offices in London (thus the name “the Whitehall studies”).
Wealthy people have a longer life expectancy than poor people, and wealthy countries have longer life expectancies than poorercountries, and those with wider gaps between the rich and poor have wider gaps in life expectancy; in this regard the US is at greater risk than wealthy nations with smaller gaps. The neat interactive website from Gapminder allows you to track wealth with life expectancy over time since 1800. The GINI index measures the income disparities within countries, and its use allows correlating income inequality with life expectancy; like several other health measures (e.g., infant mortality) life expectancy goes down with increasing inequality even when a country (such as the US) is rich overall.
So yes, our Social Security and Medicare systems mean that those who live longer will have more financial benefit, and that they are more likely to be more well-to-do than those who die younger. In addition, those who are poorer are more likely to live longer with disability. But the real news is that poverty and social deprivation work in many synergistic ways to decrease the health of the poor. This is what we need a coordinated and comprehensive strategy to address.

And the first step is recognizing and acknowledging it.

The high cost of US health care: it’s not the colonoscopies, it’s the profit

On June 2, 2013, the Sunday edition of the New York Times ran a major investigative article by Elizabeth Rosenthal called “The $2.7 Trillion medical bill”, with the subtitle “Colonoscopies explain why the US leads the world in health expenditures”. It is a damning article about the US health care system, and the fact – fact – that our costs are much higher than those in other countries but our outcomes are often worse, and large portions of our population are not even covered.
Of course, it is not all colonoscopies. Yes, the average cost for a colonoscopy in the US is $1,155 compared to $655 in Switzerland (for example). And many cost much more; in the first paragraphs of the article we hear about charges of $6,385, $7,563.56, $9,142.84 and $19,438 — “…which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.” ! But the graphic at the top of the article compares US prices for other common procedures with those of other first-world countries: Angiogram $914 US, $35 Canada; hip replacement $40,364 US, $7,731 Spain; MRI $1,121 US, $319 Netherlands; Lipitor (atorvastatin, a drug to treat high cholesterol) $124 US, $6 New Zealand.
But colonoscopies provide a good example for why we pay so much more for procedures – and it is not because they are of higher quality:

“Colonoscopies… are the most expensive screening test that healthy Americans routinely undergo — and often cost more than childbirth or an appendectomy in most other developed countries. Their numbers have increased manyfold over the last 15 years, with data from the Centers for Disease Control and Prevention suggesting that more than 10 million people get them each year, adding up to more than $10 billion in annual costs. Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation. They are often prescribed and performed more frequently than medical guidelines recommend.
The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.”
Welcome to the world of for-profit health care. Where the principle of “maximize profit” determines what health care institutions do. Where “what we do” (our “product”) is health care, but we prefer to do it on those with really good insurance. Where we adjust our charges to maximize the difference between what it costs us and what we are paid. Where the rules set by insurers or government with the aim of regulating costs are seen as challenges to be gamed for maximum profit. The movement of colonoscopies – and many other procedures – from doctors’ offices to “surgi-centers” is a great example. If performing colonoscopy in an office was unsafe, moving to a surgi-center might be a good idea, but there is little evidence that it was. Moreover, the increased price for performing a procedure in such a center far exceeds the increased cost of doing it there; the reason for the move is not patient safety, but taking advantage of a loophole to be able to charge more.
Rosenthal’s article is a long one; it extensively documents both the high cost of health care in the US and the reasons why it is so high, which are rarely related to quality. This is illustrated by an article published in the Times a few weeks earlier, “New Jersey hospital has highest billing rates in the nation”, by Julie Creswell, Barry Meier, and Jo Craven McGinty. “The most expensive hospital in America is not set amid the swaying palm trees of Beverly Hills or the luxury townhouses of New York’s Upper East Side,”they write, but Bayonne Medical Center, in Bayonne, NJ, where the average charges are 4.1 times the national average charge, not to mention what Medicare will pay. For some services it is much higher: “Bayonne Medical typically charged $99,689 for treating each case of chronic lung disease, 5.5 times as much as other hospitals and 17.5 times as much as Medicare paid in reimbursement. The hospital also charged on average of $120,040 to treat transient ischemia, a type of small stroke that has no lasting effect. That was 5.6 times the national average and 23.6 times what Medicare paid.
How can they get away with this? Who will pay them so much? After all, if I can buy a Chevrolet for $25,000 at one dealer in town, why would I pay $75,000 for the same car somewhere else? Ah, but health care is different. For one thing, you might be sick when you have to find a hospital to care for you, and you might live in Bayonne! Of course, Medicare will only pay what Medicare pays, but if you have most types of commercial insurance (not to mention, of course, if you are uninsured), it is another story. To guard against excessively inflated charges, most insurers have contracts with providers (hospitals, doctors, etc.) that determine how much they will pay for a procedure or treatment of a disease. This saves the insurer money. In addition, in order to encourage you to go somewhere that they have negotiated these lower rates, “in-plan” hospitals, they pay a lower percent of the cost – and you pay more – if you go “out of plan”.
And it is precisely this effort to control costs that many for-profit hospitals (like Bayonne) have turned on its head to generate greater income. They have gone “out of plan” for all health plans. This means that when you show up in their ER, or are admitted, you have a higher co-pay, and co-insurance charge, and the insurer pays them more money. Which is why the insurer doesn’t want you to go there, and you might (once you knew this) not want to go there either. Except, of course, you’re sick, and you live in Bayonne, and it is the closest ER. Talk about gaming the system!
Spending & Coverage (2010)
Total health spending per capita
Government health spending per capita
% uninsured
Health outcomes (2010)
Life expectancy at birth (2011)
81.3 yr.
78.7 yr.
Infant mortality per 1,000 births
Costs per episode (2012)
Doctor’s office visit
Hospital day
Childbirth delivery (normal)
Hip replacement
Heart bypass
Tests (2012)
Abdominal CT scan
Name-brand drugs (30-day prescription, 2012)
Sources: Organisation for Economic Co-operation and Development and International Federation
of Health Plans.
I have implied that much of the reason for the high cost of health care in the US is the high cost of procedures. Frankly, that is true. It is why procedural specialists make so much more than primary care physicians. This is why decreasing the difference in income potential for proceduralists and primary care doctors would be good for everyone and save money: there would be more people doing primary care and less incentive to do unnecessary procedures. Consumers Report, in its July 2013 issue, has an article on the patient-centered medical home (PCMH) movement, which seeks to achieve the “triple aim” of higher quality, greater patient satisfaction, and lower cost. The article, “A doctor’s office that’s all about you”, also addresses the high cost of care in the US, comparing it specifically to France, which spends 11.6% of its GDP on health care and  “is generally acknowledged as having one of the world’s best health care systems.” Needless to say, the comparison is not flattering to the US, which spends 17.6% of GDP on health care.
Richard Wender, MD, a leader in US family medicine, commenting on the “Colonoscopies” article, says “Using health care as a driver of corporate economics as opposed to a public good is the fundamental cause of our medical inflation.” Lee Green, MD, an American who is now a family medicine leader in Canada, adds “Having practiced most of my career in the US, and now practicing in Canada, the contrast is quite evident. The US health care system is not designed to get you the care you need, it is designed to get you the care that someone can make a profit giving you. If you’re poor and uninsured, that’s none – no matter how much you need it. If you’re well-insured, it’s a lot – including quite a bit you don’t need, and even some that is harmful.”

This is crazy. We know the problem, and we know the solutions. All we need is the will to implement them. Maybe this continued exposure will generate it. We can hope so.

Integrated Health Systems and Cost: The Price is the thing!

When the Affordable Care Act (ACA) was being developed, much emphasis was put on the effectiveness of integrated health systems as a way to save money but still deliver quality health care. Many studies from various research centers had looked at cost to Medicare and found that places – usually smaller cities – with large integrated health systems spent less on Medicare without noticeable decrements to quality. These systems can have a single provider of both inpatient and outpatient care (such as the Mayo Clinic) or close collaborations, including shared electronic medical records (as in Grand Junction, CO). The presumption of policy makers creating ACA was that Medicare spending, which is much easier to track, would reflect overall spending. However, a recent article from the National Bureau of Economic Research by Zack Cooper, Stuart Craig, Martin Gaynor and John Van Reenen, The Price Ain’t Right? Hospital Prices and Health Spending on the Privately Insured, demonstrates that this assumption was incorrect. Reviewing overall costs in the 306 Hospital Referral Regions (HRRs, developed by the Dartmouth Atlas of Health Care) in the US, they discovered wide discordance between Medicare costs and overall healthcare costs. Indeed, many of the places that were highly-touted for lower-Medicare-costs-but-still-high-quality, notably Grand Junction, CO (which was, for example, cited as a success story by Atul Gawande in his June, 2009 New Yorker article “The Cost Conundrum”) have far higher than average costs overall. (Dr. Gawande has just had a new piece in the New Yorkerdiscussing the implications of this new article.)
The New York Times coverage of this study, by Kevin Quealy and Margot Sanger-Katz, The Experts Were Wrong About the Best Places for Better and Cheaper Health Care(December 15, 2015), includes a terrific feature that allows interactive access to the data collected by Cooper and his colleagues. You can put in a town (really, HRR) and find out where it ranks in terms of both Medicare and private costs. Grand Junction, for example, while ranking 3rd lowest of the 306 HRRs for per-capita Medicare spending, was the 42nd most expensive for private insurance spending. Rochester, MN, home of the Mayo Clinic, is another city lauded for its low Medicare costs (14thlowest), but its private spending is 10th highest! McAllen, TX, cited by Gawande in 2009 for being #1 in Medicare spending (and now still #4) is only 140th in private insurance spending. Tucson, AZ, on the other hand, while only in the lower middle (82nd from the bottom) in Medicare spending, is 7th lowest for overall costs. The Kansas City region, where I live, was atypically near the middle for both, 142nd lowest for Medicare and 82nd  lowest for private costs. New York City is high in both, but it is 2nd for Medicare and 34th (quite a bit lower) for private insurance. The map in the article depicts HRRs as low, middle or high for both Medicare and private insurance.

So, what’s up? Were the experts trying to fool us? No, but the flaw  was the assumption that Medicare spending reflected overall spending. The data in this article demonstrates that it does not. It also reveals something about integrated health systems, especially those that dominate their smaller cities, given that some of the “top performers” for Medicare, like Grand Junction and Rochester, MN, were so high for private insurance. The integrated nature of these plans allows them to save money on patients by a variety of methods – they can be seen in ambulatory settings rather than in hospitals or ERs, and they share electronic medical record systems, and thus the information recorded therein, saving money by not having to repeat tests, x-rays, etc. This lower utilization is good for these health systems because Medicare is a relatively low payer, and because they can’t negotiate these rates – Medicare pays what it pays (it is a single-payer system, with minor regional variations). However, the same characteristic – being the dominant player in town – allows such integrated health systems to negotiate much higher rates with private insurers. Thus the mismatch; overall cost is a multiple of price for each service times the number of services delivered. These systems decrease the number of services for people insured by Medicare, for whom they cannot control the price (whether this does or does not decrease quality is a separate question) but they raise the price for services to people with private insurance. That places like Tucson and Kansas City have relatively lower prices for private insurance reflects the absence of a single large dominant system in those cities.

‘“Price has been ignored in public policy,” said Dr. Robert Berenson, a fellow at the Urban Institute, who was unconnected with the research’, in the Times article. Other health policy experts, such as Princeton’s Uwe Reinhardt, have been warning about this for decades. In the effort to pass the ACA, and please both providers and insurers, this point was in fact ignored, and it is the source of most of the common legitimate criticism of the ACA – that in many places decent health insurance policies bought through the health exchanges are unaffordable. With higher prices in these regions, insurers pass on the cost to their customers.  This is illustrated in the NPR story “Obamacare Deadline Extended As Demand For Health Insurance Rises” on December 18, 2015, which documents both the success of ACA measured by the large increase in the number of people signing up for coverage and their frustration at the frequently-high cost of this coverage. Of course, this is completely unrelated to the criticisms leveled at ACA by the Republican candidates for President and their allies in Congress, whose “solution” – abolish ACA – is Marie Antoinette-like. While the French queen is reputed to have said, in response to being told that the peasants had no bread, “then let them eat cake!”, Republicans, hearing that many people cannot afford health insurance on the exchanges even with subsidies, or get Medicaid in states (that they control) which have not expanded it, respond “let them pay out of their own pocket!”

The issues and solutions are clearly laid out by the reliably insightful Dr. Don McCanne is his “Quote of the Day” on this topic. A solution cannot come from a jerry-rigged program that allows either insurers or health systems or both to maximize their profit. It needs to come from a system that starts with price controls, most effectively by a single-payer system such as Medicare. There are, as he notes, still risks – mainly that health systems may under-utilize services when they cannot make profit, leading to lower quality of care. But we can guard against this both on the regulatory end, by measuring quality outcomes and holding providers responsible, and through the market because the incentive to not provide services to Medicare patients because they can be more profitably provided to the privately -insured (the “opportunity cost”) goes away.
The infatuation of both policy makers and providers for integrated health systems is not entirely misplaced. The potential savings from shared data and not repeating tests, and more importantly for caring for people in the most clinically appropriate setting (inpatient, ER, outpatient surgery center, primary care, long-term care) is a real positive feature of these systems. But to the extent that these providers are allowed to use their market muscle to raise prices to insurers which are passed on to beneficiaries, it becomes a real negative.

The key feature of a good health system is that it is not focused on balancing the financial interests of big insurers and big providers, but that it puts the benefits to patients, to the people’s health, first.

Treatments that don’t cure the disease; we are spending money on the wrong things

In “Heralded treatments often fail to live up to their promise” (Kansas City Star, May 17, 2014), Alan Bavley, writing with Scott Canon, continues to demonstrate that he is one of the excellent health journalists – excellent journalists – in the US, along with Elisabeth Rosenthal of the New York Times. The common practice in the news media (and, thanks to a typo, “medica”) is to hype the new, exciting, dramatic, expensive, and hard to believe even though you want to. In politics, we often see the media acting as flaks for the government, the rich, and the powerful (sometimes, of course, these can be in conflict). Bavley and Rosenthal  and their ilk actually do investigative journalism, trying to the best of their ability to find out the truth rather than to reprint press releases.

The article begins with a review of a surgical procedure that was designed to control high blood pressure (hypertension) without drugs, by cutting some of the nerves to the kidneys. It made sense, it was seen as a big breakthrough (“The potential benefit was huge,” said a cardiologist). Unfortunately, when actually subjected to appropriate scientific study, it didn’t work. Or, rather, it worked just as well as placebo, a sham surgical procedure. The same cardiologist remarks ““This could be considered the biggest disappointment in cardiology of this century, but “the medical community went about it right.” 

Science worked. Unfortunately, the authors add,
“If only that were always the case. A combination of industry marketing, overly eager doctors, demanding patients and news media ready to cheer on anything that sounds like a breakthrough is popularizing many drugs, surgeries and other treatments long before they’re adequately tested. Far too often, they’re ultimately proved ineffective, no better than older, cheaper therapies, or even hazardous. Billions of dollars are wasted and tens of millions of patients are put at risk”

Yup. They go on to cite the Vioxx scandal, in which Merck concealed evidence of its biggest-selling drug causing an increase in heart disease. But that was taken off the market; many other unproven (or worse, proven to be ineffective) treatments are not. They talk about arthroscopic knee surgery, still often being done for conditions for which it has been shown to be no more effective than a sham procedure. They discuss surgical robots, costing upwards of $1.5 million, and proton-beam radiation treatments (those babies, the machines, really cost a lot!) for which the evidence of effectiveness compared to more standard and much cheaper treatment is mixed, at best. But hey, if you’re a hospital, and the competition has robots and proton-beam accelerators, who’s going to come to you if you don’t have one? Poor people? Heaven forfend!

And it is all about getting the advantage on the competition to make more money. A good argument can, and should, be made that competition in hospitals helps no one. That if there were an expensive item that there were an actual medical need for one of in the community, there should be one, not one at every hospital. But that would presume that the goal of the health system was to increase the health of the American people at the lowest effective cost. It isn’t. It’s to make money. If I can get your patients to come to me instead, it is seen as a victory (from a competitive business sense). It is really a loss for the health of our people and the pocketbooks of us all.

It is particularly depressing because that money is not buying us health. If you still harbored the belief that “we have the best health care system in the world”, it’s time to acknowledge that you are wrong (although we forgive you given the hype!). We should all know how expensive our health care system is, that we spend way more than any of the other developed countries (members of the Organization for Economic Cooperation and Development, OECD). The attached graph, from Steven Woolf, MD, PhD, who was a plenary speaker at the recent Society of Teachers of Family Medicine Annual Conference, shows a comparison of spending and life expectancy for the OECD countries. That’s the US way off to the right, spending more than anyone by far, but having a life expectancy close to the Czech Republic. Better than Mexico, Poland, Slovakia, Hungary and Turkey, but at enormously greater cost!

Woolf was the lead author of the Institute of Medicine’s (IOM) recent report “Shorter Lives, Poorer Health” , which presents depressing, but unfortunately accurate, data on our health status. We are among the “leaders” in death rates from communicable and non-communicable diseases and from injuries. Only for a few causes are our death rates better than the average. Our life expectancy at birth is worse than any of the 17 comparison countries for men, and second worst for women. Our probability of survival to age 50 is lower than any of 21 comparison countries. At any age until 75, we are never better than 15 out of 17 in terms of life expectancy. We do have better survival rates once we reach age 75, but there is no information on how much of that is keeping people alive despite poor quality of life.

Want more? In case you think it is only the minority populations (although that would be part of our population), non-Hispanic whites rank no higher than 16 of 17 at any age below 55. And the only portion of our population for whom mortality rates have risen is non-Hispanic whites with less than 12 years of education. From 2005-2009, the US had the highest infant mortality rate of the 17 countries and the 31st highest in the OECD. Non-Hispanic whites and mothers with 16+ years of education also have higher infant mortality rates than those in other countries. Among the 17 peer countries, mortality from transport accidents decreased by 42% in the OECD between 1995 and 2009, but by only 11% in the US. The same trends hold for child and adolescent health – and ill-health and mortality.

And then there are the areas where we really shine, particularly health issues related to guns.
  • In 2007, 69% of US homicides (73% of homicides before age 50) involved firearms, compared with 26% in peer countries.
  • A 2003 study found that the US homicide rate was 7 times higher (the rate of firearm homicides was 20 times higher) than in 22 OECD countries.
  • Although US suicide rates were lower than in those countries, firearm suicide rates were 6 times higher.
We have the highest child poverty rates in the OECD, our preschool enrollment is below most countries, and the ratio of social services spending to medical spending is below almost all other OECD countries.
This is insanity. We are spending enormous amounts of money, but we are spending it so that our hospitals can compete with each other, so that we can deliver the most expensive and high-tech care whether it benefits people’s health or not, and we then do not have any money left to do the things that would really enhance health: expanding education, creating jobs, decreasing poverty, ensuring that people had homes and enough to eat.

Not to mention the guns.

What can we really expect from ObamaCare? A lot, actually.

