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Mandela’s AIDS Legacy of Silence and Courage

Dec 9, 2013• 1

By Arthur Caplan

Even the greatest among us can stumble.

As the world mourns the passing of Nelson Mandela, it is important to look at the one area where the iconic former president of South Africa slipped — AIDS. The most outstanding moral figure of our age did not do what was needed as HIV began to destroy the country he loved. But his actions after he realized his failures are an important part of his legacy.

South Africa is beset with the worst epidemic of HIV in the world. According to the United Nations, out of a South African population of just over 51 million, 6.1 million of its citizens were infected with HIV in 2012, including 410,000 children under the age of 14. An estimated 240,000 South Africans died in 2012 from AIDS. There are 2.5 million children orphaned because of the disease. The grim social, economic and medical toll AIDS has exacted on Mandela’s country is almost beyond description.

In 1990, when Mandela was released from a 27-year prison sentence, the rate of HIV infection among adult South Africans was less than 1 percent. When the anti-apartheid activist was elected president four years later, AIDS was on it way to being an out-of-control plague, with infection rates doubling every year. In 1998, the rate of HIV infection among adults in South Africa was almost 13 percent, with 2.9 million people HIV positive.

Mandela and his party were more or less indifferent to AIDS throughout his five-year tenure. There were other huge challenges in rebuilding the new post-apartheid nation — but the indifference was not just a matter of priorities. Mandela and his party did not want to admit they had a problem.

Why they did not take prompt action to slow the epidemic’s spread is not clear. Perhaps Mandela and his people — like United States President Ronald Reagan and his administration in the 1980s — found the disease and its modes of transmission too repellent to acknowledge. Maybe they did not want to tarnish the new state with a problem that at the time carried so much stigma and shame.

Power Up: What’s Next in Technology for Youth and Wellness

Dec 9, 2013• 4

By Jamia Wilson & Deb Levine

It’s time for those of us working in health tech to power up—and use our health tech muscle to make a real and lasting difference in young people’s lives.

In video games, power ups restore game characters’ health, increase their strength, shield them from damage, give them special abilities, and help them beat the odds. In health tech, power ups can help us find winning solutions for improving young people’s health and wellness.

Power Ups for Youth Health Tech:

Data-Driven (+1 Power Up) – Data can inform new research and spark insights, and well-visualized data can transform perceptions and change behavior. Young people prefer when information is shown, rather than stated. Use data visualizations to help young people understand how they fit into the big picture.
Connected (+1) – Health tech cannot be tied down by time, place, or even platform. A safe, connected, networked, multi-platform mindset should be our default.
Agile (+5) – We need to learn quickly what works, keep what does, and discard what doesn’t. You only get one chance with young people, so you’d better make it good.
Innovative (+10) – At its best, health tech will be creative and even disruptive. Let’s focus on radically accelerating and scaling our best solutions.
Authentic (+25) – Trust is the most indispensable currency for dealing with youth. Period.

The Really Bad Math Behind the Social Security Cuts

Dec 8, 2013• 22

By Stephen Soumerai

Among the sacrifices Congressional representatives placed on the altar of deficit negotiations is an “inflation adjustment” that will shave “only” a few hundred dollars from an average, newly retired Social Security beneficiary’s income each year