Despite the constant refrain heard from many (particularly Republicans, particularly in Congress, and particularly from the particularly self-promoting Sen. Ted Cruz of Texas) that “ObamaCare” (the Affordable Care Act, ACA) is the first sign of the coming apocalypse, and concerns from people like me that it is a great deal for insurance companies and will still leave many people without coverage, it is going to happen and it is going to be a good thing for the health of many people. It’s too bad that the crêpe being hung by the nay-sayers is believed by so many, largely a result of it being so well funded. Of course, this doesn’t mean that Sen. Cruz is going to change his tune or that I am going to stop worry about those who continue to be without insurance (especially in states that don’t expand Medicaid, like mine).
Some have suggested that the biggest fear Republicans have is that it will work, and people will benefit, and that now is the time to scare people to try to get rid of it, since once it is in place people will not want to give it up (see: Medicare). Right now, satirist Andy Borowitz can make fun of the right’s hyperbole with bits like “Fox News: Obama In Plot To Force Americans To Live Longer”, but when people actually do get health care, and the costs do go down, and maybe they do live longer, or at least live in better health (longer “healthy life expectancy”, or HALE; see The State of US Health: improved over 20 years, but not nearly enough”, July 14, 2013), they are going to be happy with it. When you can get health insurance even though you have a pre-existing condition, when you can get health insurance on the exchange marketplace even though your employer hasn’t offered health insurance to you, when you can afford the premiums because those between 133% and 400% of the poverty level will get federal subsidies, it is not likely to make you unhappy and you are very unlikely to want to give it up.
Of course, those who are under 133% of poverty were to have been covered by Medicaid expansion, and this is not going to happen in a lot of states, so these folks will be left out. Chang and Davis, writing in the Sept-Oct issue of the Annals of Family Medicineexamined “Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries”. Using a large federal database (NHANES) they compared over 13 million people in each category, and found that the potential beneficiaries were more likely to be male and white and to have about the same level of educational attainment as current recipients. They also had better self-reported health status, and were less likely to be obese or depressed. The prevalence of diabetes and hypertension were about the same, and the potential beneficiaries were more likely to be smokers and heavier drinkers. So, in general, expanding Medicaid to this larger population would result in a healthier (and thus less costly) group to care for, although with significant risk factors. This is related to the argument I have for expanding Medicare to include everyone (a single-payer health system): the highest cost utilizers, the old and disabled, are already in it and expanding it will, thus, not cost as much more as one might think (or certainly not as much as using the private insurance market as we currently do, or even under the Obamacare expansion).
Two editorials accompany this article. Danel Derksen discusses how the ACA will offer opportunities for (and challenges to) both family physicians and public health, while J.P. Silvers compares the objectives of the plan and the results that it is likely to achieve in the real (“imperfect”) world, with emphasis on the potential for “market failure” as the limiting factor. He lists the 3 main objectives of the ACA as 1) reforming the private insurance market, 2) expanding Medicaid, and 3) changing the way that medical decisions are made. The first, the effort to get those currently left out of the insurance market primarily because they are self-employed or work for small companies, is to be accomplished by the subsidized health insurance exchanges, with quite significant subsidies; the idea is that competition will lead to lower prices and better coverage. If this doesn’t happen (“market failure”) then the goal is not going to be achieved. So far, I note, in most states it seems to be working.
Expansion of Medicaid to cover people who are below 133% of poverty and yet not currently eligible was a cornerstone of the program, and the one that the Supreme Court made optional; per this map from the www.Bankrate.comwebsite, 23 states + DC will be expanding Medicaid, 21 will not be, and 6 are undecided. The fact that the federal government will be paying for it seems to have convinced several Republican-controlled states (e.g., Arkansas, Kentucky, North Dakota, and Arizona) that it would be a good idea. Of course, it is a good idea, and not doing it is a way for those who are themselves “feeding at the public trough” (legislators who get publicly-funded insurance) to punish the needy, falsely cloaking themselves in the language of conservatism. As Silvers notes, to really improve health, Medicaid rates will need to be high enough that providers will actually care for beneficiaries.
The third area is changing medical decision making, to both improve the quality of care and lower the cost, issues about which I have often written (see, for example, Controlling the cost of health care by doing the right thing, Sept 22, 2013). Silvers cites, in particular, comparative effectiveness research (CER) which will show us which things work and which things cost the least to achieve comparable results, and which, it is to be hoped, would actually change medical practice. He then goes on to describe the factors which exist in our “imperfect world” that threaten the achievement of these goals, because “There are serious problems in the way the US health system is organized and paid, in the information and choices available, and in the ability of participants to respond to the pressures and incentives provided in reform.” The three classes of problems he discusses are “when decisions are delegated to someone who is supposed to act strictly in our interest as an agent, but doesn’t”, such as brokers who are paid commissions from someone else for signing us up; limits on potential competitors (as arising from pharmaceutical patent protection); and “when one party in a transaction has differential information that allows them to dominate or exploit decisions”, in play with regard to physicians, hospitals, drug companies, insurance companies, and almost everyone involved in health care compared to regular folks. He notes “Finally, the plethora of perverse payment incentives is the most obvious problem in having informed free choice leading to the optimal outcomes desired.”

And this is the real point. The web of multiple strategies for achieving coverage are incredibly complicated, with roots in both the Clinton plan and Massachusetts’ “Romneycare’ and (ironically) in the ideas of right-wing think tanks over the last several decades. This patchwork of fixes has always been a Republican (and conservative Democratic) hallmark. While Silvers titles his final section “What does it mean for the future and what can be done?”, in fact he mostly tells us what the risks are rather than what could be done. There are many who suggest (or fear) that the biggest threat from a potential failure of Obamacare would be that it would make the fact that a single-payer system would be much simpler and effective more obvious; see Morici “First Obamacare, Then a Single Payer System” on, cited by Don McCanne in Quote of the Day.

That’d be nice.

Guns and the Public’s Health: what can we do?

 “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”
Recognize those words? The Second Amendment to the Constitution of the United States, what all the fuss is about. In addition to the confusing use of commas, apparently more generously applied in the 18thcentury, we have two key phrases. The final phrase, “shall not be infringed”, is read by the NRA and other “gun rights” zealots (and it is important to remember that only a minority of NRA members, and a smaller minority of gun owners, support this position) to mean essentially “no legislation regulating guns in any way”. That includes assault rifles, semi-automatic and maybe even automatic rifles, armor-piercing (“cop killer”) bullets, and any other weapon or gun modification that creative minds can come up with. Of course, it has been noted that none of these types of weapons were available at the time of the Constitution, when firearms were muzzle-loaded muskets, quite different from current weapons (see graphic).

The NRA take the position that there is qualitatively no difference, as noted by its President, Wayne LaPierre, after the December 2012 massacre at Sandy Hook Elementary School: “Absolutes do exist. We are as ‘absolutist’ as the Founding Fathers and framers of the Constitution. And we’re proud of it!” Others (including me, in case you were wondering) would disagree, and say that clearly at some point the quantitative difference becomes qualitative. This is the only amendment they are absolutist about; the First Amendment says “Congress shall make no law… abridging the freedom of speech…”, but it has long been settled that it is not OK to yell “Fire!” in a crowded theater.
The other obviously important phrase is “A well regulated Militia”. Again, obviously, this has been the source of much discussion, with the NRA taking the position that “Militia” just means “everyone” (kind of a stretch), and (as far as I can tell) “well regulated” means, um, not regulated at all. Is this cherry picking the words one wants? Maybe, but I can’t imagine how it is possible to ignore completely the words “well regulated”. But does it matter? Yes, when we live in a country where
The 36,252 deaths from firearms in the United States in 2015 exceeded the number of deaths from motor vehicle traffic crashes that year (36,161). That same year, the US Centers for Disease Control and Prevention reported that 5 people died from terrorism. Since 1968, more individuals in the United States have died from gun violence than in battle during all the wars the country has fought since its inception.
Bauchner et al., Death by Gun Violence—A Public Health Crisis, JAMA, October 9, 2017[1]
Those are staggering numbers, and certainly justify the assertion that it is a “public health crisis”.
The authors also note that “60.7% of the gun deaths in 2015 in the United States were suicides, a fact often ignored. That is a majority. A large majority. If it were an election, 60.7% would be considered a landslide. But with guns it is a mudslide of death. I have written before about suicide (e.g, Suicide: What can we say? December 13, 2013, Suicide in doctors and others: remembering and preventing it if we can September 14, 2014, Prevention and the “Trap of Meaning” July 29, 2009) and its impact on myself and my family, with my son’s successful suicide-by-gun at the age of 24. My son, to my knowledge, had never used a gun before his final act. He lived in a state and city with strict gun control laws (some of which, sadly, have been eliminated by the courts). He was nonetheless able to go to another state, buy a carbine (terrific choice! No permit needed, even in those days, like a handgun would require, but short enough to reach the trigger with the barrel in his mouth!), and use it. It would be easier now, in that state and many others.
My son was apparently very committed to this act, and was successful despite some obstacles. But for many, many people it is the availability of guns that make a spur-of-the-moment decision lethal. I have noted before that nearly 95% of suicide attempts by gun are lethal while less than 5% by drug overdose are. My clinical experience is that many suicide survivors do not repeat their attempts (though many do). The successful suicide rate for young adult males in low gun control states is several times higher than in high gun control states. And on and on.
But the epidemic of suicide and murder and mass murders resulting from the easy availability of guns has not changed the legal landscape. After the Las Vegas massacre, there was a small ray of hope that maybe one of the most egregious products the white terrorist Stephen Paddock used, the “bump stocks” that effectively convert semi-automatic to automatic rifles, might be limited; even the NRA voiced some possible support. But never underestimate the cowardice and lack of moral fiber of the Congress; Speaker of the House Paul Ryan has suggested that this be done by regulation rather than legislation. This is absolutely because it will not require any congressperson to actually vote for it and thus be targeted by the zealots in the next election. Hopefully, not literally targeted by guns, but do not forget Gabby Giffords and Steve Scalise!
Dr. Bauchner, who is the editor-in-chief of JAMA, also joined the editors of several of the other most prestigious US medical journals, New England Journal of Medicine, Annals of Internal Medicine, and PLOS Medicine in an editorial that appeared in all their journals (this link is the the NEJM), ‘Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals’.[2] Again, this emphasizes the fact that guns are a public health epidemic in the US, and that there is little likelihood of anything being done at the federal level to stem its carnage. It recognizes that there is a variable response at the state level, with some states going as far as trying to legally prohibit physicians from asking about guns in the home (Florida; since struck down by the courts) while others have had stronger regulations. Many legislatures have also acted to prevent the cities in their states from acting independently to regulate guns in any way. One of the most insane was the state of Arizona suing to prevent the city of Tucson from destroying guns seized from criminals. The legislature mandated that they be sold – thus keeping them on the streets – and the Arizona Supreme Court upheld this, saying state law trumped local ordinances!
Given this situation, the joint editorial suggests that there are many things that physicians can and should do, including (quoted):
·        Educate yourself. Read the background materials and proposals for sensible firearm legislation from health care professional organizations. Make a phone call and write a letter to your local, state, and federal legislators to tell them how you feel about gun control. Now. Don’t wait. And do it again at regular intervals. Attend public meetings with these officials and speak up loudly as a health care professional. Demand answers, commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to organizations fighting for sensible firearm legislation. Ask candidates for public office where they stand and vote for those with stances that mitigate firearm-related injury.
·        Meet with the leaders at your own institutions to discuss how to leverage your organization’s influence with local, state, and federal governments. Don’t let concerns for perceived political consequences get in the way of advocating for the well-being of your patients and the public. Let your community know where your institution stands and what you are doing. Tell the press.
·        Educate yourself about gun safety. Ask your patients if there are guns at home. How are they stored? Are there children or others at risk for harming themselves or others? Direct them to resources to decrease the risk for firearm injury, just as you already do for other health risks. Ask if your patients believe having guns at home makes them safer, despite evidence that they increase the risk for homicide, suicide, and accidents. [this is what the Florida law would have made illegal]
·        Don’t be silent.
The first (JAMA) editorial says:
Guns kill people….the key to reducing firearm deaths in the United States is to understand and reduce exposure to the cause, just like in any epidemic, and in this case that is guns.
The fact is that while physicians have influence and moral authority, so do other health professionals, and, in fact, so do all of us. So the advice must pertain to all of us.
Don’t be silent.

[1]Bauchner H, Rivara FP, Bonow RO, Death by gun violence—a public health crisis, JAMA online Oct 9, 2017, doi:10.100/jama.2017.16446
[2]Taichman DB, Bauchner H, Drazen JM, Laine C, Peipert L, Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals’, October 9, 2017DOI: 10.1056/NEJMe1713355

Medical schools are no place to train physicians

Doctors have to go to medical school. That makes sense. They have to learn their craft, master skills, and gain an enormous amount of knowledge. They also, and this is at least as important, need to learn how to think and how to solve problems. And they need to learn how to be life-long learners because new knowledge is constantly being discovered, and old truths are being debunked. Therefore, they must learn to un-learn, and not to stay attached to what they once knew to be true but no longer is. They also need, in the face of drinking from this fire-hose of new information and new skills, to retain their core humanity and their caring, the reasons that (hopefully) most of them went into medicine.
Medical students struggle to acculturate to the profession, to learn the new language replete with eponyms, abbreviations, and long abstruse names for diseases (many are from Latin, and while they are impressive and complicated, they are also sometimes trite in translation, e.g., “itchy red rash”). They have to learn to speak “medical” as a way to be accepted into the guild by their seniors, but must be careful that it does not block their ability to communicate with their patients; they also need to continue to speak English (or whatever the language is that their patients speak). “Medical” may also offer a convenient way of obscuring and temporizing and avoiding difficult conversations (“the biopsy indicates a malignant neoplasm” instead of “you have cancer”).  But there needs to be a place for them to learn.
So what is wrong with the places that we are teaching them now? Most often, allopathic (i.e., “MD”) medical schools are part of an “academic health center” (AHC), combined with a teaching hospital. They have large biomedical research enterprises, with many PhD faculty who are, if they are good and lucky, are externally funded by the National Institutes of Health (NIH). Some or many of them spend some of their time teaching the “basic science” material (biochemistry, anatomy, physiology, microbiology, pharmacology, pathology) that medical students need to learn. By “need to learn” we usually mean “what we have always taught them” or “what they need to pass the national examination (USMLE Step 1) that covers that material”. This history goes back 100 years, to the Flexner Report of 1910. Contracted by the AMA, educator Abraham Flexner evaluated the multitude of medical schools, recommended closing many which were little more than apprenticeship programs without a scientific basis, and recommended that medical schools be based upon the model of Johns Hopkins: part of a university (from the German tradition), grounded in science, and based in a core curriculum of the sciences. This has been the model ever since.
However, 100 years later, these medical schools and the AHCs of which they are a part have grown to enormous size, concentrating huge basic research facilities (Johns Hopkins alone receives over $300 million a year in NIH grants) and tertiary and quarternary medical services – high tech, high complexity  treatment for rare diseases or complex manifestations of more common ones. They have often lost their focus on the health of the actual community of which they are a part. This was a reason for two rounds of creating “community-based” medical schools, which use non-university, or “community”, hospitals: the first in the 1970s and the second in the 2000s. Some of these schools have maintained a focus on community health, to a greater or lesser degree, but many have largely abandoned those missions as they have sought to replicate the Hopkins model and become major research centers. The move of many schools away from community was the impetus for the “Beyond Flexner” conference held in Tulsa in 2012 (see Beyond Flexner: Taking the Social Mission of Medical Schools to the next level, June 16, 2012) and for a number of research studies focused on the “social mission” of medical schools.
The fact is that most doctors who graduate from medical school will not practice in a tertiary AHC, but rather in the community, although the other fact is that a disproportionate number of them will choose specialties that are of little or no use in many communities that need doctors. They will, if they can (i.e., if their grades are high enough) often choose subspecialties that can only be practiced in the high-tech setting of the AHC or the other relatively small number of very large metropolitan hospitals, often with large residency training programs. As they look around at the institution in which they are being educated, they see an enormously skewed mix of specialties. For example, 10% of doctors may be anesthesiologists and there well may be more cardiologists than primary care physicians. While this is not the mix in world of practice, and still less the mix that we need to have for an effectively functioning health system, it is the world in which they are being trained.
The extremely atypical mix of medical specialties in the AHC is not “wrong”; it reflects the atypical mix of patients who are hospitalized there. It is time for another look at the studies that have been done on the “ecology of medical care”, first by Kerr White in 1961 and replicated by the Robert Graham Center of the American Academy of Family Physicians in 2003 (see The role of Primary Care in improving health: In the US and around the world, October 13, 2013), and represented by the graphic reproduced here. The biggest box (1000) is a community of adults at risk, the second biggest (800) is those who have symptoms in a given month, and the tiny one, representing less than 0.1%,  is those hospitalized at an academic teaching hospital.  Thus, the population that students mostly learn on is atypical, heaving skewed to the uncommon; it is not representative of even all hospitalized people, not to mention the non-hospitalized ill (and still less the healthy-but-needing-preventive care) in the community.

Another aspect of educating students in the AHC is that much of the medical curriculum is determined by those non-physician scientists who are primarily researchers. They not only teach medical students, they (or their colleagues at other institutions) write the questions for USMLE Step 1. They are often working at the cutting edge of scientific discovery, but the knowledge that medical students need in their education is much more basic, much more about understanding the scientific method, and what constitutes valid evidence. There is relatively little need, at this stage, for students to learn about the current research that these scientists are doing. Even the traditional memorization of lots of details about basic cell structure and function is probably unnecessary; after 5 years of non-use students likely retain only 10% of what they learn; even if they need 10% — or more – in their future careers, there is no likelihood that it will be the same 10%. We have to do a better job has of determining what portion of the information currently taught in the “basic sciences” is crucial for all future doctors to know and memorize, and we also need to broaden the definition of “basic science” to include the key social sciences of anthropology, sociology, psychology, communication, and even many areas of the humanities such as ethics. This is not likely to happen in a curriculum controlled by molecular biologists.
Medical students need a clinical education in which the most common clinical conditions are the most common ones they see, the most common presentations of those conditions are the most common ones they see, and the most common treatments are the ones they see implemented. They need to work with doctors who are representative, in skills and focus, of the doctors they will be (and need to be) in practice. Clinical medical education seems to work on the implicit belief that ability to take care of patients in an intensive care unit necessarily means one is competent to take care of those in the hospital, or that the ability to care for people in the hospital means one can care for ambulatory patients, when in fact these are dramatically different skills sets.
This is not to say that we do not need hospitals and health centers that can care for people with rare, complicated, end stage, tertiary and quarternary disease. We do, and they should have the mix of specialists appropriate to them, more or less the mix we currently have in AHCs. And it is certainly not to say that we do not need basic research that may someday come up with better treatments for disease. We do, and those research centers should be generously supported. But their existence need not be tied to the teaching of medical students. The basic science, and social science, and humanities that every future doctor needs to learn can be taught by a small number of faculty members focused on teaching, and does not need to be tied to a major biomedical research enterprise. Our current system is not working; we produce too many doctors who do narrow rescue care, and not enough who provide general care. We spend too much money on high-tech care and not enough on addressing the core causes of disease.

If we trained doctors in the right way in the right place we might have a better shot at getting the health system, and even the health, our country needs.

President Obama on the ACA and next steps: what do we really need to improve our health?

On July 16, 2016, the JAMA took the unusual step of publishing an article by the President of the United States. “United States Health Care Reform: Progress to date and next steps”, by Barack Obama, JD, is by definition “political” and a defense of his administration’s health care policy and achievements, but it is also a well-documented piece of policy research. In it, the President details the improvements in both health care access and actual health status achieved by Americans since the passage (in 2010) and largely-full implementation (in 2014) of the Affordable Care Act (“Obamacare”), and provides evidence to support the central role of the ACA in creating those positive changes. He particularly notes that this improvement is not simply a result of improvement in the economy recovering from the Great Recession of 2008; this is supported by the fact that many indicators of breadth of coverage (what percent of people had health insurance), quality of coverage (how good was it), cost of coverage, and quality of care were getting worse for a long time before 2008.
The President provides data to demonstrate the increase in the number of insured people, especially in the 31 states that have expanded Medicaid. But coverage has expanded even in the others, due mainly to the availability of coverage on the Health Insurance Exchanges, the decrease in cost despite dire predictions for rate increases by insurers, the move (seen variably across the country) away from fee-for-service and towards comprehensive care reimbursement for health care providers, the decrease in the Medicare drug coverage (Part D) “donut hole”, the improvement in health status and quality outcomes from greater tobacco control, and many other positive results of ACA.
President Obama also bemoans the changes that the ACA was unable to achieve because of Republican opposition (while this could be perceived as partisan, it is fact, and fact strongly acknowledged by the Republican Party which has voted to repeal ACA dozens of times). He ends with a lengthy plan for the future, a future in which he will not be President, and what yet needs to happen to improve health and health care in the US. This includes the expansion of Medicaid to all 50 states, increasing competition in the marketplace so all Americans have access to a choice of plans, and limiting the control of special interests, especially drug companies:
The second lesson is that special interests pose a continued obstacle to change. We worked successfully with some health care organizations and groups, such as major hospital associations, to redirect excessive Medicare payments to federal subsidies for the uninsured. Yet others, like the pharmaceutical industry, oppose any change to drug pricing, no matter how justifiable and modest, because they believe it threatens their profits.
While the President does not call out the insurance industry as he does the pharmaceutical industry, he renews the call for a “public option” to compete with private insurance companies. He stops short of supporting a single-payer system, invoking “pragmatism” (defined as “we have to find something palatable to those who oppose change because they are doing so well now”) “Simpler  approaches to addressing our health care problems exist at both ends of the political spectrum: the single-payer model vs government vouchers for all.”
When I am confronted by this pragmatism argument, I am somewhat sympathetic. Given the opposition both from Republicans in Congress and entrenched, wealthy and powerful industries (not only pharmaceutical and insurance, but also providers), the passage and implementation of the ACA was a formidable victory. All of the data cited by the President is true, and almost all of it is good. More people ARE covered, the quality of their coverage has improved, the cost to the system (and in most cases to individuals) has gone down, and there have been positive developments in the areas of quality improvement, fraud, and value, and moves away from fee-for-service to comprehensive care. The President led this effort and has the right to be proud, but the holes in the health system that remain are still very large.
For many people, good health insurance coverage is unaffordable; they buy policies on the exchanges that do not cover their needs when they get sick. For many others, there is still no coverage – most of those below 137% of poverty in states that have not expanded Medicaid, those without legal documentation, and some others. The powerful provider, insurance, and pharmaceutical industries have an outsized voice in determining health policy. The disorganized and fragmented nature of our health system and piecemeal nature of coverage and incentives for coordination of care, even with the ACA, lend themselves to healthcare industries (including doctors and hospitals) finding “work-arounds”, or “gaming the system”, for their self-interest.
The key, essential issue in considering past, present and future healthcare and health insurance reform is whether the goal is to maximize the health of the American people or something else (mainly, as I have suggested before, industry profit). There is a cohort of politicians, pundits, and commentators, who are ideological devotees of the unfettered market (and of Ayn Rand novels) who actually are against maximizing health for all; they may be unusually influential, but they are few. There is a larger group, the corporations who are believers only in their making profit, which means the free market only when it advantages them and government support of their industries when that advantages them. And, of course, there are the many politicians and pundits who are on their payrolls, direct or indirect (e.g., campaign contributions). Their role has always been powerful and is greater since the Citizens United Supreme Court decision that said corporations are people and money is speech.
But the largest group is regular people, trying to get by and trying to make sense out of these purposely-obfuscated policy issues. They include folks with and without insurance, like those who are interviewed by Dr. Paul Gordon on his Bike Listening Tour across America, who say things like “Obama Care helped the poor, but now the working class is struggling”. People who are trying to figure out what kind of insurance to purchase on an exchange, and very often opt for the plan with the lowest premiums that will take the least out of their monthly income so that they have more for food, housing, and other necessities as well as some entertainment or relative “luxuries”. And who only find out when they get sick how bad that coverage is, and how much debt they are going to be in, because they lost that gamble.
The reason for this is that, as I have often discussed (perhaps first in “Red, Blue, and Purple: The Math of Health Care Spending”, October 20, 2009), most people are, at any given time, not sick. Most people, especially younger people, will not be sick at any time for the whole year, or a number of years. Thus spending high monthly premiums for good (or better) coverage seems like a burden, and it is. Until, of course, they get sick. Until they get cancer, or get in a car wreck, or have a premature baby, or find their hitherto pretty-well-controlled chronic diseases spiraling downhill. Advocates of consumer choice may say “tough luck, that’s the market”, but this is people’s health. Consistently, surveys of the American (and most other) people find that the vast majority want everyone to have access to high-quality care when they need it – and even want it for “other people” that they don’t know. But the solution, even with ACA, forces them to gamble on their future health while ensuring that insurers and drug makers and the biggest healthcare providers make money. It is a plan to create fear and anxiety and insecurity, despite the accuracy of the overall improved health, and financial, picture that the President paints in his article.
There is a solution. It is indeed a single-payer system. One where everyone is covered, and pays what their incomes can reasonably afford, where the whole society is the risk pool rather than the individual, and people don’t have to gamble with their future health. We could have that, and most of us would relish it (like the vast majority of citizens of other developed countries who have it), and it would provide our only reasonable hope of truly controlling cost and improving quality.
But we are going to have to fight for it. Power does not relinquish control and money easily.

Decreased need for blood transfusions: bad for business but good for people

The New York Times of August 23, 2014, contains a front-page story by Matthew L. Wald with good news. The use of blood in the US has gone down, because the need has gone down significantly: a decline of almost one-third over the last five years. One big reason is that new surgical techniques, such as laparoscopy and other “minimally-invasive” methods, have replaced many of the traditional “cut someone open” surgeries, so there is thus less blood loss and less need for transfusion. The other reason is that guidelines for blood transfusion have been more standardized and made more stringent, so that only people who really need blood get it rather than it being administered “routinely” to people after certain kinds of surgery. Certainly, in my institution, the physician who is director of our blood bank keeps a close eye on transfusions being ordered for people whose blood counts are above the generally-recommended cut-offs (provided of course, that they are not actively hemorrhaging). Since blood transfusion, like any other treatment, can have negative effects (the transmission of viral diseases like Hepatitis B and C, and HIV are not very significant any more now that we can test for them, but transfusion reactions still occur, especially in those who have multiple transfusions), it is obviously a good idea to limit them to only when they are really needed. Wald notes other reasons:
…new guidelines emphasize treating patients for anemia [my note: not with transfusions but with treatments that encourage the body to make more of its own blood, such as iron] in the weeks before surgery to minimize the need for transfusions. Cancer therapies have also changed in a way that reduces transfusion needs. So has surgery: In a total hip replacement, loss of 750 milliliters of blood, about 1.5 pints, was considered standard; now it is just 200 milliliters.
So it is a little surprising that the title of the article is in the negative: “Blood industry hurt by surplus” in the print edition (a little less negative, “Blood industry shrinks as transfusions decline” in the on-line version), and much of its thrust is about how this decreased need for blood and associated pressure from its purchasers (mostly hospitals) for lower prices is leading to decreased profits, industry consolidation, and worker layoffs. I assume that (based on the fact that the on-line version is part of “Business Day”) that this is in part because it is a business article and that Mr. Wald is a business reporter, not a health reporter. I guess it is indeed too bad for the owners of the for-profit blood banks (as opposed to the non-profit American Red Cross), and it is really bad for the workers, many of whom seem to be represented by the Communication Workers of America, who are losing their jobs. But from a health point of view, the fact that people are only getting blood transfusions when they really need them, and that the frequency of that need is declining, is a very positive development.
One of the more interesting points that Wald makes is the cost of blood products:
Nonprofit organizations collect whole blood from unpaid donors, but hospitals may pay $225 to $240 a unit, according to executives in the business, which covers a variety of costs, including testing. If the unit is billed to the patient, the price can be $1,000 or more.
That’s quite the markup. The markup from unpaid donors to the cost to hospitals is in part explained by the cost “…for storage, management and inventory losses; around a million units a year are discarded, mostly because they are not used soon enough.” Fair enough; these are real costs that must be covered, and the blood banks are bearing them, and hospitals want to pay less for the blood. Less justifiable is the markup by the hospitals, from less than $250 to over $1,000 per unit of blood, although as I have often discussed, this is not atypical for hospital charges. Once again, this is an example of business interest (maximizing profit, even in non-profit hospitals) diverges from the health interest of people (to get their care at a reasonable cost).
The treatment of positive health developments as negative business developments is not new, or unique to blood banking. If more care can be safely and effectively delivered in the outpatient setting, so that hospital admissions decrease, it may be bad for hospital business but it is good for people. If cheap drugs are effective for preventing or treating serious medical conditions (like aspirin to prevent heart attack in men or stroke in women, or folic acid – a vitamin – given to pregnant women to prevent neurologic defects in babies), it may be bad for companies making more expensive drugs to do the same thing, but it is good for people. Conversely, when a previously generic and cheap drug is allowed by a glitch in federal law to be patented, it is good for business but bad for patients (this actually happened in the case of the anti-gout drug colchicine; see the April 16, 2010 guest blog by R. Steven Griffith, VISA and colchicine: maybe the banks and Pharma really ARE in it for the money!). If we have duplication (or triplication, or quadruplication, or whatever) of expensive health care services so that there are more cancer centers, or MRI machines, or transplant centers than a community needs, it may be perceived as necessary for that individual hospital to “compete” but it costs our health system (that is, us all) more money.
What is interesting about this article is the difference in how the cost of health care services are treated by a business reporter (good or bad for business) and how they are treated by a health reporter such as Elisabeth Rosenthal, whose series of NY Times articles (e.g., “The $2.7 Trillion medical bill”) extensively document the high costs and markups in health care. The question for the rest of us is what we feel is more important, business profits or quality cost-effective health care, without unnecessary markups or excessive redundancy in capacity. It is sad when jobs are eliminated because certainly our people need jobs, but that is another question.
I think I am pretty clear on where I stand.

Medical communication is indeed often “lost in translation”

I often write about the things that I believe make a big difference in the health of people. Some of these are access to the health system, particularly financial access in the US. The bizarre and inappropriate structure of the US health system in terms of overemphasis on high-tech, subspeciality care at the expense of adequate primary care is extremely important. I also believe that the “social determinants of health”, the characteristics of people’s lives that are not usually considered as part of the health system (socioeconomic status, environmental exposures, stress, education, housing, etc.) are major contributors to health.

I have also written about medicine in terms of recommendations for prevention and screening from different organizations (I tend to advocate for those from the US Preventive Services Task Force) and about treatments that are promoted but are often of minimal benefit and sometimes harm to people. Occasionally, I even venture into the area of medical research, trying to help folks understand how science progresses, and how there is rarely a “breakthrough” as big as the news media like to trumpet. As a medical educator, I am very concerned about how we train doctors, and have also frequently written on that topic.

Most of these themes are focused on “population health” rather than the management of individual patients with individual diseases, not because the latter is unimportant but because these issues are extensively addressed in many other outlets, and the ones that I have described are, I think, not as well understood both by the medical community and the general population. I believe that the almost exclusive emphasis in our country on treatment of individuals limits both our commitment to addressing population and system issues, and the resources available to do so.

However, sometimes there is an issue that is mostly about human behavior, something that could be changed, and would make a big difference in the healthcare experiences of most people. One of those I have touched on before (Medical schools are no place to train physicians, January 5, 2014), because I see it as a key part of medical education, is communication between health care providers and their patients. This was addressed in an outstanding “Opinionator” blog that appeared in the New York Times on February 9, 2014, “Lost in Clinical Translation” by Theresa Brown.

Ms. Brown is apparently a nurse, but what she discusses is at least as applicable to doctors and to other health professionals. Starting with a reference to the Gary Larson “Far Side” cartoon here, she gives excellent examples of failures of communication that were disturbing to patients, but did not, apparently, disturb the health professionals who, presumably, thought they were communicating as clearly as Ginger’s human owner does. One story is of her friend’s husband, who a heart procedure called a “cardiac catheterization” to look for blockage in the arteries that supply the heart itself, which can cause a heart attack. (That description is, I hope, clear; when I told my residents, however, I just said “he had a cardiac cath”, which was very clear to them but would likely have mystified most patients.) As it turns out the test was completely normal, but this was not clear to the obviously very worried wife who understood almost nothing about what she was being told (for example, that he was being kept overnight in the intensive care unit because this is routine after such a procedure, not because his condition required intensive care!).

This sort of thing happens a lot. Daily. Hourly. There are many reasons for poor communication to occur between health professionals and patients. Some are that people, when they are scared and sick and in a strange place, have difficulty listening to strange words and understanding unfamiliar concepts. They may have to be told again and again, just as, I tell my students and residents, we all had to study to pass exams even though we’d be “told” everything once, in the lecture. But there are a lot of other things that are our fault, and can be remedied by different behaviors.

One, we – doctors, nurses, and other health professionals — are very comfortable in the hospital, and we take it in stride; it is our “briar patch” and we’re at home, but for patients and families it is a scary place full of thorns. I ask doctors and nurses to think about they would feel if they had to go to court, as witness or defendant or plaintiff, and look at how easily the attorneys comport themselves. It is a good reminder of how patients feel in a hospital.

Two, we speak “medical” fluently. We have such familiarity with both words and concepts that we assume that they mean something to regular people (which is, by the way, the correct English term for “patients” and “patients’ families”). But usually they don’t; words that mean very different things sound a lot the same; even if people have heard them before they usually have only a vague idea of what they mean, and the difference between “is” and “is not” is, while obviously very significant, not always clear to folks. I point out, just for an easy one, how often we use “negative” when we are describing a normal test. We should ALWAYS use “normal” or “not normal”. “Negative” sounds bad. “Positive” (which is often bad) sounds good!

Three, we often use obfuscating words, unnecessarily medical words when regular ones will do fine, and use lots of modifiers and adverbs that make what we are saying even more unclear. The use of such modifiers (“probably”, “likely”, “potentially”, ‘possibly”) may make what we say more technically accurate, but can obscure the message. Similarly, we are often uncomfortable giving bad news, and when we use such modifiers we may think we are lightening the load a bit for the patient, but really we are being more unclear. When we hide behind medical words, we are protecting ourselves from having a long and perhaps difficult discussion; completely subconsciously, I’m sure, we expect that maybe they won’t understand, and thus won’t ask hard questions. Also we tend to speak in the third person, kind of distancing both ourselves (first person) and the patient (second person) from what we are saying. All these are illustrated by thinking about how a statement like “The biopsy result showed that the tumor was probably malignant” conveys a very different (and probably incomprehensible) message than “you have cancer”.

It is a lot to think about, but the good part is that these behaviors can change. We just have to want to, and work at it.

NOTE: The Medicine and Social Justice blog will appear less often than it has, intermittently or maybe not at all, for some time. I am on sabbatical and will be engaged in writing a book, more or less on the themes described in the first two paragraphs of this piece, the themes that have been the subject of this blog.

Medicare and Medicaid at 50: Time to include “US” all

On Thursday, July 30, Medicare and Medicaid turned 50 years old. The anniversary was marked by an event held at the Truman Library in Independence, MO, which I attended. Why there? In 1965, President Lyndon Johnson signed those bills (officially Titles XVIII and XIX of the Social Security Act) there, in the presence of former President Truman and his wife Bess, who received cards #1 and #2. The location was chosen for its symbolism even in 1965, because Truman had fought for a national health insurance system and lost. Nearly 20 years later, Johnson honored his legacy by signing these two major bills (also opposed by the AMA) in his library. Both presidents thought that this was a down-payment on the national health insurance system that was sure to come soon. But it took another 45 years to pass the Affordable Care Act (ACA), and we still don’t have universal health insurance, and ACA and even Medicare are under constant attack. At least now it is not the AMA that is the active opposition.
This event was not the first held at the Truman Library to remember that day. Seven years ago, a group of single-payer activists organized a 43rd anniversary celebration there, both to commemorate the signing and to call for a universal health insurance system. That event was less “official” but more passionate, with talks by both local KC Congressman Emanuel Cleaver II and Rep. John Conyers of Michigan. Rep. Conyers’ first year in Congress was 1965, the year Medicare and Medicaid passed, and all those years later he was still vital and still in Congress and was the sponsor of HR 676, the national single payer bill. This year’s event had more of the feel of an administration press conference with several federal and Missouri bureaucrats speaking. Some of talks, including those by Truman’s grandson Clifton Truman Daniel and former Missouri state rep and insurance commissioner Scott Lakin, were good, but only one had any real passion. That was given by Bridget McCandless, MD, the CEO of the Health Care Foundation of Greater Kansas City (HCFGKC), which sponsored the event.
There is a reason for that. Before taking the reins of HCF, a “conversion” foundation established with the money that came from the sale of a group of not-for-profit hospitals to for-profit HCA, Dr. McCandless, a self-described “Independence girl”, was the medical director of the Jackson County Free Health Clinic in Independence, caring for the many people in that area who could not otherwise access excellent health service. She cared for people who had little, whose lives, in Dr. Camara Jones’ metaphor (most recently discussed in Racism and the Social Determinants of Equity: Camara Jones at Beyond Flexner 2015, April 19, 2015), were lived on the edge of the cliff before they even got sick. Dr. McCandless’ clinic provided a safety net that prevented many people from falling to the ground below. The “lucky” ones were those who were old enough (or disabled enough) to qualify for Medicare, and poor-plus-something enough to qualify for Medicaid. For those people, these federal programs, which now cover about 30% of Americans were indeed life savers.
Dr. McCandless, whose foundation is committed to funding programs that help the underserved and uninsured (the exceptional founding CEO, Steve Roling, was in the audience), talked, as did other speakers, about the difference that Medicare had made in the lives of seniors; before it they (and their families) lived their retirement years in financial fear of sickness. But her passion really showed when talking about Medicaid, originally seen as a means of providing access to health care for the poor. You certainly have to be poor to receive Medicaid, very poor in many states including Missouri, but that is not sufficient. She told us that you have to be “poor and”. Poor and pregnant, poor and the mother of small children, poor and disabled, poor and in a nursing home, poor and – and the tears rolled down her cheeks – a child. ACA was intended to expand this federal-state collaboration to encompass all the “just” poor (with the exception of those who are undocumented), but Missouri, and Kansas, the other state in the Kansas City metropolitan area, are among the states that have not done so.  Dr. McCandless eloquently expressed her hope that our states would rise to the need, that our legislators and leaders would rise to the decency, to remove the “and” by expanding Medicaid.
While it is possible that Missouri, and Kansas, and the other states that have taken advantage of the 2012 Supreme Court decision (National Federation of Independent Business v. Sebelius), that otherwise upheld the ACA, to not expand Medicaid will still do so, it is unconscionable that they have not yet, that they have left so many people who could now be accessing health care uncovered. It is a land-office business for the safety net clinics in the area, like Dr. McCandless’ former practice, but it is a volume that they can barely care for. When people get very sick, and show up in the Emergency Department and get admitted to the hospital, those hospitals bear the brunt of care without payment, but even their usually powerful lobbies have so far not been successful.
The opposition to this expansion, the opposition to ACA, and even threats to Medicare are often said to be politically driven, but they are ideologically driven. They are driven by the agendas of billionaire elitists, most of whom have never known any hardship. They have been able to further expand their already-considerable influence as a result of the Supreme Court’s Citizens United decision, and blithely fund the election of their minions to state houses and legislatures.  The New York Times on Aug 2, 2015 documents that fewer than 400 families have contributed the almost half the money in this election cycle. Former Oklahoma football coach Barry Switzer once said that many of the privileged were “born on third base and think they’ve hit a triple” (although most of these billionaires were actually born within arm’s length of home plate!). Indeed, they have no empathy; they are selfish and mean. Their minions, who enjoy the power their sponsors’ money provides for them, must be (if they are not truly stupid) also mean, but actually are not fiscally prudent; not funding health care for our people costs us a lot. Medicare already covers our most costly ill (they are old; this is why raising the age for Medicare eligibility to 67 or 68 will save little money). It is way past time for it to cover the rest of us.
Rep Jim McDermott of Washington, a physician and long-time single-payer advocate, has introduced the American Health Security Act of 2015, which will authorize and provide federal funds to support single-payer programs developed by states. It should be passed, but it probably won’t be while we have a Congress bought and paid for by the rich mean selfish people. We have had single-payer bills in Congress before, Rep. Conyers’ and before that Rep. Ron Dellums’. It is time to pass them. We need to go beyond the ACA, we need to make sure states expand Medicaid and take the “and” out of the “poor and” for eligibility. But we need to go farther.

For 50 years Medicare has been literally a life-saver for our seniors. Now we need to expand it to include everyone. Everybody in, nobody out!

Contraception, women’s health and dignity, teens, and stupid legislators

A bill before the Maine legislature would allow women to obtain a year’s worth of oral contraceptives at a time, rather than the previous 3-month limit. This is a good thing, as argued by its sponsors and supporters. Women typically take oral contraceptives for long periods of time, and the requirement that they return to refill their prescriptions every 3 months is at best an inconvenience and at worst a burden. It is a burden women should not have. Indeed, there is no good reason to require a prescription for oral contraceptives at all.
This does not mean that there are no reasons put forward by opponents; if there were none, there would be no opponents. Overall, the opposing arguments fall into 3 categories: money, control, and wacko paranoia. If women only have to fill prescriptions once a year there will be fewer prescriptions being filled, which could be a small hit to pharmacies. The bigger objection is from insurers, as addressed in an article in the Portland Press-Herald of April 19, who worry that it could become a “mandate” for coverage with no cost share for other contraceptives, particularly those that are more expensive for insurers.
Control is a big and insidious issue. The idea that women are incapable of making their own decisions, particularly with regard to their reproductive systems, is as outrageous as it is persistent. For generations women have fought and often won struggles to be considered legally as “people” (implicit definition: men); to have the vote, to own property, to divorce. But no area has been as fraught with (yes, “fraught” requires a preposition!) opposition as the entire area of women’s reproduction. From before the time of Margaret Sanger, every source of pressure – religious, economic, and legal – has been brought to bear against the idea that women should have control of their own bodies and particularly their reproduction. The struggle continues; abortion rights are the most vulnerable today, but as the opposition to the Maine bill illustrates, contraceptive rights are scarcely secure.
Even among the biggest supporters of contraception, there can be poor decisions. Nearly 20 years ago I sat on a Planned Parenthood advisory board, and many of its members were surprised that I strongly opposed a requirement that women have a Pap smear before receiving a contraceptive prescription. The logic of those who supported it was that the inducement of receiving contraceptives would encourage women to get their Pap, which was then recommended. My position was that the negative incentive of the Pap (and associated pelvic examination, see below) would keep women, especially young women and teens, from getting their contraceptives, and thus likely increase unwanted pregnancies. I am sure that that Planned Parenthood, and other contraceptive providers, no longer have such a requirement. Indeed, we no longer recommend Pap smears for women under the age of 21, and for others, they are recommended only every 3 years. Regarding the screening pelvic examination, it simply violates the first criterion for a screening test – there must be condition that can be screened for in an asymptomatic person. This has led the American College of Physicians, having reviewed the evidence, to recommend against it, while the US Preventive Services Task Force (USPSTF) somewhat incomprehensibly, gives it an “I” (evidence is insufficient to recommend for or against) recommendation. This is summarized in a recent review from the Agency for Health Research and Quality (AHRQ). The American College of Obstetricians and Gynecologists still basically advocates it, although it suggests the decision be made individually between the woman and her doctor, no real change from when I discussed it on July 3, 2014 (”The screening pelvic examination: not annual, not ever”).
Being a major provider of contraception does not save PP from the wrath of Congressional Republicans; indeed, while abortion is the flaming tip of the spear of conservative opposition, the right’s opposition to PP is also against those that do not do abortions, but mainly provide contraception and other women’s health services. The good news is that the GOP may be unable to attach defunding PP to the “health” bill (Obamacare repeal) because it is being done at a budget resolution. You might think that providing contraception would be seen as a good thing, since fewer unwanted pregnancies would lead to fewer abortions, but this is not their logic. [I think that they are, basically, anti-sex, at least that practiced by others, as demonstrated by all the patently false claims we hear constantly in school-based clinics that prescribing contraception will “encourage” sex.]
Of course, it does not. Hormones encourage sex, yes. Social pressure encourages sex, for sure. But not contraceptives; what they do is prevent pregnancy. Amazing. And if the whole campaign against PP, as well as opposition to allowing a year’s worth of OCPs, is grounded in a mindset that wants to control women, the issue for young women (and their partners) is far worse. They are seen as not only women, but immature and incapable of making wise decisions. There is some basis for the idea that they are immature, as parents know; the brain is not fully developed until at least the mid-20s and the last part to develop is the ability to make “executive decisions” – taking the information that you have, looking at it completely and objectively, and making a smart choice.  This is why teens and young adults make poor decisions in driving and, conversely, make the best soldiers.
But this is not a justification for restricting access to contraceptives, condoms, or other health services that might prevent bad outcomes. Because teens make not make the most mature decisions, and often regret them later, it doesn’t mean that they won’t make them. So we need to make it as easy as possible for them to not have long-lasting negative consequences, like STIs and unintended pregnancy. There need to be as few barriers as possible for young people to not get (or make another) pregnant, to not get preventable sexually-transmitted infections (STIs). These would include making oral contraceptives over the counter, making condoms in front of the counter, and preferably free. Should a young woman (or man) come to a clinic for care, invite them in, see them quickly, meet their needs. For goodness sake, don’t make it hard, don’t send them somewhere else to register as they’ll walk out the door!
The editorial in the New York Times, May 13, 2017, “The health care bill’s insults to women”, documents the degree to which women in rural and underserved areas, where more than half of PP’s clinics are, will lose if Medicaid doesn’t cover services at PP. It notes that in 105 counties, PP is the only provider of reproductive health services. The editorial starts with insensitive “sophomoric” quotes from several congressmen and senators, including one from Kansas Sen. Pat Roberts that “I wouldn’t want to lose my mammograms!”. Sen. Roberts would be well advised to identify which of the areas in Kansas, particularly in the very rural “Big First” district he once represented as a congressman, would be among those losing services. A lot, actually, especially since one OB/Gyn from Great Bend is now busy representing the district in Congress. Of course, Dr. Roger “the poor just don’t want health care” Marshall probably didn’t take care of many underserved folks.
This is not the way to go. Our goal must be to increase health as much as possible, not to create obstacles to it.

Pre-existing conditions and profit-taking: the causes of our healthcare problems

Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News and author of “An American Sickness” (discussed in this blog on April 15, 2017, United Airlines, health care, and a system designed to privilege the powerful) has an op-ed in her old newspaper, the New York Times, on May 29, 2017 titled “We all have pre-existing conditions”. That is a good and accurate title, but a little different from the print title “The cost of pre-existing conditions”.  That cost is high, to the people with those conditions, and less obviously, to the overall society. This includes their families and friends, of course, but also their employers. When a potentially treatable condition excludes you from having health insurance, you are less likely to get it treated, and more likely to get sick and miss work. The spectrum of conditions that insurance companies used in the pre-ACA era to exclude people was broad. Rosenthal notes specific examples including having had an abnormal Pap smear, a history of being on anti-depressants, a history of taking thyroid medication, and being on post-menopausal hormone treatment. Of course, once you are excluded and have no insurance, you don’t seek care for other conditions either, either pre-existing or those that develop later or might have not been recognized. Not only could insurers exclude you for having a pre-existing condition, but there was no regulation of what or how significant that condition had to be. We have heard stories of people being denied treatment for cancer because, on signing up, they had “failed to report” a pre-existing history of treatment for things as minor as an ingrown toenail or acne!
The ACA, also known as Obamacare, changed that. It eliminated the ability of insurance companies to exclude people based on their pre-existing conditions, thus rendering moot the question of what conditions could be excluded. It also prevented those insurance companies from charging more money to people with those pre-existing conditions by requiring “community rating”; they had to set their rates based upon the overall actuarial risk of the entire community in which they sell insurance. The same principle is why those of us who receive our health insurance via employers, especially large employers, usually have lower rates for better coverage – because the risk pool is everyone who works for that company, and while many are sick, many more are younger and healthier (after all, this excludes all the people who are not working). Thus, the requirement that the individual policies sold under ACA had to be based on the community rating was critical for many Americans to be able to get even close to affordable health insurance.
For many, the cost on the individual marketplace was still too high. For those whose pre-existing conditions had previously made them unable to get insurance, it was often still a boon. For those who were younger and healthier, though, who had had cheaper policies or gone without coverage altogether, they now had to pay more. After all, community rating means an average, so those at lower risk will pay more than they would have with individual rating, and certainly more than with no insurance since the ACA had the “individual mandate” requiring them to get coverage. The bigger problem is that in some geographic areas, many (or most or in some cases all) insurers decided that the benefit of offering insurance (i.e., making money) was not worth the risk of paying out for actual medical care. This is especially true in rural areas, where low population density and a higher proportion of older and therefore sicker people make for a poor risk/return ratio.
The problem, of course, for those younger and healthier people who chose to forgo coverage or, after the individual mandate, to buy the cheapest and crappiest policies, is that they can get sick. They can discover that they have cancer, whatever their age. Or get into a car accident, requiring many surgeries and long treatment and rehabilitation (did they have car insurance?). Or be burned in a fire started by smoking (did they have homeowner’s insurance? Did they opt to not pay the higher premiums that they can legally be charged for being smokers?) Or they can have a premature baby that needs treatment in a neonatal ICU.  Or, particularly for the older group who knew they had a problem like hypertension, diabetes, or arthritis but were hoping they’d stay relatively asymptomatic, they can have a downturn – have a stroke or a heart attack or a serious infection or pain so bad that they can no longer work. And then they find that the “affordable” (i.e., crappy) health insurance that they bought is almost as bad as none.
So we have a conundrum. To work, health insurance has to include everyone, the sick as well as the healthy. But the healthy, especially those with lower incomes, don’t want to pay what seems to be the unfairly high rates that they have to in order for the whole system to be fair. The older and less healthy may want health insurance, but still be dissuaded by the high premiums. The sick need the coverage, but again, without the healthier paying in, the cost for them is too high, and results in either their being unable to afford it or the insurers being unwilling to cover them even if it means leaving an entire market.
Let’s look at some facts:
1.      The US spends more on health care than any other county, by far.
2.      The US has, on a population basis, worse health outcomes than most other developed countries, far worse than many.

This is the true conundrum. How can we pay so much for so little? It is because we pay an enormous percent of our “health care” expenses for drug company (and drug “middlemen”, pharmacy benefits managers) profits, insurance company profits, and income for for-profit and function-like-for-profit non-profit hospitals. As documented by Eric Lipton and Katie Thomas in the May 29, 2017 Times (“Drug lobbyists’ battle cry over prices: blame the others”), there is plenty of blame to go around! In addition, the percent that is actually spent on health care on treatments (and sometimes cures) is primarily for far advanced disease, not prevention and early diagnosis and treatment. We spend almost nothing on public health and prevention.
We keep telling ourselves lies (our healthcare system is the best in the world, the ACA is the problem, drug companies need to charge so much because they spend so much on research and development, etc.) but fewer and fewer of us are believing it. Many of the people who are worst affected voted for Donald Trump and for Republican congressmen who have devised the AHCA (American Health Care Act) that will “solve” the problem by essentially eliminating health insurance coverage for 23 million Americans, 14 million in the first year alone, according to estimates by the non-partisan Congressional Budget Office (CBO). The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.
Is there any way out of this conundrum? Yes. We have the money, obviously; we are spending it. Fifty percent of health care spending is already government, 60% if you include the lost taxes from the employer portion of health insurance. We make the community being rated everyone in the US. We all have one health plan. We are all covered. We all get all necessary services. We don’t lose coverage by leaving or jobs for any reason, from family needs to an entrepreneurial start-up. The old and vulnerable among us are covered and have their needs met, and the healthy among us win by staying healthy and having coverage when we need it. We pay for it by eliminating the profit centers, and not by cutting taxes on the wealthiest of us.
It can be done. It has been done. In every other developed country. We have the resources to do it here. We must need to stand up to the entrenched and powerful profiteers.

Good enough for government work: Quality, Cost, and Gaming the System (Part 4 of 4)

This is the fourth and final part of the 23rd Charles Odegaard Lecture, “Good enough for government work:Quality, cost and gaming the system. I will put the entire talk up as an attachment soon.
Is this really true? Aren’t some of our costs “our fault”, or at least “their fault”, that is other people? What about those folks who are “gaming the system”, by holding out on buying insurance until they get sick? Aren’t they driving up costs? Insurers like Aetna and Anthem make the accusation that people are misusing Special Enrollment Periods (SEPs) for this purpose. This is debunked by the evidence, cited by Michael Hiltzik of the Los Angeles Times, but even if they were, they’re poor people trying to get by! Wondering if they can put off buying health insurance so that they can pay the rent! Who is really in a position to develop and implement strategies to “game the system”?


Unsurprisingly, as Hiltzik also reports, it is the insurance companies (as well as big health system providers) who are masters of these strategies. Besides, if we have concern about “buying to use” behavior, the best answer is to get rid of the jumble of insurance companies and enrollment periods and have one national health insurance plan that has, in the words of the recently deceased Quentin Young, “everybody in, nobody out”.
The most amazing thing about all of this, the way in which the system is gamed, is the way it transfers public money intended to provide healthcare for people into private pockets far in excess of the cost of providing that care. Himmelstein and Woolhandler provide us with data that shows that we already pay for a national health system, with over 50% of “health” costs being borne by government, far over 60% if we count the loss of revenue from employer contributions to insurance being tax deductible, but we still don’t come close to covering everyone, because our system is so inefficient, and so much boodle is being raked off.
Nowadays, when we hear the phrase “good enough for government work”, we tend to think of something that is poor quality, or only just meets the minimum standards set by government. The Urban Dictionary defines the phrase as “Probably not the best, but what the hell, at least we got the job done to minimally acceptable standards.” And, yet, when this phrase first came about it was a compliment; it meant that the government set minimum standards of quality that had to be met, and if you had someone (say a contractor) doing work that was “good enough for the government” it meant that it met those standards of quality, that they weren’t ripping you off by doing shoddy work. What we have now is our publicly-funded health system being cannibalized by profiteers, and enabled by a government that often seems to care more about cost than quality.
Charles Odegaard, the medieval historian and former University of Washington president after whom this lectureship is named was, and I quote from the Coastal Research website, “an impassioned proponent of the idea that every school within a university should be engaged in the advancement of society in the communities and regions that surrounded it. As a result of Dr Odegaard’s leadership, UW became a leader in the decentralization of medical education, including the unprecedented commitment to training physicians from and in the surrounding states of Alaska, Montana, Idaho and Wyoming.” [1]
There are great positives to decentralization, whether for education of doctors or for administration of social programs. It can decrease the cost of large, unresponsive central bureaucracies, and put control in local areas that are more knowledgeable about and responsive to the needs of their populations. There are, also, risks. Sometimes control at the local level is more about maintaining the power of one sector of the community at the expense of others; one just has to look at localities and states in the South in the Civil Rights era defying integration (or, perhaps, many states and localities more recently). More to the point of this talk, there is the risk that smaller, more decentralized activities can be more easily underfunded. Think about the deinstitutionalization of people with severe and persistent mental illness toward the end of the 20thcentury. When I was in medical school, I was taught that 1 in 3 hospital beds was occupied by someone with schizophrenia. That is certainly not true today, because of deinstitutionalization. And so we do not have the horror of people with mental illness warehoused in enormous facilities, but we also do not have anywhere near the degree of community-based mental health services that would allow them to live successfully in the community. We have people with mental illness living on heating grates and under bridges and, according to a June 2015 article by Matt Ford in The Atlantic, our nation’s largest mental hospital is a jail (absolutely believable to anyone who has ever worked in one).[2]. It is only ok to decentralize when we can assure that necessary programs will be maintained and will be well funded. We have long since privatized the health care in most prisons, and there is a (to me) disturbing movement to privatizing prisons altogether. Cost, again, trumps quality. Especially, of course, if the prisoners are mostly “not us”. Seeing a trend?
So…is it possible to have quality and still reduce costs? Of course. Our system is not only financially inefficient, and the victim of massive skimming by the private companies, but it is one which is geared to care for individual patients rather than populations; where there is not rational allocation of resources to the areas where they will do the most good, but rather decisions made for each individual, often where the provider has a financial incentive to do more. Oregon’s CCOs, a kind of state-sponsored but decentralized (there are 15 in the state) ACO designed only for Medicaid patients, have provided some movement in this direction, but they are limited because they are, in fact, only for Medicaid patients. This permits skimming, as we see in recent data that shows that the places long touted for their efficiency and low cost for Medicare, like Grand Junction CO and Rochester MN, are among the most expensive for private insurance. The same characteristics, integrated health systems which control most of the care in a community, that allow them to be efficient with fixed Medicare funds, also allow them to raise the rates for private insurance. Gaming the system.
We could have a good health care system. It needs to be built upon quality, and quality has to be based on consensus, and has to apply to everyone, rich and poor, young or old. It cannot be segmented into different versions of quality for privately insured, Medicare, Medicaid, and uninsured people. The “how-to” is not hard; other countries have shown us how. The money is not hard, we are already spending excessive amounts. What we need is the will. 

Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?

On February 2, 2011, I posted a piece titled Outing the RUC: Medicare reimbursement and Primary Care, describing the activities of this group, officially the “Specialty Society Relative Value Scale Update Committee” but known as the RUC, which is convened annually by the American Medical Association (AMA) to set the relative value of different kinds of work done by doctors. I included the accompanying graph, from the Robert Graham Policy Research Center of the American Academy of Family Physicians (AAFP). It shows the relative income of different specialists over time (FPs are the line at the bottom) and suggested that this might well impact specialty choice by students. I noted that the reason for the income disparities was the different weight given the work done by different specialists, and that the RUC was dominated by subspecialty societies. I pointed out that the real problem is that this encourages expensive procedures (by making them expensive) and that this skews the entire health care system.
I did not, however, call the RUC “The shadowy cartel that controls Medicare”. No, that is the title of a lengthy recent investigative piece in the Washington Monthly by Haley Sweetland Edwards that documents, in detail, the creation, formation, function, and results of the RUC’s activities that justifies this sobriquet. The problems documented are profound. Medicare has to pay for the work that doctors do, and it is pretty obvious that performing heart surgery should be paid more than freezing a wart. But how much more? And how does that relate to your doctor’s office visit or doing and interpreting a CT scan? And that doctor’s visit; is it for a cold or to manage 5 different chronic diseases? It’s complicated stuff. So the Center for Medicare and Medicaid Services (CMS) relies (90% of the time or more) on the recommendations of the AMA-convened RUC.
Note, above, that in the full name of the RUC the term “specialty society” is included; the members of the RUC are appointed by medical specialty societies, but are then told to then be completely objective and not look out for the interests of those societies, the specialists, or themselves! “Put your RUC hat on,” Edwards describes the chair of the committee telling its members, But even if you believe that this is possible, the outcome of RUC decisions would demonstrate that it is not in fact the case (“…in talking to a half-dozen current and former RUC members, including both generalists and specialists, the image of the committee that emerges is less a gathering of angels, cloaked by some Rawlsian Veil of Ignorance, and more akin to a health care-themed Game of Thrones.”) While the RUC only makes recommendations for Medicare, because all other payers base their payment rates upon Medicare, it is essentially controlling the cost of the entire health care system.
Medicare spending is like a pie, a fixed amount of dollars divided up based upon RUC recommendations. The original basis for this division, the Resource Based Relative Value Scale (RBRVS), developed by William Hsiao, may not have been equitable for primary care, but the modifications since then have been a disaster. When the first Bush administration gave the task of making these decisions to the AMA, “…the most powerful interest group in the industry,” Hsaio says “…that was the point where I knew the system had been co-opted….It had become a political process, not a scientific process.”
Edwards goes on, in great detail, to show the ways that the AMA maintains power – and makes lots of money – by controlling the RUC and the charge codes that are associated with it. And also describes, in detail, how it has a negative impact on primary care (“These manipulated prices are also a major reason why specialists are in oversupply in many parts of the country, while a worsening shortage of primary care providers threatens the whole health care delivery system. It’s precisely because the RUC has overvalued certain procedures and undervalued others that radiologists now make twice what primary care docs do in a year—that’s an average of $1.5 million more in a lifetime”) and why (“While the primary care docs make up roughly 40 percent of physicians nationwide, they have only 14 percent of the votes on the RUC.”). I would argue with the math, though; over a 30-year career every $100,000 of additional annual income results in an additional $3 million in lifetime income, and many sub-specialists earn several times $100,000 more than primary care doctors.
The idea of having independent, non-governmental, groups advise on policy is not necessarily a bad one. An excellent example of this is the US Preventive Services Task Force (USPSTF), which makes recommendations, based on the scientific evidence, about which preventive tests are effective and which are not. In Guidelines, bias, and your health, June 30, 2013, I cite an article by 2 USPSTF members who are concerned that by tying payment for services to positive recommendations by USPSTF, the Affordable Care Act (ACA, “Obamacare”) could politicize their work. The RUC has no such compunctions. While USPSTF is intentionally composed mostly of primary care physicians and examines only the scientific evidence, the RUC is dominated by specialists, who are appointed by specialty societies, who have a great financial stake in its decisions. And if the cartoons attached depict the doctors as poker players, the AMA is the “house”, which not only takes a cut of all decisions, but owns them and sells them back to anyone who wants to use them.
Edwards’ article is full of quotes from important – especially those who were formerly important in public life, both Republican (e.g., Gail Wilensky and Thomas Scully, heads of CMS during the GHW Bush and GW Bush administrations respectively) and Democratic (e.g., Bruce Vladeck, who headed CMS under Clinton), who are extremely critical of the entire process behind the RUC, see it as corrupt, and see it as a major contributor to a US health system that spends incredible amounts of money in a wrong-headed, upside-down way to reach mediocre health outcomes. Unfortunately, none of them changed it when they had government power (if they even tried to).
I would like to add two notes:
  1. All specialists are not paid the same. Some (e.g, psychiatrists, some subspecialty pediatricians, some neurologists) are earn much the same as primary care doctors. Some (e.g., radiologists, orthopedic surgeons, neurosurgeons, anesthesiologists) earn several times more. Much of this is built into the RBRVS, which vastly overvalues procedures compared to cognitive care, and exacerbated by the RUC.
  2. The last time I wrote about the RUC, I received a response from the AMA (AMA response to “Outing the RUC”, February 5, 2011). It said “The entire premise of this column is false.” If you wish, you can read my reply in that blog piece. Nice to know they read it.

In summary, the flaw is not just the RUC, but the entire nonsensical non-system of medical care we have in the US. Medical care should be paid for by a single payer, and rates determined by an independent body without a financial stake in the outcome. Health care should be a lot more than simply medical care. And the health of our people will be most impacted by investment in the core functions of society: housing, food, education and jobs.

Delmar Boulevard, Geo-mapping, and the Social Determinants of Health

The social determinants of health are those factors that affect people’s health status that are the result of the social situation in which they find themselves. Thus, in the well-known graphic from Healthy People 2010 (dropped, for some reason, from Healthy People 2020), which I have reproduced several times, they complement the other determinants such as the biological (genetics), but are represented in most of the other areas. Physical environment and socioeconomic environment, certainly, but even “behaviors” are affected by the circumstances into which one is born and lives. So is biology, actually, as we learn more about genetic coding predisposing some people to addictive behaviors. Certainly it is not all volitional or evidence of weak character.
The social determinants of health can be partially enumerated, and include adequate housing (including sufficient heat in the winter), adequate food, education, and also a reasonable amount of nurturing

and support from your family. In short, they are “the rest of life”, outside and often ignored by the healthcare system. Camara Phyllis Jones, in her wonderful “cliff analogy” (which I have also reproduced before) creates a metaphor in which medical care services are provided for those who need them (or “fall into them”) along a cliff face, while the social determinants of health are represented by how far a person, or a group of people, lives from that cliff face. As such, it illustrates the degree of protection that we all have from falling off that cliff, more for some and less for others.[1]

One of the clearest ways to show the impact of these determinants is by a technique called “geo-mapping” in which certain characteristics (income, educational level, gang violence, drug use, number of grocery stores or liquor stores, public transportation routes, whatever you can think of) are laid over maps of a city, town, or region. We have seen these portrayed on TV or in the newspapers as national and state maps for political events (such as what areas voted for who), but they can also be very useful for understanding the different challenges faces by people living in different areas. The work of Steven Woolf and his colleagues at Virginia Commonwealth University has greatly contributed to this work; in addition to their incredibly useful County Health Calculator, has produced graphs that can be found on the Robert Wood Johnson Commission for a Healthier America site that show how life expectancy can vary dramatically in different neighborhoods, as in the map displayed of the Washington, DC area, mapped along Metro lines for greater effect, or the one of my area, Kansas City, Missouri (which doesn’t have a Metro!)
A recent contribution to this field has been made by Melody S. Goodman and Keon L. Gilbert, of Washington University in St. Louis, who mapped the dramatic differences across Delmar Boulevard in that city, in “Divided cities lead to differences in health”. Their graphic shows the disparities in education, income, and housing value, and, unsurprising, racial composition, on either side of Delmar. This work was covered in a BBC documentary. Dr. Goodman, speaking to a symposium from her alma mater, the Harvard School of Public Health, is quoted as saying “Your zip code is a better predictor of your health than your genetic code.”
This is a pretty sad commentary, given not only the incredible amount of money that has been spent on unraveling the genetic code but the amount of faith and expectation that we have been convinced to have in how this new genetic knowledge will facilitate our health. By knowing what we are at risk for, genetically, the argument goes, science can work on “cures” that target the specific genes. This is a topic for a different discussion, but in brief one problem is that the most common diseases we suffer from are not the result of a single gene abnormality. It is probable that, at least in the short-to-medium term, knowledge of our genetics will be more likely to lead to higher life insurance rates than cures of our diseases. The more profound issue, however, is that there is evidence from the social determinants of health, from the work of Woolf and Goodman and many others, that we do not address the causes of ill health even when we know what they are.
Why is this so? Why is there such great resistance to understanding, believing, that investment in housing, education, jobs, and opportunities will have a much greater impact on people’s health than more and more money spent on high-tech medical care (and, of course, profit for not only the providers, but the drug and device companies and middleman insurance companies)? It is in part because we hope (and, when we are more privileged, expect) that we will be the beneficiaries. And it is also because we choose to believe that those who do not have the benefits we have (of money, education, family) somehow “deserve” it because of character flaws.
The issue of “fault” is articulately addressed by Nicholas Kristof in a New York Times Op-Ed on August 10, 2014, “Is a hard life inherited?” Kristof argues that it is, not genetically but because the circumstances to which one is born and in which one grows up, the presence of caring parents who read to you rather than beat you, who take care of you instead of abusing drugs, as well as adequate food and housing make a tremendous difference in how you turn out.

Indeed, another major study by Johns Hopkins sociologist Karl Alexander, to be published in his “life’s work”, “The Long Shadow: Family Background, Disadvantaged Urban Youth, and Transition to Adulthood”, and covered on NPR, confirms this. Alexander and his colleagues tracked nearly 800 children for more than 20 years, and found that those from less privileged backgrounds with lower incomes and less supportive families did worse. Only 33 of the children moved from the low income to the high income bracket. Problems with drugs and alcohol were moreprevalent among white males than other groups, but they did better financially anyway. Some people, rarely, overcome the deck being stacked against them, but most of those who do well after being born with relative privilege would likely not be among them had they been in the same situation.  Kristof writes:

ONE delusion common among America’s successful people is that they triumphed just because of hard work and intelligence. In fact, their big break came when they were conceived in middle-class American families who loved them, read them stories, and nurtured them with Little League sports, library cards and music lessons. They were programmed for success by the time they were zygotes. Yet many are oblivious of their own advantages, and of other people’s disadvantages. The result is a meanspiritedness in the political world or, at best, a lack of empathy toward those struggling…
That lack of empathy leads to a lack of action; we are willing to accept people living in conditions that we would never accept for our family and neighbors, not only across the globe but across town, or even across a street. From the point of view of health, our priorities and investments are misplaced when we do not address the social determinants of health as well as cures for disease. When we do not try to change the known factors of zip code that impact our health as we investigate those of the genetic code.
If there are to be “cures” that come from our understanding of genetics, there is every reason to expect that they will be one more thing that is available to the people on the south side of Delmar Boulevard in St. Louis long before they are to those on the north side of the street.

[1] Jones CP, Jones CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228

Quality health outcomes depend upon the Social Determinants of Health

On the heels of the publication by the Center for Medicare and Medicaid Services (CMS) of how much money Medicare paid to individual physicians (discussed on this blog in Medicare payments to doctors: the big issue is the underpayment for primary care, April 9, 2014), we have revelations of inequity in Federal payments to health providers. A panel of the National Quality Forum (NQF), convened by the Administration to look at this issue, has determined  that payments for “quality of care” to hospitals under the Affordable Care Act (ACA) tend to reward those hospitals caring for higher-income patients and penalize those who care for the poor (Robert Pear, “Health law’s pay policy is skewed, panel finds”, New York Times, April 27, 2014). This cannot be the way we want to go, and thankfully that is the conclusion reached by the panel. It is, however, the NQF that developed these 600 or so quality indicators, and has not recommended adjusting them for the socioeconomic status of the patients that a hospital cares for (although it does adjust for severity of illness).
What is happening is that the measures of quality of care are largely not measures of what is done for patients in the hospital, but how they do after – are they readmitted shortly after discharge, are the diseases for which they are being cared for under better control or not, do they get follow-up care. The fact is that for a variety of reasons including money, education, transportation, and competing demands, poor people do not do as well as better-off people, even controlling for the quality of care that they receive when they are hospitalized. A number of panel members comment on this in the Times article, including NQF president Christine Cassel, who says “Factors far outside the control of a doctor or hospital — patients’ income, housing, education, even race — can significantly affect patient health, health care and providers’ performance scores,” and panel member Steven H. Lipstein, CEO of BJC HealthCare in St. Louis who adds “The administration’s current policy on adjustments for socioeconomic status are quite inadvertently exacerbating disparities in access to medical care for poor people who live in isolated neighborhoods. I’m sure that’s not what President Obama intended with the Affordable Care Act.”
These comments are true, but the thrust of the NQF’s comments was the unfairness to the hospitals. This is important as far as it goes – it is outrageous to pay extra money for “quality of care” to hospitals that care for the privileged and penalize those that care for the underserved. Many of the members of the panel and other commenters quoted by Mr. Pear focus on academic teaching hospitals, which indeed care for a disproportionate share of poor people; however, public hospitals (in those areas where they exist) are even more affected. But what is more important is how this issue illustrates the power of what are called the “social determinants of health”, the situation that people live in before they access medical care, and after they are discharged, have on health outcomes.
Health advocate and policy expert Kip Sullivan is more pointed in his comments on Don McCanne’s “Quote of the Day” for April 28, 2014. “The notion that doctors and hospitals are screwing up and will behave if they are subjected to punishment and reward by third parties is not new. The Code of Hammurabi (1750 BC) subjected Mesopotamian doctors to a combination of reward (more shekels) and punishment (cutting off of doctors’ hands)…But even Hammurabi didn’t recommend punishing the patients.”  If hospitals that care for poor people are effectively financially penalized for doing so, they will (at best) be further financially challenged in providing that care, and at worst will do their best to not care for the poor to the extent that they can.
Why would the NQF and the Department of Health and Human Services (HHS) take such a position, one that seems both unfair and even mean? One might be tempted to suggest that rewarding the “haves” and punishing the “have nots” is what is usually done by government policy, but we would hope that, given its rhetoric on health care – and the creation of the ACA in the first place – the Obama administration would not be guilty of such intent. We get some better idea from Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services, who is quoted in Mr. Pear’s article as saying “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients. Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”
Now, this sounds almost noble, like a values-based response to critics such as those on the NQF’s panel. However, the clear and obvious flaw in such logic is that hospitals have the power to change the lives of these patients in such a way as to decrease their risk for poor outcomes to be equal to, or better, than, those of higher socioeconomic status. They don’t, and to the extent that they could do more work in the community to help this situation, it would cost more money, so it is absurd that they be financially penalized. Dollars spent by government on health care should first and foremost be required to be spent on health, not on making money for providers (doctors or hospitals) who can by virtue of their location (and possibly other strategies) avoid taking care of the neediest. Hospitals should be judged and reimbursed on the quality of care that they deliver, equitably and without prejudice with regard to socioeconomic status, but cannot reasonably be judged on outcomes which depend on factors far outside the control of those hospitals.
The real issue is that people who are poor have a lot more to contend with than the services delivered as health care. It is not uncommon for our hospital to be treating a person with a bone infection made worse by their diabetes who needs 6 weeks of IV antibiotics. This can be delivered by a home health care agency, and most insurance will pay for it. But it becomes a problem if the person does not have insurance. And is even more complicated when they do not have a home. These people stay in the hospital, at exorbitant cost, for the whole duration of treatment. But would our quality measures be better if we only cared for those with homes and insurance? Would the hospital make more? Of course, as Mr. Sullivan points out, while the hospitals lose financially, ultimately it is the patients who suffer.
The social determinants of health are well-portrayed in the “cliff analogy” developed by Dr. Camara Jones and her colleagues,[1]and discussed in my blog of September 12, 2010, “Social Determinants, Personal Responsibility, and Health System Outcomes”. The care given by hospitals occurs at the bottom of the cliff, after people have fallen, but their risk, both before arriving at the hospital and in returning home, is that they are living so close to the cliff face; their housing is poor, their neighborhoods are dangerous and polluted, their schools do not educate, and food is often scarce and not nutritious.  In their study comparing health costs in the US and Europe, Elizabeth Bradley and colleagues discovered that while the US spends far more on “health care”, if you add in basic social service spending, the difference decreases, but that the US spends most of its combined health-and-social-service spending on medical care.[2](Discussed in a New York Timesop-ed, “To fix health care, help the poor” by Bradley and Lauren Taylor, and in my blog “To improve health the US must spend more on social services”, November 18, 2011.)
It is understandable that, given the political climate in Washington and state capitals and the flak that they took for ACA, the Obama administration does not want to put major effort into addressing the social determinants of health by developing programs to meet the core needs of poor people in our country, to prevent them from getting sick, to give them access to meaningful post-hospital care, to have health workers in communities, punish polluters, decrease crime, and limit health risks. Understandable, but not OK. And in the meantime, on this narrower issue, it obviously requires adjusting for socioeconomic risks for hospitals caring for the poor when their quality incentive payments are calculated.
But sometime soon we are going to have to address the core problems.

[1] Jones CP, Jones CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved,
[2] Bradley EH, Elkins BR, Herrin J, Elbel B.,Health and social services expenditures: associations with health outcomes, BMJ Qual Saf. 2011 Oct;20(10):826-31. Epub 2011 Mar 29

Free speech, religious belief, and facts: how does it affect health?

The massacre at the French magazine Charlie Hebdo was shocking and horrible, as are the massacres and atrocities that occur regularly with less immediacy to those in the West, such as those committed by Boko Haram in Nigeria. The most positive result was the massive outpouring of support for free speech, for being able to say and print what you want even if it offends people. And, I would add, particularly if it offends the powerful, which Charlie Hebdo also did. More than a million in the streets of Paris saying “Je suis Charlie” (“I am Charlie”), with more than 40 heads of state in attendance, even if they didn’t actually lead the march, but were photographed together on a protected side street. And even if many of them sponsor severe repression of free speech in their home countries. 
The inclusion of Israeli Prime Minister Benjamin Netanyahu was particularly problematic given the violently repressive policies of his government, but given that the companion attack was on a kosher supermarket where four Jews were killed, the symbolism was important even if a lightning rod for (largely just) criticism of Israeli government policy. Less appreciated was the message from Netanyahu that French Jews should all come to Israel, and more appreciated were the sentiments of French Prime Minister Manuel Valls that ‘France Without Jews Is Not France’, and the demonstrators, most of whom were not, who carried signs that said “Je suis juif” (“I am Jewish”).
But the necessary condemnation of terror, and moves to avert it, along with the necessary condemnation of anti-Semitism and the conflation of Jews with the actions of the government of Israel (or the conflation of Islam with the actions of Islamic terrorists) does not solve the problem of communication, that people see “truth” so differently. I don’t know that I can offer much more insight into the conflict of seeing truth through the lens of religious doctrine (and of course some people and groups’ interpretation of religious doctrine) and a “liberal” concept of the value of free speech. I was interested in the perspective of Maajid Nawaz, a British Muslim who became a radical Islamist at 16, served 4 years in an Egyptian jail where his readings changed his perspective and later founded Quilliam, an anti-jihadist think tank in London, expressed on NPR’s Fresh Air. Asked by host Terry Gross how he saw himself as the same person, given his loss of relationships including family and friends since his “conversion”, Nawaz spoke about commitment to justice. He said it was the blatantly unjust treatment of Muslims that motivated him to fight as an Islamist, and the same commitment to justice that makes him oppose terrorism. Ideologically, I think that this is a good start.
 Most countries, including France and the US, have a mixed relationship with free speech. In the US (which I know much better), many people not only support free speech for positions that they agree with but also positions that they can tolerate listening to. Of course, however, true support for free speech means support for speech you abhor, hate, despise, think dangerous. Not, of course, the same as action (“your free speech stops just short of my nose”), but certainly includes free assembly and demonstrations to express views. If one’s religious views include opposing anyone’s right to criticize your religion (or, even more, as illustrated by the Inquisition or ISIL’s massacres of Yazidis, not adopt your religion), you are clearly endorsing a society antithetical to free speech. And, of course, with the grossly immoral series of US Supreme Court decisions that money is speech and that corporations are people who can exercise that “speech”, the entire concept of free speech in our country is perverted.
Closer to home, and closer to the usual themes of this blog, health and social justice, we see again how beliefs not only threaten free speech but threaten our ability to act as an honorable and just society because groups of people see things so differently. The reasons given are many: our social isolation from groups of people unlike us (residential segregation by race and class and age and educational level), our ability to receive “customized” news, where what we watch on TV or find on the Internet is that which agrees with what we already believe. When people hold views based on their faith, it may be difficult or even unreasonable to expect to change it; this is what “faith” is. However, when people hold views that are not religious and are demonstrably wrong in the face of the facts, and those beliefs are held as firmly as those that are religious, and those beliefs threaten the core well-being of other parts of our society, we would hope that they could change.
I have often written about the Social Determinants of Health. These are the conditions of people’s lives that make them more vulnerable to illness, less likely to be able to prevent it through both health screening and living in places and circumstances in which prevention is possible. For example, not near areas of high pollution, not in poor quality cold housing, not in no housing. To have shelter, and decent food, and the opportunity for education for themselves and their children. All the things that characterize their lives and come before their access, or lack of access, to the health system comes into play. If we are to improve the health of the American people, we must not only provide equitable access to health care geographically, financially, and socially (with language access and caring and actual interest in people’s health) but also address those social determinants that disadvantage so many in the pursuit of their health.
And then I read the results of a survey by the Pew Research Center that says a majority of well-to-do Americans think that poor people “have it easy”. Widely reported, including by the Washington Post which leads with “There is little empathy at the top”, and CNN, which reports “54% of those with the greatest financial security believe thatpoor people today have it easy because they can get government benefits without doing anything in return’…Only 36% of the wealthiest say ‘poor people have hard lives because government benefits don’t go far enough to help them live decently.’” I want to say this is unbelievable, but I have to believe it is true that they think this. I am, nonetheless, aghast that they could think this. What world do they live in? Is it really true that their only contact with poor people is on TV news, Fox News at that? Have it easy?
Would they want to test that? Live like poor people for a while? Even knowing that – unlike real poor people – they could return to their comfort in a month or a week, would they be able to tolerate it? Not being able to pay their bills, not have heat, not have decent or sufficient food, not be able to afford the doctor, not be able to take off work without losing pay to go to one even if they had health insurance? I think – I know – that if they did they would feel differently about it being easy to be poor. But while there is great value to “walking a mile in someone else’s shoes”, there is a way to know what is going on without even doing that. It is called opening your eyes, looking at the facts.

Even when they are uncomfortable, even when they challenge your beliefs, or more importantly your sense of self-entitled comfort. To not do so is part of no one’s religion. This is the responsibility of free people. 

What is right about the ACA, and how to address what is not

There has been much criticism of the Affordable Care Act (ACA, Obamacare) both from the Right, which is apparently horrified that public funds are actually being used to help needy people rather than bail out banks, and from the Left, which thinks it hasn’t gone far enough to help meet people’s healthcare needs. Count me in the latter camp, for reasons I will address soon.
However, first to address the criticisms from the Right.  On the whole they are wrong (no pun intended). The fact is that the ACA has done good. About 10,000,000 people who were previously uninsured have now gained health insurance coverage, both from the health insurance exchanges (that include subsidies for the low income) and through expansion of Medicaid, in those states that have opted to do so. This is a GOOD THING. One of the major reasons that the ACA has not done more good is a result of the specific actions that the Right has taken. The most obvious is the failure to expand Medicaid in states that they control, a fiscally unwise decision that is based entirely on a combination of ideology (Malthus as seen through the fantasy novels of Ayn Rand) that is about helping the wealthiest become even wealthier, and the politics of meanness (we will get votes by appealing to folks who don’t want to help them, usually code for racial and ethnic minorities). It is fiscally unwise because, in contrast to traditional Medicaid in which the federal government pays 60-80% of the cost (based upon the income levels of the state), under expansion it pays 100% of the cost for 4 years and then 90%. Medicaid expansion covers everyone under 137% of the poverty line. In contrast, in Kansas, for example, it only covers people who are BOTH very poor (under 30% of poverty) AND have another “qualifying” condition – most commonly mothers of young children and those children, and the disabled. Obviously, this excludes many people in Kansas, and millions across all of the states that have not expanded Medicaid.
There have been many other efforts to limit people benefiting from ACA. Many states (like Kansas) refused to open state-sponsored exchanges, and have tried to obstruct the federal exchanges, even trying to intimidate those working to sign people up. It tried to block passage of the ACA in Congress, and when it gained majorities has blocked every effort to expand funding, and blocked the creation of a “public option” to compete with private insurance companies. The entire series of efforts on the Right to block, limit, and try to kill ACA make its criticisms reminiscent of the person who killed his parents and asks for mercy from the court on the grounds that he is an orphan!
And yet, although it is largely their fault, some of the criticisms of ACA are spot on. Premiums have continued to go up in many places, making the policies available on the exchanges unaffordable to many. Combined with the fact that, despite the “individual mandate”, the penalties for not participating are far less than the cost of insurance, people are not buying it. Or they are buying terrible policies, also permitted by the ACA, that turn out to be worth very little when their purchasers actually get sick. In some places, major insurance companies (like Aetna and Humana) are pulling out of the exchange marketplaces altogether because, even with such high premiums, they are losing money.
The reason for this phenomenon is well-described in Health Care Law’s Beneficiaries Reflect Its Strengths, and Its Faults by Abby Goodnough and Reed Abelson in the New York Times of October 14, 2016. People with chronic diseases, many of whom had been previously uninsurable because of these pre-existing conditions, have flocked to buy insurance on the exchanges. They now have coverage, and are using it; they are among the 5% of people who cost 50% of health dollars (described by me in Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009), or 75% under the exchanges (per an official of Blue Cross/Blue Shield of Tennessee cited in the article). The difference is because the first estimate is based on all people in the country, and the BC/BS experience in Tennessee and elsewhere is based upon people who have actually signed up for coverage in the exchanges. In a vicious circle, low-income but (currently) healthy people, especially the young, have chosen to not sign up; this leaves the pool of those covered disproportionately ill and thus costly. Without premiums coming in from the people who would cost little or nothing, insurance companies’ outlay for care (the “medical loss ratio”) is too high for them to make a profit (or, at least, as much profit as they want to), and so premiums continue to rise, driving more people (and insurers) out of the marketplace. In addition, the competing demands of survival among low-income people are tremendous, as documented in the October 31, 2016 issue of The Nation, by Monica Potts in “The American social safety net does not exist”. (H/t Bob Bowman, on the Medicine and Social Justice Facebook page.)
This is the basis of the criticism from the Left – that the private insurance-based model of the ACA was designed to benefit the insurance companies (which is now sometimes failing). This was the purpose of the individual mandate, to get everyone, healthy or not, to buy in. But the solution is not to raise the penalty for not signing up, which is obviously counterproductive, but to automatically put everyone in the same pool, regardless of income, pre-existing conditions, age, or the state that they live in. This is what would happen in a national health insurance program, as advocated by Senator Bernie Sanders. Conceptually, it can be seen as putting everyone in the federally-run Medicare program (which already has, by virtue of insuring the old and disabled, the highest risk people). All of us are in, whether we need medical care or not. It is “insurance” only in the broadest sense, because everyone is in the pool, and the public sector – all of us, from our taxes and income-based premiums, pays for it.
Some people know that they are sick. They have one, or often more, chronic diseases. They may have cancer. They may have had trauma requiring multiple surgeries. These are the people who cost the most today. But all of us are at risk for joining that group, when we find out tomorrow that we have cancer, or are in an accident, or have a premature baby, or just gradually gather more chronic conditions as we age. These are those of us who find ourselves without coverage because, when we were healthy, it was too expensive. But it doesn’t have to be that way; a single-payer national health program covers all of us all the time.
The core concept of most insurance is that you only “win” by losing; you collect when your house burns down, or you are in a car accident, or you die. Health care should not be that way. We all should get preventive care, acute care, and care for our chronic conditions, physical and mental.

We can do this. We should. Now is the time. Now is way past time.

How can a health care system lead not to ruin but to, actually, health?

After a year of reporting in a series of articles in the New York Times (several of which I have commented on in this blog) on the crisis in health care, Elisabeth Rosenthal summarized her conclusions in a Times piece on December 22, 2013, “Health Care’s Road to Ruin”. As the title makes clear, those conclusions are not positive. She summarizes highlights from her investigations that look at the extremely high cost of health care in the US compared to other countries, the extreme variability in pricing depending upon where you are in the US, and the opaque and incomprehensible methods of coming up with pricing and the regulatory incentives that are continually gamed by providers. On the other end of the spectrum, she summarizes both the poor health outcomes at a population level in the US compared to other countries, and the more personal, poignant and dispiriting stories of individuals who die, are bankrupted, or both by our health “system”.
As Ms. Rosenthal notes, the stories that she tells could be “Extreme anecdotes, perhaps. But the series has prompted more than 10,000 comments of outrage and frustration — from patients, doctors, politicians, even hospital and insurance executives.”  She goes on to discuss the potential solutions that those commenters, and others, have suggested, including regulating prices, making medical schools cheaper or free, not paying fee-for-service that rewards volume rather than quality. But, she says, “the nation is fundamentally handicapped in its quest for cheaper health care: All other developed countries rely on a large degree of direct government intervention, negotiation or rate-setting to achieve lower-priced medical treatment for all citizens. That is not politically acceptable here.”
In reality, however, the idea that the health industry is somehow, before or after the ACA (“Obamacare”) an exemplar of the free market and the success (or not) of private enterprise, is entirely a myth, a facile construct that is used by those making lots of money on the current system to block change. Medicare, as I have discussed (e.g., Outing the RUC: Medicare reimbursement and Primary Care, February 2, 2011), sets the rates that they will pay for Medicare patients, and private insurers pay multiples of Medicare rates. Services as mostly fee-for-service, except in HMOs, and integrated health systems (such as Kaiser), and for Medicare inpatient admissions which are paid at set fees based on the diagnosis (through a system called Diagnosis-Related Groups, or DRGs). The entire system of what is profitable for a health care provider (meaning a hospital or other health care facility or a doctor or group) is based on this policy; it is profitable to provide cancer care because Medicare (and thus other health insurers) pay an enormous amount to administer chemotherapy drugs. Cardiac care, orthopedics and neurosurgical interventions are also very profitable. (Oh! Is that why my hospital chooses to focus on these areas instead of psychiatry, obstetrics and pediatrics?!) The doctors who do all these things want you to think (and think themselves) that it is because what they do is so hard or that they work so hard; it is in fact a regulatory policy glitch. In addition, a majority of the money spent on “health care” is public funds, not private, if you add Medicare, Medicaid, federal, state and local government employees and retirees, and add in the tax break for employer contributions to health insurance (i.e., taxes forgone because this employee reimbursement is not counted as regular income).
So the majority of the money being spent on health care is public money, and the system is already highly government influenced with government policies setting reimbursement rates. The only thing “private” about it is the ownership and profit, both by providers and insurance companies. In other words, it is a parallel to our financial services industry: private enterprise is given a license to make money from everyone, and the government finances it. The only difference is that for financial services, the government steps in to bail them out only after they have already stolen all our money, while in health services the profit margin is built in from the start. Thus, Rosenthal’s comments, and quotations from others such as Dr. Steven Schroeder of the University of California at San Francisco: “People in fee-for-service are very clever — they stay one step ahead of the formulas to maximize revenue.” But, of course, we the people, through our elected representatives and regulators, allow them to do so. And, therefore, the arcane network of incentives and disincentives built into the ACA to try to get reasonable results at reasonable cost – and still ensure insurance companies make lots of profit.
The solution is very simple; emulating one or the other systems in place in every other Western democracy. The simplest is closest to us is Canada, and a single-payer system, essentially putting everyone into Medicare. Voilá! We are all covered by the same system, providers can provide care to people based upon their disease, not their insurance status, and rates can be set at the level that we as a people are able to tolerate, or willing to pay, for the health care we want and need. The clout of the empowered will bring along benefit for everyone. There will be no more gaming the system, trying to attract certain patients with certain insurance rather than other. Or, in a more complex fashion, we could follow the example of other countries; Switzerland, for example, has multiple private insurance companies rather than a single payer, but they are highly regulated and non-profit; they are told by the government what they can charge and what they must cover.
The argument that Americans will not accept major government involvement and regulation is pretty flawed, both because of the involvement of the government in regulating the health system already (mostly to ensure profit for providers and insurers) and because regular people see the advantage of universal health care. Rosenthal writes that “All other developed countries rely on a large degree of direct government intervention, negotiation or rate-setting to achieve lower-priced medical treatment for all citizens. That is not politically acceptable here.” Study after study has shown strong support for a universal health care system from the American people; however, certain very powerful vested interests would likely lose out:  “’A lot of the complexity of the Affordable Care Act arises from the political need in the U.S. to rely on the private market to provide health care access,’ said Dr. David Blumenthal, a former adviser to President Obama and president of the Commonwealth Fund, a New York-based foundation that focuses on health care.“
The political need is for the wealthy and powerful. This is why ACA ensured that insurance companies would get their cut. Elisabeth Rosenthal does not say so in so many words, but she does say that “…after a year spent hearing from hundreds of patients like Mr. Abrahams, Mr. Landman and Mr. Miller, I know, too, that reforming the nation’s $2.9 trillion health system is urgent, and will not be accomplished with delicate maneuvers at the margins. There are many further interventions that we know will help contain costs and rein in prices. And we’d better start making choices fast.”
A universal health care program, Medicare for all, in which everyone was automatically enrolled just as current Medicare recipients are now, would be just fine.

Beyond Flexner: It is time to stop shoring up the bridge and figure out how to cross the river!

I recently attended the “Beyond Flexner 2015” conference in Albuquerque, NM. Originally titled “Beyond Flexner II”, it was a followup to the 2012 “Beyond Flexner” conference in Tulsa, OK, which I discussed in my June 16, 2012 post “Beyond Flexner: Taking the Social Mission of Medical Schools to the next level”. The first conference was itself in part stimulated by the 2010 publication of “The Social Mission of Medical Education: Ranking the Schools” by Mullan, Chen, et al. in the Annals of Internal Medicine.[i] Fitzhugh Mullan, head of the Medical Education Futures group at George Washington University, was co-director of this recent conference along with Arthur Kaufman, Vice Chancellor for Community Affairs at the University of New Mexico Health Science Center. The organizing committee was a “Who’s Who” of leaders in the movement to make medical schools more accountable for meeting the actual health needs of the people of the United States, including Gerry Clancy, host of the 2012 conference in Tulsa, and several of the other authors of 2010 paper.
The attendees at the 2012 conference in Tulsa were captured in a posed photograph, crowded but with  recognizable faces. This would not be true of the nearly 400 people in Albuquerque, who also represented a much wider group. In addition to more university sponsors (including Florida International University, which will host the next conference in 2017), several other foundations have joined the Josiah Macy, Jr. Foundation, which helped sponsor the first conference as well. The bulk of the attendees were medical school faculty, with some residents and students, but others from a wide swath of those with an interest in the impact of medical school output on health were in attendance. Notably, this included people from the cooperative extension services based at our nation’s land grant universities, who have been collaborating with health sciences centers to create “health extension” programs in a number of states (The Primary Care Extension Service, July 12, 2009);  New Mexico’s HEROs (Health Extension Rural Offices) program is one of the national leaders.
There were a number of stimulating and provocative speakers, including Camara Jones, about whom I have already written, who spoke about racism and the Social Determinants of Equity. Don Berwick, founder and senior fellow at the Institute for Healthcare Improvement, and former interim Administrator of the Center for Medicare and Medicaid Services (CMS), gave a powerful talk about the direction of healthcare in the US. His most powerful metaphor was of the Choluteca Bridge in Honduras, which was so well built that it withstood Hurricane Mitch in 1995. Unfortunately, the hurricane relocated the river, so that now it no longer functions for its intended purpose! Dr. Berwick also noted that if the US spent 15% of its GDP on health care, instead of the current 18%, it will still be higher than #2, Switzerland. If the US had spent at the per capita rate of Switzerland over the last 25 years, it would have spent $15.5 TRILLION less. That is real money, and could have been used to address many of the social determinants we are always told there is not enough money to do.

Perhaps the most stirring talk was given by H. Jack Geiger, former Dean of the Sophie Davis (now City University) School of Medicine in New York. Accurately described as a “living legend”, Dr. Geiger founded the first two community health centers in the US, in Charlestown, MA near Boston and in Mound Bayou, MS. He was a founding member of the group Physicians for Social Responsibility (PSR), the US affiliate of the International Physicians for the Prevention of Nuclear War (IPPNW), and Physicians for Human Rights (PHR). In his introduction we were reminded that Dr. Geiger was once chastised by a federal bureaucrat for writing prescriptions for food for his patients in Mississippi, and told that the federal funds supporting his program were to be for treatments. His now-classic response was that “the last time I checked my medical textbooks, the treatment for malnutrition was FOOD!” He noted that the last decade might be called that of raising consciousness of the Social Determinants of Health, but that because many of these are determined by (and are currently being eroded by) the political process, called for the next decade to be that of the Political Determinants of Health. He did not mention, but I note, that while IPPNW won the Nobel Peace Prize (1985), the Nobel Prize for “Medicine” in fact goes exclusively to researchers in the basic sciences. How wonderful, fitting, and appropriate would it be to go to someone like Jack Geiger, whose life’s work had really made a difference in the health of people!
In writing about the 2012 conference I suggested that certain goals be the focus of the “Beyond Flexner” movement:
·         Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?
·         Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?
·         Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?
·         Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?
I believe they are still valid. The Social Determinants of Health (SDOH) were discussed everywhere in the conference, and Health Disparities are the central focus of addressing them, or in Dr. Jones’ phrase, the Social Determinants of Equity. Community Engagement was emphasized through the broader participation in the conference (such as the people from Extension services) and one of its highlights was an afternoon of tours of such community-engaged programs in Albuquerque. I went on a visit to the city’s International District, and the East Central Ministries, which operates an innovative clinic driven by community health workers, an Urban Farm, and a small factory manufacturing ollas, unglazed clay jugs used for low-water-use irrigation.
Diversity was certainly addressed by many of the conference speakers, including Dr. Jones and Marc Nivet, Chief Diversity Officer for the Association of American Medical Colleges (AAMC), who pointed out how poorly our schools have done. In the 1990s The AAMC had a goal for minorities of “3000 by 2000”, but in the last 35 years African-American applicants have increased by 1000 and admissions by only 250. Jose Rodriguez and his colleagues writing in Family Medicine note that African-Americans peaked at 8.1% of medical students in 1994, and was down to 7.23% in 2010, Hispanics are up to 8.25% despite a much higher % of the population, and underrepresented minority (URM) faculty in medicine has increased from 7% to 8% from 1993 to 2010 despite an increase in those same groups in the general population from 23.1% to 31.4% in the same period.[ii] In the accompanying editorial, which I wrote, I call for an immediate, dramatic, and comprehensive effort to change both the socioeconomic and racial makeup of our medical school classes.[iii]
If anything was a little disappointing to me at the conference, it was the degree to which the audience was less willing to pick up on the issue of lack of diversity. While there was applause for the comments of Drs. Jones, Nivet, and others, most of the questions and comments focused on the SDOH. These are extraordinarily important, and emphasizing the need to teach them in medical school is as well, but poverty will not be solved quickly. Diversity, on the other hand, could be; our medical school class next year could look dramatically different if we changed the criteria by which we admit so that half the class came from the lower 50% of income and we had double the percent of minorities.
Many of the conference attendees were from newer medical schools, whose goals are more tied to SDOH, Community Engagement and Diversity, and they were celebrated from the podium. But while they may deserve this celebration, the older medical schools need to be held responsible as well; unless they change their admissions practices and their goals to serve the communities, the impact of the newer schools will be only at the margins.
There is a lot to do, and to accomplish it will take a movement. Hopefully a movement growing from “Beyond Flexner” can start the process.

[i]Fitzhugh Mullan, MD; Candice Chen, MD, MPH; Stephen Petterson, PhD; Gretchen Kolsky, MPH, CHES; and Michael Spagnola, BA. The Social Mission of Medical Education: Ranking the Schools. Ann Intern Med. 2010;152(12):804-811. doi:10.7326/0003-4819-152-12-201006150-00009
[ii]Rodriguez JE, Campbell KM, Adelson WJ, Poor representation of Blacks, Latinos, and Native Americans in Medicine, Fam Med 2015;47(4):259-63.)
[iii]Freeman J, Diversity goals in medicine: it’s time to stop talking and start walking, Fam Med 2015;47(4):257-8.

“Hidden Figures”: Racism, sexism, anti-science, public health and cancer

I recently saw the wonderful film “Hidden Figures”, which tells the story of the African-American women who worked as “computers” (when the word meant “people who do computations”) on the NASA program that sent men (and later some women) into space. The focus was on three of the most significant of these women, Katherine Goble Johnson, Dorothy Vaughan, and Mary Jackson. Ms. Johnson (played by Taraji P. Henson) is a gifted mathematician who calculated the trajectories of many of the early space flights (including, as portrayed in the movie, John Glenn’s orbital flight in February, 1962) and the later Apollo 11 moon landing in July, 1969. Ms. Vaughan (played by Octavia Spencer) became an early and leading computer programmer, a supervisor at NASA. Ms. Jackson (played by Janelle Monáe) was the first African-American female engineer at NASA. All of these women, and no doubt many others, were critical to the NASA space program.
All of them, as the film documents, were “firsts”. Among many such firsts, Katherine Johnson (then Coleman) was one of the first African-Americans and first African-American woman to desegregate the graduate school of West Virginia University. Dorothy Vaughan was one of the first programmers and first African-American woman supervisor at NASA. Mary Jackson became NASA’s first African-American woman engineer, after winning a court case that allowed her to desegregate Hampton High School to attend night classes. When asked in the film by a white supervisor if she would still want to be an engineer if she were a white man, she says that if she were “I would already be an engineer!” She also gives a terrific speech to the judge in her desegregation case about the significance and importance being a “first”.
“Hidden Figures” portrays and does not downplay the blatant and overt racism and sexism that existed in that period, legally in the Jim Crow South where the film takes place at the NASA Langley facility in Hampton, VA, in 1961, after Brown vs. Board of Education but before the Civil Rights Act of 1964. There are separate drinking fountains, and a separate coffee pot for Ms. Johnson, and as graphically depicted in the film, a half-mile run for her to go to the only “colored women’s” rest room to relieve herself! The laws in the South came down, but racism – and sexism – there and in the rest of the country are hardly things of the past.
But this is not a movie-review blog; it is about medicine and public health and social justice. The social justice aspect should be obvious, but let me start the discussion of health and medicine with science. Clearly, science was at the forefront of NASA’s mission, and the film depicts how the need for “best and the brightest” overcame even the structural racism of the American South for these women. On a larger scale, though, the idea that science was the future, that knowledge and education and learning and discovery were critical to America and the world, are also implicit, scarcely discussed in the film (save for a few inspirational speeches, such as President John Kennedy’s). In 1957 Sputnik, the first satellite, was launched by the Soviet Union, in April 1961 cosmonaut Yuri Gagarin orbited the earth and a month later Alan Shepard was the first American to do suborbital flight. Glenn’s 1962 orbital flight was only 7 years before the Apollo 11 landed on the moon!
I was alive then, a fairly young child for Sputnik, older for Gagarin and Shepard and Glenn, and just graduated from college for Neil Armstrong’s “a small step for a man, a giant leap for mankind” speech. I was a part of (maybe at the time I thought “victim of”) President Kennedy’s physical fitness program, doing push-ups and sit-ups and chin-ups so we could “beat the Russians”. I was also a student, learning and excited by science. I was impressed by the space program, but not as dedicated a devotee as many others. Perhaps this was because I was not enoughof a science geek, but perhaps it was also in part because it seemed natural, the advancement of knowledge and science was natural, progress was natural. Maybe I was less awestruck than older people in the same way that more recent generations have been less impressed by the technology of computers and cell phones. But we all (I thought) believed that science, and learning, and advancement were what the future was about. We had come through “the war” (WWII), and Americans had jobs, and their children were going to school, and while there were still fights to be waged for racial and gender and economic justice, the outcome was, we knew, unquestionable progress.
But maybe not any more. While we built the Interstate Highway system in the 1950s, while we were able to go from suborbital flight to a man on the moon in 8 years in the ‘60s, now we are in an era where many Americans – including many of our leaders – deny the incontrovertible facts of man-made global warming and climate change. An era in which science and scientists and not to be trusted, where, when facts challenge our beliefs, we make up “alternate facts”, where education and knowledge, rather than things to be sought after and admired are seen as “elitist”, where the only persistent “good” is the enrichment of the already richest, whatever the cost to the rest of us and to the planet. On April 23, 2011 (“Cabaret” and “Inherit the Wind”: Will we again reap what is being sowed?) I wrote of how the play “Inherit the Wind”, written in the late 1950s, was meant as an allegory for McCarthyism, since the “ignorance” that denied evolution in 1920 Tennessee was no longer an issue; evolution was fact. And yet 60 years later it was still being questioned. We see the same, today, for all aspects of science and knowledge; this is a real test given by a “Christian” school!
But what about medicine and health? Is that not still the New Frontier? We may have abandoned even the shuttle program with manned spaceflight, and the launches from Cape Canaveral may be all private satellites out to make a profit (or spy on us), but isn’t NIH our new NASA? Didn’t President Obama promise a campaign to defeat cancer in the same way President Kennedy declared our intention to get to the moon? Well, maybe. NIH’s budget is not only stagnant, but its funding overwhelmingly goes to very basic research and to find “bullets” to kill cancer, as if it were a disease rather than scores of diseases, almost all different. But there is far, far less funding to prevent cancer, not only to find the causes of these diseases, but to even eliminate the causes when we know them. Where is the funding for public health? Sure, there are some victories. Smoking, the major cause of death for decades (and, although it is a cause of many cancers, more of the deaths it causes is from increased heart disease and chronic lung disease than cancer), is down, but the fight against it has been a long and hard one and is not over. Other environmental causes of cancer such as air, water, and soil pollution are minimally addressed, because, like smoking bans, they might decrease the profits for some businesses and the wealth of the wealthiest.
“Hidden Figures” has some brave acts by its white characters. John Glenn (Glen Powell) refuses to fly unless Katherine Johnson rechecks the calculations (and thus she gets her job back). Al Harrison (Kevin Costner), the NASA chief, takes a crowbar to the “Colored Women’s Restroom” sign when he discovers that it is traveling to far-off segregated restrooms that is taking Ms. Johnson away from her job. Yes, these can be seen as self-serving (helping them to get theirjobs done) but they are also, in the context, heroic. I was recently sent copies of archives of mimeographed newsletters from civil rights groups based in southern Brooklyn, where I grew up; one of them contains an article from 1965 about young African-American women being denied membership in a “cabana club” (in the NORTH! In Brooklyn, NY! In 1965!), until the singer Julius LaRosa shows up asks the folks picketing outside why they are there, says “I don’t perform in segregated places”, and intervenes.
John Kennedy said we should go into space not because it was easy but because it was hard. Maybe we shouldn’t do things just because they are hard, but we need to not deny what we don’t completely understand just because it is easy. We need science and we need progress and we need public health. People may not know everything themselves that environmental scientists and scholars and mathematicians and physicists and doctors and public health workers know, but they should be proud of those who do, and encourage and support them. We need more girls and minorities to enter the STEM fields, as in programs such as that in NYC documented in the February 17 New York Times.  We need more Katherine Johnsons, and Dorothy Vaughans, and Mary Jacksons, and the love and respect for learning and truth that they stood for.
We even need more Julius LaRosas.

“It’s always worse than you think … even if what you were thinking is pretty bad”

On the heels of the Epi-Pen® scandal (well, at least I think it is scandalous, Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016) in which Mylan Pharmaceuticals and its CEO Heather Bresch raised the price of this life-saving medication 500% (and her salary by about the same degree), that itself followed last year’s Daraprim® scandal where Turing Pharmaceuticals and its CEO Martin Shkreli raised the price of this anti-parasitic drug over 5000% (Drug prices and corporate greed: there may be limits to our gullibility, September 27, 2015), we have some good news. Sort of. Brent Saunders, CEO of Valeant Pharmaceuticals, also identified last year for hefty price increases in two life-saving heart drugs,has now announced it will keep its price increases under 10%. Of course, it will raise the price 9.9%, which is certainly less than 10%, and even less than 9.99%, which they could have done and still been below 10%. There is speculation that this may have been in response to proposed federal legislation that would have increased the scrutiny on drug price increases of 10% or more, but of course we cannot know for sure.
The predatory greed of drug companies is becoming legendary, threatening to eclipse that of insurance companies as the leading bad guys in keeping Americans from being able to afford the medical care that they need. After all, insurance companies have increased every form of payment (premiums, co-insurance, co-payments and deductibles) that people, the insured, need to pay out of their own pockets in an effort to decrease the probability that they will be bankrupted when they need medical care. This is sometimes justified by the risks that they take; particularly by the “adverse selection” that occurs because it is the sick, rather than healthy, people who were most likely to sign up for insurance under the ACA’s insurance exchanges. The “individual mandate” of ACA was supposed to prevent this, but the penalties people have to pay are far less than the cost of buying insurance for many (if they are unsubsidized), and maybe they won’t even be caught. Or get sick.
Of course, the degree to which insurance companies are actually losing money rather than simply making less profit than they would like is uncertain, but it is clear that, at least in some markets, it is close. The transfer of many patient-borne costs from premiums to co-insurance, co-payments, and deductibles is designed to keep premiums from going even higher, but of course impacts the sick more. In (at least slight) contrast, the price increases of pharmaceuticals can only be justified by an ethos of “charge what the market will bear”, and make as much as possible before regulators come down on them. In a really ‘cool’ effort reported by the New York Times on September 16, 2016, Mylan is trying to get the federal government to add Epi-Pen to its list of life-saving preventive medications. This would mean direct users would not have to pay so much, but Mylan would continue receive its outrageous price – supported by all of us, as federal taxpayers. Now, there’s a really terrible solution! (Good solution: lower the price. A lot.)
And they have been doing it for a long time. Pharmaceutical companies bought dinners, bought presents, and bought trips for doctors who prescribed their drugs. There has been some clamping down on the most egregious excesses in recent years, but they have not been eliminated. Especially concerning are the revelations (no news to physicians) of the aggressive promotion of opiod pain relievers to doctors, and their contribution to the incredible epidemic of prescription opioid addiction in the US today (48,000 women died of prescription drug overdose between 1999 and 2010, a period during which prescription drug addiction increased over 400% among women and 237% among men, according to the American Society for Addiction Medicine. The Centers for Disease Control and Prevention (CDC) reported:
We now know that overdoses from prescription opioid pain relievers are a driving factor in the 15-year increase in opioid overdose deaths. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report. Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have also quadrupled since 1999.
The entire campaign to “eliminate pain” was largely supported by opioid manufacturers, such as Purdue and Abbott through their creative marketing to physicians. The most “funny”, reported by STAT, was the use by a drug rep of creatively-arranged donuts to catch the attention of an orthopedist who would not otherwise meet with him, by appealing to his sweet tooth. It is not, of course, really funny, and it is almost worse that physicians could (and maybe still can) be bought not by trips to the Bahamas but by a box of donuts!
Speaking of donuts, we have the even more incredible exposé in the Times that for decades, beginning in the 1950s, the sugar industry worked assiduously to fund and support researchers whose work blamed dietary fat, rather than refined carbohydrates (sugar) for the prevalence of heart disease, (“How the sugar industry shifted blame to fat”, September 12, 2016). This was not a one or two time payoff to a couple of researchers, but a continued campaign over more than a generation to have the scientific community, and thus the rest of us, minimize the impact of sugar on heart disease. This work forestalled the more recent campaigns to limit sugar-containing foods, especially soft drinks, and was a major contributor to an epidemic even greater than opioid addiction, obesity and its related health effects. Sugar is not a prescription drug, but it probably has had more negative health consequences than all prescription drugs together.
So who can we trust? I have often argued for the scientific community, but such reports of corruption of scientific research are sobering; at least, we can say that today there are increased safeguards in place. Clearly we cannot trust politicians; while they will respond to the crises in the news (like drug price increases and such) they are dependent on contributions from large corporations, and those large corporations are pursuing their financial interests. Whether directly involved in our medical care, like insurance companies and drug companies and hospital chains, or dramatically affecting our health like the high-calories food industry (including sugar), or polluting and destroying our environment like many energy companies, our interests (at least as far as our health is concerned) are not their interests, and there is often (or usually) little overlap between the two. As a physician colleague put it, “It’s always worse than you think … even if what you were thinking is pretty bad.”
Pursuit of financial gain by such companies is not in the interest of our public, or private individual, health. The most vulnerable of us – the poorest, sickest, youngest and oldest and least empowered – suffer first and most, but all of us suffer. Drug prices should be regulated tightly, and competition (including pricing as in other countries or import of drugs) should be encouraged; insurance should be single-payer, and the impact on the public’s health the main criterion in deciding on environmental pollution.
Profit should have no place in determining our health or health care.

Roosevelt University: A commitment to diversity and social justice

On December 13, 2013, I attended the winter Commencement ceremonies at Roosevelt University in Chicago. As a new member of the University’s Board of Trustees, it was my first such event at Roosevelt; the Board had met the day before. I have, of course, been to other graduations. Some have been of family and friends, but most have been as a faculty member in medical school. I have sat on the stage looking out at the assembled graduates and families before, but never in the role of a Trustee, and never at Roosevelt.
Graduations are pretty special events. At the medical school graduation ceremony, we look on as our future colleagues march across the stage, many of them people we know and have taught, while their families watch and clap and sometimes cheer. We have pride in them, and also wonder how fast the time goes, remembering when they were just starting a few short years earlier. But the Roosevelt graduation was different, and not just because it was not a medical school and not just because I was there as a Trustee.

For starters, it was in Chicago’s beautiful Auditorium Theater, in the Auditorium Building designed by Louis Sullivan, opened in 1889 and about to celebrate its 125th anniversary next year. I have been there before but only in the audience; sitting on the stage looking out at this gorgeous auditorium whose balconies soar 6 or 7 stories, filled with 4,000 people, was amazing. Roosevelt owns the Auditorium, and the building has long been its home, but recently the 40-story Wabash Building has been built next to it, rising 40 stories, the top 27 dorms with priceless views, its own architectural splendor complementing in a very different way that of Sullivan.
There were also some special events during the graduation. The honorary degree recipient was Joe Segal, a Roosevelt alumnus who for 60 years has run Chicago’s Jazz Showcase, bringing all of the great jazz artists of those years to perform at a series of venues; I began attending his shows in the 1970s. Danielle Smith, graduating with a bachelor’s degree in Special Education (and a minor in Spanish) was the first-ever current student to be commencement speaker. She was joined on the stage by Sheree Williams, receiving a Master’s in Early Childhood Education, who was the 85,000thgraduate of the school (it took 60 years to get to 65,000 and only 6 for the next 20,000).
Those of you who read my last post, Suicide: What can we say?, know that the date, December 13, was also the 11th anniversary of my son Matt’s suicide. While the two facts are coincidental, they are not unrelated; my presence on the Board and thus at the graduation was entirely about Matt. A few years after leaving his first (quite elite) college and then obtaining an associate’s degree, Matt moved back to Chicago and enrolled at Roosevelt. He loved it. It was, and is, a school, originally established to focus on returning GIs and people of color, that both educates young (and older) people from all backgrounds and prides itself on its diversity, and its explicit commitment to social justice. This resonated with Matt, and does with me. I later met President Charles Middleton through the sponsorship that Matt’s mother and I do of the annual Matthew Freeman Lecture in Social Justice (see, most recently, Matthew Freeman Lecture and Awards, 2013, April 26, 2013), and later when he hosted my group of American Council on Education fellows at the university. Dr. Middleton calls Roosevelt the “most diverse private university in the Midwest”, and sitting there as the graduates cross the stage it is not hard to believe. Virtually every race and ethnicity was represented by the graduating students, many obviously first-generation Americans, and the pride in their faces was unmistakable.
In her speech, Ms. Smith spoke about coming to Roosevelt from an all-white, middle-class, suburb, in large part to play tennis – which she did. She also, however, learned about diversity, and met fellow students from all races, religions, ethnicities, and socioeconomic groups, and made them her friends. She talked about a concept that she had never heard of before but was omnipresent at Roosevelt, social justice, which she says will guide the rest of her life. Ms. Williams’ presence on the stage, as 85,000th graduate, may seem like a quirk, but she also is “typical” of Roosevelt; an African-American woman who received her bachelor’s in education there and now her Master’s, and will be teaching second grade in Chicago, before, she plans, to get her doctorate. Wow.
President Middleton, in his closing address, asked several groups to stand. They included the international students, who had to add learning English in addition to their studies, and the families, friends and other supporters who jammed the Auditorium. Most impressive, to me, however, was when he asked all the graduates who were the first members of their families to get a degree at their level to stand. Some were getting doctorates and master’s degrees, but the large majority of the graduates were receiving bachelors. Two-thirds of the graduates stood, to rousing cheers.
There are plenty of colleges that offer the opportunity for students from working-class and poorer backgrounds to get an education, for first-generation students to learn. They include the our community colleges (I still remember a talk at the 2008 ACE Conference by the president of LaGuardia College in NYC, where she said — as I remember it — “there are two kinds of colleges; those that try to select the students who will be the best fit at their institutions, and community colleges, that welcome students”), and our state universities. And some are private schools, like Roosevelt. And others may have the explicit commitment to social justice that Roosevelt does.
But I am proud to be associated with one that so overtly and clearly demonstrates it.

Cross-posted to “Life, the Universe, and a Few Things”

Medical interventions we shouldn’t be getting: issues of cost, health, and equity

Many of us are concerned about the cost of medical care, particularly in the US. We are also concerned about the care that we, ourselves or our families and friends receive. We want the diagnostic tests and treatments we get to be likely to benefit us and to not cause us harm. Or, if there is chance that we may be harmed, that the probability and degree of benefit exceeds the probability and degree of harm. Sometimes there can be a tension here: we want to spend lesson health care globally (and certainly less on the portion that just goes into the pockets of big corporations, like pharmaceutical companies and device manufacturer, insurers and huge health provider networks), but don’t want to scrimp on things that may benefit us. Especially when we are well-insured and not paying for it directly out of our pocket.
Fortunately, there are many times when these two different interests come together, when tests or treatments that are costly are also of no benefit to us, and may cause us harm. The problem is that sometimes our doctors recommend them to us anyway, or, frankly, we ask for them (because we’ve read about it on the Internet or seen an ad on TV or because a doctor recommended it for our Cousin Shirley who had the same thing, or at least something that sounded a little the same). How can we, as patients, know when our doctors are recommending a test or treatment that is not indicated for us, will not benefit us, may even cause us harm? How do we know when we are appropriately advocating for ourselves as opposed to asking for something inappropriate? It is not easy, but we can try.
One answer is NOT to reject all medical recommendations for diagnosis or treatment, to assume that something “natural” is always right. Medicine can do a lot; it can treat a lot of illnesses that can cause you to suffer or die prematurely. There are many tests that are proven useful or valuable for making diagnoses. Another is to not reject things simply because they cost money (difficult when you don’t have much and they cost a lot), but also not to ask to have them because you havemoney (or insurance). To a great extent it is asking your doctor questions, asking about the degree of benefit, hoping that they are up to date, trying to question what the likely benefit is from another test or treatment, especially if costly. It also, sadly, means understanding if the doctor themselves, or a company they work for, stands to make profit on the test or treatment, since this creates a conflict of interest (but certainly does not mean that it always or usually isn’t appropriate).
There is an entire medical literature on medical overuse, and your doctor should be familiar with it, or at least the most egregious overuses that are in her/his field. A recent article in JAMA Internal Medicine , “Update on Medical Practices That Should Be Questioned in 2015”, by Morgan et al., reviews some of these.[1]The authors reviewed the literature on articles published in 2014, and came up with 104 that at least one of the 3 thought was very important, and 33 that all agreed were very important. The article reports on the “Top 10”, because this is a nice, round number and because it seems to be a manageable number of things for doctors to remember. Just these 10 represent a lot of excess tests and excess expense.
I will summarize some of these 10 (the ones I feel are most relevant; you can find them all in the article), both to remind doctors and other health care providers who might not have seen it, and because other readers may have had these tests recommended. Before doing so, it is important to review the difference between a screening test, done on the general population (or a subset of it) who don’t have any symptoms, and a diagnostic test, which may be the same test done on someone with symptoms related to what that test tests for. Frequently a test is useful for diagnosis for someone with symptoms but in someone without may not only be of little use, but find “false positives” that end up leading to more testing with more cost and greater risk.
  • There Is No Benefit to Screening for Asymptomatic Carotid StenosisNone, for screening. Ultrasound or other tests may be of value for people with TIAs or other symptoms.
  • Screening Pelvic Examinations Are Inaccurate in Asymptomatic Women and Are Associated With Harms That Exceed Clinical Benefits. Again, none, for screening. You can’t screen for ovarian cancer. I have been trying to convince my residents of this for years, despite their being often taught otherwise by OB-Gyns. This is the part where the provider puts his/her hands inside. It is NOT the same as a Pap smear, which is recommended for screening.
  • Head Computed Tomography Is Often Ordered but Is Rarely Helpful. Often finds clinically insignificant abnormalities. Also, often repeated with no added benefit. (“A retrospective cohort analysis reviewed 130 patients admitted for any cause at least 7 times during a 1-year period to a tertiary care center. Patients received a mean of almost 7 CT scans, including 3 head CT scans. More than one-third (36%) of head CT scans were ordered to evaluate for altered mental status. Only 4% (7/127) of head CTs had clinically significant findings that resulted in a change in management.”)
  • Thyroid Cancer Is Massively Overdiagnosed, Leading to Concrete Harms.  Study is from S. Korea, where they screen for it.
  • There Is No Benefit to Paracetamol (Acetaminophen) for Acute Low Back Pain. “The median times to recovery were 17 days in both of the paracetamol groups and 16 days in the placebo group.” This does not mean we should be using opioids, though. In fact, when we give opioids for good reasons, like postoperative pain…
  • Postoperative Opioid Use Continues Past the Postoperative Period.

Some overuse comes because practices once felt to be appropriate, but now shown not to be, are being taught to trainees, who either don’t know or are loathe to disagree with their instructors. Some comes, consciously or not, from the potential for providers to make money. Another recent JAMA Internal Medicine[2]study looked at family medicine and internal medicine residents who saw “secret shoppers”, standardized patients who were requesting inappropriate imaging. About 25% of the time the tests were ordered, which could be seen as either bad or good (75% of the time they weren’t). The study also showed no difference between those residents who got significant feedback and those who didn’t, and similar (and generally good) techniques of communicating to the patients why these were not indicated. An interesting wrinkle is that some of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were imaging studies not recommended by the American Academy of Family Physicians and American College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are not recommended against by the  American Academy of Orthopaedic Surgeonsin their “Choosing Wisely recommendations. Of course, orthopedists stand to benefit from doing surgery on these patients. (By the way, among the recommendations of the AAFP is not doing screening pelvic examinations!)
What is the social justice issue here? After all, tests and treatments that are not indicated should not be done on anyone, regardless of financial or insurance status, racial or ethnic characteristics. Indeed, one could argue that those with more money or better insurance would be the most likely recipients of extra tests. But poorer, or less well-insured, people often don’t get the tests and treatments that they actually need (which has often been discussed in this blog; see for example Dead Man Walking: People still die from lack of health insurance, November 17, 2013), while tests and treatments are overused for others. This creates the (accurate) perception of a two-class health care system, and the (sometimes, perhaps, less accurate) perception that the disadvantaged are, in addition to not getting care they need, are not getting discretionary care that benefits the wealthy. Also, the more money spent globally on unnecessary medical care, the less available for necessary non-medical initiatives (housing, food, education) that would actually create better health.
A single payer system would not in itself achieve this goal, but it would create far more equity in the allocation of healthcare dollars, and at least eliminate the profit motive that might impact the recommendations of some providers and healthcare institutions.

[1] Morgan DJ, Dhruva SS, Wright SM, Korenstein D, Update on Medical Practices That Should Be Questioned in 2015, JAMA Intern Med. 2015 Dec 1;175(12):1960-4. doi: 10.1001/jamainternmed.2015.5614.

[2] Fenton JJ, Kravitz RL, Jerant A, et al., Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial, JAMA Intern Med. Published online December 07, 2015. doi:10.1001/jamainternmed.2015.6840

Ebola, risk, and the public’s health

My friend Allen Perkins received a text from his college-student daughter asking if she should be worried about the Ebola virus. His reply, discussed in “Ebola virus and the dread factor” in his excellent blog, “Training Family Doctors” was “Are you considering moving to west Africa?” This was wise and profound fatherly advice, based upon an understanding of the epidemiology of disease. While is it obviously a serious problem in West Africa (particularly Liberia, Sierra Leone, and Guinea), it is not in the United States. Many other things are much more of a threat in the US, including, as Allen points out, “death from bee stings” (100 per year in the US).
Ebola might someday become a significant problem in the US, but it is unlikely and is not now. Many other health problems are. College students like Allen’s daughter should be sure that they have all their recommended immunizations for diseases that can be prevented by vaccine, including HPV and meningococcus, a very serious and often deadly cause of meningitis that can become epidemic where young people live together in close quarters, like college dormitories (and army bases). Yet, many do not receive these immunizations for reasons that range from passively not getting it done (less of a problem in schools where it is required) to having beliefs, or having parents who have beliefs, that vaccines are dangerous and should be avoided (in some cases this can trump school requirements). They are, by the way, wrong. The net benefit far outstrips the risk. Having your child get meningococcal meningitis and die or have serious brain damage, or get cervical cancer, is not something you want.
But focusing on conditions over which we have little or no control, rather than the ones we do, is fairly epidemic in this country (and likely others). Dr. Perkins focuses on the “dread factor”, about how news reports (not to mention thriller movies) whip up fear about these diseases. On the other hand, mostly what we can do is fear them, while the diseases which we individually might be able to have an impact on would require us to have to maybe do something hard: change our diet, start exercising, stop smoking, not drink so much or at the wrong times. I have written in the past about a patient who had a terror of breast cancer, a disease for which she was not at an increased risk based both on her youth and lack of family history. On the other hand, she did not seem particularly worried about the health risks of her uncontrolled high blood pressure, smoking two packs of cigarettes a day, or having unprotected sex with several different men.
Most of us can see that this is not logical, and maybe even snicker a little about her poor decision making. But it is only a little extreme. Many, perhaps most, of us, could do a better job of eating right, of exercising, of not smoking or drinking excessively (which for many people is “at all”). If not Allen’s daughter, many of her classmates are at much greater risk from going out and getting drunk on a weekend night, increasing their risk of motor vehicle accidents, sexual assault, poor judgment in choosing voluntary sexual encounters, and long term habituation for those with a predilection for or family history of alcoholism, just for starters. But taking action to prevent such bad outcomes is hard, requires effort, and often means not doing things we like in the short term, such as eating tasty-but-unhealthful foods, drinking with friends, smoking when we are addicted to nicotine, driving when we (or the driver) is only a “little drunk”, or having to do unpleasant exercise. Or it can conflict with our self-image: wearing a bicycle or motorcycle helmet, eschewing doing things that our friends are doing. Worrying about things that we can do nothing about, like breast cancer or Ebola, may be a little irrational, but it is in some way comforting because if the bad thing happens we are an innocent victim.
In addition, there are actions a society can take, that could make even more of a difference from a public health, population health, point of view, saving more lives, but these require political will. Sadly, this is often more lacking than individual will. Guns are the prime example; many state legislatures and legislators make it a point of personal pride to advocate for there being no restrictions at all on what kind of guns (e.g., automatic weapons) and ammunition (e.g., armor piercing bullets) people can have or where they can carry them (everywhere, open or concealed). Helmets and alcohol regulation are other areas where opportunity for prevention is often missed. Car safety has been increased by car and highway redesign and tobacco has been increasingly regulated (against the opposition of the industry, it should be noted, in both cases) for the benefit of public health, but many opportunities remain.
Indeed, expanding health coverage to all those below 133% of poverty by Medicaid expansion continues to be opposed by those who want to be seen as against Obamacare. This may be irrational from a public health point of view, but in many states it is rational, if offensive, for being re-elected. The most unjust and inequitable part of it all is how the effects of poor public health policies most affect the most vulnerable, poorest, least empowered people in our society, or indeed any society. Public health education campaigns tend to focus on diseases that have well-funded advocacy groups and affect the majority population; a recent qualitative study of African-American women found that they were very aware of the threat of breast cancer, but hardly at all of stroke – a disease statistically more likely to affect them.
Speaking of public health, it is gratifying to see some newspaper coverage of Ebola that is not sensationalist or scary.U.S. Colleges See Little Risk From Ebola, but Depend on Students to Speak Up”, by Richard Pérez-Peña in the NY Times, August 30, 2014, addresses the small but real risk that may affect colleges from students who have (unlike Allen’s daughter) actually traveled to West Africa. Even better is “Leadership and Calm Are Urged in Ebola Outbreak” by Donald G. McNeil, Jr., which presents a rational, thoughtful, public health approach, and discusses public health strategies which have been used in the past in major crises and are beginning to be implemented in West Africa. These strategies center around the use of local, respected experts who can effectively communicate with the people in their countries, rather than international aid agencies. The goal is to help people to utilize appropriate prevention and protection measures rather than panic. Again, as in the case of the other personal behaviors described above, this can be hard for people, especially when it contradicts cultural and religious values (such as how the dead are buried). But having voices who are local, who understand the culture, and have both medical/public health credentials and individual credibility, is extremely important. Of course, unlike the Ebola “scare” articles, these were both on page 8 of the newspaper, but have a more prominent position on that day’s Times homepage.
So what are the lessons? Understanding risk is not always easy, especially when an epidemic with a hugely high mortality rate threatens.  Doing something is harder than not doing anything, and it can thus be tempting to worry more about the things that we can’t do anything about rather than those we could reasonably take action on. The same is true for public health issues that need to be addressed at a societal level.
And, of course, it is always the most vulnerable who suffer the most.

Kansas only state to increase number of uninsured: A how NOT to do it strategy

The title of Alan Bavley’s article, “Kansas is only state to see an increase in its uninsured rate, survey says”, (Kansas City Star, August 5, 2014) kind of says it all. It could be seen as a victory by some. Four years after the passage of the Affordable Care Act (ACA), aimed at expanding health coverage to more Americans by a combination of strategies including the creation of both state-run and federally-run (for those states that chose not to run their own) insurance exchanges to match people seeking coverage with insurance companies and subsidizing premiums for the moderately low-income, and expanding Medicaid for the very low-income, Kansas has succeeded in actually reducing the number of people covered!

The adult uninsured rate in Kansas rose from 12.5 percent last year to 17.6 percent during the first half of this year, giving the state the seventh-highest rate in the nation, according to data collected as part of the Gallup-Healthways Well-Being Index…. in other states uninsured rates declined or remained unchanged. Kansas was the only state with a statistically significant increase in the percentage of uninsured residents.
One could construct a fantasy out of whole cloth demonstrating how this proves why the opponents of the ACA were right all along; that it is not increasing health care coverage because it is evil and socialist, and that the increased costs for some people, along with cuts in the number of employed folks because of policies that do not always support “job creators” (read: very rich people) have decreased our employer-based insured group. Of course, that would be incorrect, but I expect to see it anyway.

In fact, those governing my state have worked very hard to make this happen. Governor Brownback and most of the state legislature are strong opponents of Obamacare, and have done what they could to make it not succeed. When the Supreme Court ruling allowed states to opt out of expanding Medicaid, Kansas did so, eliminating the very poor (under 133% of poverty) from the method the law intended for them to receive coverage. Kansas also chose not to develop a state-run insurance exchange and pu up as many obstacles as it could to the federally-run one. One of two Court of Appeals decisions (discussed in this blog in ACA: Where are we? And where should we go?, July 27, 2014) ruled that subsidies could be available only to enrollees in state-run exchanges (which Kansas doesn’t have); it hasn’t gone into effect yet, because another district’s Court ruled the other way, so we will have to wait for the Supreme Court to decide, but if it is upheld would bolster the number of Kansans not getting insurance.

But a decrease in the number of insured? The only one? Surely that is a notable accomplishment. How did we pull that off? “’It’s eye-popping. Kansas really sticks out,’ said Dan Witters, research director for the Well-Being Index, an ongoing national poll that surveys people’s health, relationships and finances.” For starters, it could, possibly, not be exactly true, but a data anomaly of the survey somehow. This is basically the position of the state’s Insurance Commissioner, Sandy Praeger, who said

…the number “appears to be an anomaly that needs more review. To have the uninsured jump that much in one year would be unprecedented.” The uninsured numbers in Kansas have hovered around 12 to 13 percent for many years, Praeger said, adding, “We will try to find out where the discrepancy is.”
This is worth noting, as Praeger is one of the few honest, trustworthy, and non-ideological members of state government in Kansas. Note that she does not claim that it is a liberal lie, or that it is a good thing, but just that it is inconsistent with previous data and she will try to find out why there is a discrepancy. If that is the reason, I’m sure she will.

But there are reasons to think that the numbers may not be inaccurate, even if they turn out not to be quite as bad as this survey indicates. Since the election of Governor Brownback in 2010, and with the support of the legislature, taxes in Kansas have been slashed, particularly income tax rates on high-income people and corporations and business taxes. The motivation was a profound belief in supply-side economics, that tax cuts would stimulate job growth.  Unfortunately, it has not. Job growth in Kansas has been more sluggish than in the country as a whole, and the state is facing enormous deficits. Cuts in spending have been dramatic, but the problem is, in fact, on the supply side – not enough tax revenue.  People don’t have jobs, and thus often don’t have enough income to qualify themselves for the exchanges, even if subsidies are allowed by SCOTUS to continue. The state has a very large number of undocumented workers (and most are indeed working, or in families of people working) who would not be eligible for coverage by any part of ACA, and can only get it if their employers pay for it. Which many do not.

While many states with Republican governors have pursued many of the same tacks as Kansas, including limiting the impact of ACA and cutting taxes, Kansas has been in many ways a test case for these strategies, even more than Wisconsin, because of its strong Republican tradition. Americans for Prosperity has a very strong political and financial influence in the state, and it is heavily financed by the Koch brothers whose Koch Industries is based in Wichita, Kansas (where Charles Koch still lives). Cutting taxes for the wealthy and corporations, and blocking any opposition to fossil fuel expansion, is the cornerstone of state politics, not ensuring the health or well-being of its residents.

In a larger sense, however, this is more than a story about Kansas. It may be the only state with a statistically significant increase in uninsured in the last year, but it is far from the state with the largest percentage of uninsured. Many other states that have not expanded Medicaid, and cut social services, have similar situations. Sadly, of course, many of these states (particularly in the southeast) started pretty far down, much worse than Kansas did, and have dug themselves deeper in the hole. The real story, I think, is in the states that, despite being southern and conservative, have chosen to expand Medicaid, and have seen real benefit for their people.

The Gallup poll found that the 10 states with the largest reductions in uninsured rates this year had all expanded their Medicaid programs and had either created their own exchanges or partnered with the federal government on an exchange. Arkansas saw the steepest decline, from 22.5 percent uninsured in 2013 to 12.4 percent this year. Kentucky was second with a decline from 20.4 percent uninsured to 11.9 percent.

Good policies can actually help. The state with the actual highest rate of uninsured people is Texas. “Look out, Texas,” Governor Brownback stated in announcing his original tax cuts, “here comes Kansas!”  He was talking about job growth, which we haven’t achieved, but we are making much more progress on denying people access to healthcare coverage.

Opioids and other pharmaceuticals are the tip of the iceberg: It’s the profit, stupid!

The NPR program “Fresh Air”, with Terry Gross, had Anna Lembke, MD as a guest on December 15, 2016. Dr. Lembke is the author of the recent book “Drug Dealer, MD”, in which she apparently (per the discussion on air; I have not read it) implicates physicians and pharmaceutical companies in the widely discussed “opioid epidemic”. Dr. Lembke is a Stanford psychiatrist and director of the addiction medicine fellowship there, and she is able to articulately describe what is known and what is not about the neurological impact of opiates and opioids on the brain. One important point she makes is that continued use of opioids causes tolerance and a need for higher doses; in addition she describes how chronic use of opioids causes a pain syndrome of its own (decreased tolerance to pain) in some people, and how weaning them off opioids can actually decrease or eliminate their pain.

Her key issue, however, is that the epidemic of opioid use was orchestrated by the pharmaceutical manufacturers of opioid analgesics, who heavily promoted them, created the perception among doctors and the public that physicians were heartlessly undertreating the pain that their patients were in, and hooked in (mostly) well-meaning doctors to become, in essence, their pushers (“Drug Dealer, MD”) while they made huge profits. And continue to do so. And, as the reaction to this epidemic begins to form, continues to promote new syndromes that require treatment with their drugs.

An example of this is “OIC”, opioid-induced constipation, which made its first big appearance during the Super Bowl of 2016. The commercial left it a vaguely mysterious ailment, but it is a real one. Of course, the commercial was a prelude to an advertising campaign, in this case for Movantik ®, a partial opioid antagonist manufactured by a collaboration between AstraZeneca and Daiichi Sankyo designed to treat this condition. Constipation, in fact, is the only side effect of opioids that does not decrease with continued use, so as a person uses higher and higher doses of the opioids to try to control their pain, their constipation gets worse and worse, sometimes requiring surgery and occasionally death from a ruptured colon. My reaction, while understanding we would soon see a drug for this condition promoted, was that it was a cynical and disturbing attempt to “normalize” opioid addiction. “Oh, you have this problem? Well, it’s not just you! LOTS of people have OIC!” It turns out that I was not the only one with this reaction; Ahiza Garcia on in a piece on CNN Money called “Super Bowl drug ad sparks big backlash”, quotes Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing: “It’s very disturbing to see an ad like that. It’s normalizing the chronic use of opioids, which aren’t demonstrated to be safe over the long term.”

Of course the greed and anti-social behavior of pharmaceutical manufacturers is neither new nor is it going away. Their efforts to use doctors and exploit the public as much as they can possibly get away with in pursuit of exorbitant profits continues to generate news, and occasionally, reaction by states. We have all heard about the huge price increase in Daraprim ® by Martin Shkreli and Turing (Drug prices and corporate greed: there may be limits to our gullibility, September 27, 2015) and Epi-Pen® by Heather Bresch and Mylan (Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016) and maybe thought that this publicity would rein in further abuses. But not so. Reuters just reported in “US states sue Mylan, Teva, others for fixing drug prices” that “Twenty states filed a lawsuit Thursday against Mylan NV (MYL.O), Teva Pharmaceuticals (TEVA.TA) and four other generic drug makers, saying they conspired…on pricing of two common generic drugs, according to a copy of the complaint.” Lest you think that this conspiracy is just preventing these companies from being undercut by each other, we are talking fantastic price increases for common and necessary drugs. “The drugs involved in Thursday’s lawsuit include the delayed-release version of a common antibiotic, doxycycline hyclate; and glyburide, an older drug used to treat diabetes. Doxycycline, for example, rose from $20 for 500 tablets to $1,849 between October 2013 and May 2014, according to Senator Amy Klobuchar, a Minnesota Democrat who had been pressing for action on high drug prices.” In case you missed it, this is a 9245% increase in the price of doxycycline! And it may well be up to the states to bring such legal action, since there is little reason to think that the federal government, led by President-elect Trump and his corporate cabinet, along with the Republican-dominated Congress, will be doing anything about it.

Which, of course, is the core problem, and has been for a long time. Corporate profit has become the be all and end all of US policy. Anything that increases corporate profit is seen as good. This certainly includes subterfuge, cheating, exploitation, and corruption. While this has long been the case, it is likely to increase under the Trump administration, with its depressing panoply of corporate exploiters and climate change deniers. We are likely to see not only tolerance of encouragement and celebration of such outrageous excesses. Of course, it is fine to make a profit, but that profit should be reasonable and honest; it should not be highway robbery, generated by dishonesty, exploitation, and trampling others.

The pharmaceutical company activities cited about are the result of an attitude that “if we can make some money honestly, look how much more we can make if we are corrupt!” that pervades virtually every industry, from fossil fuels (see Rex Tillerson, the Exxon CEO who is Trump’s nominee for Secretary of State) to financial services. After campaigning against Goldman Sachs, the largest investment bank, and its ties to Hillary Clinton (“I know the guys at Goldman Sachs. They have total, total control over [Cruz],” Trump said. “Just like they have total control over Hillary Clinton”), Trump has named at least four current and past Goldman execs to cabinet-level positions, including its #2, Gary Cohn, as director of the National Economic Council. And, should anyone harbor any illusion that the survival of Goldman in the face of the collapse of rivals Bear Stearns, Merrill Lynch, and Lehman Brothers has anything to do with their being more honest or less evil, less likely to have indulged in “the Big Short” and transferred all their toxic investments to their own clients, read the recent piece by Matt Taibbi in Rolling Stone, “The Vampire Squid occupies Trump’s White House”.

Speaking of Rex Tillerson, his close ties to Russia and Vladimir Putin are seen (by the President-elect) as major qualifications for Secretary of State. In this context, the New York Times Op-Ed by Andrew Rosenthal from December 15, 2016, “To understand Trump, learn Russian”. Rosenthal notes that Russian has two words for “truth”:
The word for truth in Russian that most Americans know is “pravda” — the truth that seems evident on the surface. It’s subjective and infinitely malleable….But the real truth, the underlying, cosmic, unshakable truth of things is called “istina” in Russian. You can fiddle with the pravda all you want, but you can’t change the istina.

The pravda will change a lot with the new administration. Fossil fuel extraction is all good, climate change is a hoax, public education is bad, getting rid of the ACA will improve access to healthcare, immigrants are the problem, Putin is good, and gays and transgender people have no rights. That putting foxes in charge of the henhouse makes sense, and that having corporate titans in direct rather than indirect control of government will benefit us all. But the growth in the gap between the wealthiest and the rest of the people has grown under both Republican and Democratic administrations and anger at it was actually one of the drivers of the vote for Trump.

The istina, though, is that making the wealthiest wealthier and destroying the earth in the process is not the answer. Attention to the common good, for all of us, is the only thing that will move us forward, as a society and as a world.

Black men being killed by police: A public health epidemic

“Let’s do it to them before they do it to us,” was the line with which Sgt. Stan Jablonski (played by Robert Proskey) dispatched his troops on the old TV show Hill Street Blues. When Sgt. Jablonski replaced Sgt. Phil Esterhaus (on the death of actor Michael Conrad) they had to come up with a replacement for Esterhaus’ “Let’s be careful out there”. Perhaps the show’s writers felt it was ok coming from the shorter, pudgier actor than the 6’6” Conrad, but it has a very different meaning and very different connotation, an “us against them”.
Presumably the “them” was bad guys, not the regular folks that the police were supposed to be there to “protect and serve” but now, 30 years after the show went off the air, we realize how much this was, sadly, prescient. I am not going to recite the names of all the black men – and children – killed by police in recent years, including Tamir Rice, Michael Brown, Freddie Gray, Philando Castile, but it is an epidemic. Yes, more white people have been killed by police than black in both 2016and2017 – about twice as many – but the proportions are way off given that just over 12% of the population of the US is black. And what has been even more graphic is the lack of convictions, and frequently even prosecutions, of the perpetrators.
If these deaths were not at the hands of police, but rather had a different cause – an odd virus that struck down black men when being confronted by the police, or a very selective alien attack, we would not hesitate to call it an epidemic and search for the cause. But this issue is political, it is personal, it is an “us” against “them”, raising the issue is seen by many to be attack on the police, who heroically and at great risk to themselves protect us from evil. Certainly, the Governing Council (GC) of the American Public Health Association (APHA), by far the largest public health association in the nation, did not choose to identify the killing of black men by police as a public health epidemic when it voted, 65%-35%, against a resolution so designating it at the recent meeting in Atlanta. The resolution had been introduced a year before, and sent by the GC back to the authors to make changes to the language, which was done. But it was not sufficient.
If it was the language, felt, for example, to be denigrating to police, that was the issue, members of the group could have introduced and passed amendments to correct it. This point was made (after the vote) by APHA immediate past President Camara Jones, MD MPH PhD. But it was not the issue; the GC (and thus, the APHA) did not want to take a stand identifying the killing of black men by police in the United States as a public health epidemic. Speakers against the resolution cited personal but irrelevant concerns like “my brother is a policeman, and he is a good man”, as well as saying “the data is not sufficient to make the case that it is an epidemic”, which is patently false. The vote was portrayed as a scientific decision, but it was clearly a political one, a decision by the overwhelmingly white group to put their fingers in their ears, their hands over their eyes, and shut their mouths rather than standing up and saying “this is a problem”.
Many of these killings have been of people (usually men, but sometimes women or children) who were not involved in committing crimes. They result from the heightened suspicion police hold of black people in general. If you don’t believe that, you’re probably white. Just before the vote, I was at an session at the meeting discussing police violence against black men. Most of the group was minority (predominantly black) and were relatively young public health professionals, students, and junior faculty in schools of public health. A couple of speakers introduced the issue, but then opened the floor. One by one, in random order, unrehearsed, person after person in the group talked about their fears and their experiences; these were not prepared in advance, but slowly came out, one giving rise to another. A government employee noted that she had two young sons, and worried about their safety. Another woman, a public health professional, noted that her flight to Atlanta departed at 5:30am, so she’d left her home in a mostly-white suburb at 3:30am to go to the airport. She was followed by a police car all the way into the city. Another woman, a professor, talked about driving to a neighboring state and being followed by a police car that eventually stopped her for no reason or violation; in the process the officer asked “if you’re a teacher, why aren’t you in school?” The stories went on and on, from the mouths of professional people, most of them, in fact, women. 
Although many people would disagree, often virulently in with this age of Trump giving loud voice to aggrieved white men, being white in America is a privilege. It is a privilege of not thinking that you will be followed by police, or pulled over by them, or subjected to inappropriately probing questions by them. It creates an illusion, obviously held by the majority of the GC of the APHA, that it is mostly criminals, or “probably-criminals”, or people who look like they might be criminals, who are followed by, stopped by, and sometimes killed by police. But that is not the experience of black people in this country, not the black men shot by a police officer who makes up a story about being threated, nor of the middle-class professionals who told their stories at that APHA session. It is not the experience of the young woman who drove me to the Atlanta airport from the conference; in talking she said she had a 3-year old son and I asked if she feared for his safety not just from gangs but from police. In response she said she did, and pointed to a button hanging from her rear-view mirror and said “my uncle was killed by the police 3 years ago”. I don’t know what occurred with her uncle beyond what she told me, but I suspect it is not fate, coincidence, or Kismet that caused my driver to have her own story to tell, but rather the ubiquity of this experience among black people in America.
What about the police? Don’t we have to worry about the safety of the people who risk their lives each day to protect us? What about the fact that there are many (if not enough) minority police officers? To identify the current situation, not only the killings but the very real sense of most black people in this country that they do not have the same rights as whites, that they are, by definition, “suspicious” because of their color, does not require denigration of all police officers. Indeed, the families (especially male family members) of black police officers, and even the officers themselves when off-duty, experience the same indignities (and worse) as other black people.
It does mean that the idea that a police officer’s first loyalty is to other officers rather than to the community that they “protect and serve” must be very narrowly construed. Rather than a “thin blue line” of brothers (always, it seems, brothers, not sisters), it means that we should have tighter standards for police, excluding those who are overtly and viciously violent and racist. It means better training in identifying a situation in which you see through your prejudice and not through reality, and how to de-escalate. It means that when an officer kills a person innocent of a crime, it is not enough for other officers to have not “done it”; they must, if they were unable to prevent it, disclose it and discourage it and, yes, testify against the perpetrator. Police officers who do so are not “traitors”, they are heroes who allow the force to be thought of as we want to think of them.
The fact that even the most respectable and middle-class black people have to fear interactions with police (even when they are the ones who have called them!) is a societal scandal. The enormously disproportionate killing of black men by police is an epidemic, and like all epidemics we must identify it as such, find the cause, and treat it.
Even the APHA should be able to acknowledge that.

Status Syndrome: an important determinant of health

This is a guest post by Linda French, MD, who is Chair of the Department of Family Medicine at the University of Toledo School of Medicine.
In a recent blog (Keeping immigrants and all of us healthy is a social task), May 19, 2013), my good friend Josh Freeman wrote about the social determinants of health. When I commented that arguably the most important determinant was missing from his list he suggested that I write this book review blog as his guest. While I had long ago read quite a few papers on the topic of social determinants of health and health disparities that addressed the material that Josh covered in his blog, for me it was an eye-opening experience to read a book a few years ago by Michael Marmot (2004), The Status Syndrome: How Social Standing Affects Our Health and Longevity[1]. I found Professor Marmot’s explanations to provide a unifying idea that resonated with me.

Everyone knows that wealthier people are on average healthier than poorer people. However, it doesn’t follow that wealthier countries, including the United State (US), are necessarily healthier than poorer countries. For example, three countries that I am rather familiar with, Chile, Costa Rica, and Cuba, have life expectancies and other population health statistics that are as good or better than ours despite huge differences in average wealth.
Professor Marmot’s thesis is that, after a minimal threshold, it is not so much absolute differences in material means that makes wealthier people healthier, but rather their perceptions of their social status within their reference group. To quote him,
The remarkable finding is that among all of these people [i.e. the groups he studied], the higher the status in the pecking order, the healthier they are likely to be. In other words, health follows a social gradient. I call this the status syndrome.”

Professor Marmot is a British physician and epidemiologist from University College, London. His book carefully presents the evidence that it is the psychological experience of how much control you believe you have and your opportunities for full participation in society that is at the heart of social determinants of health.  He presents evidence from many countries and comparisons between them, and evidence related to individuals within different types of social hierarchies, and finally ends with evidence that countries with less inequality are healthier than those with more.
One example that he discusses in detail is that British office workers at the bottom of the office hierarchy have a higher risk of heart attacks than senior managers at the top, while just a generation ago popular wisdom was that highly successful “type A” personality people in stressful jobs were more prone to coronary artery disease.

Before reading his book I had seen some documentaries on primates that suggested that lower status animals had poorer health and reproductive outcomes and shorter lives on average compared with high status animals that was relatively unrelated to sufficient access to resources such as food. In addition I lived for a number of years in Chile as a young adult; my middle class income by Chilean standards was dire poverty by US standards. I was an American expatriate, a status  that was highly regarded in Chile, and also during some of those years I was a medical student. Despite the fact that I was really poor by US standards I was happy and healthy and my children also seemed as happy and healthy as US kids. After returning to the US I read some papers that included data to show that the generation of newly arrived Hispanic immigrants enjoy relatively good health outcomes, which deteriorate in subsequent generations despite the fact that the families have acquired more material wealth in absolute terms. No good explanations were included for the findings in those papers. After reading The Status Syndrome it made sense to me. The initial immigrants were probably using their country of origin as the social reference and subsequent generations had a US social frame of reference. I concluded that minority groups in this country have health disparities in large part due to the experiences of inequality and discrimination relatively more than due to absolute access to material means or even specific services – including health services.

In the latter part of his book Professor Marmot demonstrates that the countries with the best health statistics in the world are those that are both relatively wealthy and more equal. Examples of such countries are Sweden and Japan. On the other hand, countries at the other end of the spectrum present a reaffirming contrast. He spends the latter part of the book arguing for a political agenda in favor of reduction in social inequality.

If you haven’t figured it out by now, I highly recommend this book. It will transform how you think about the social determinants of health.

[1]Marmot, Michael. The Status Syndrome: How Social Standing Affects Our Health and Longevity. Owl Books. Henry Holt and Company. New York. 2004.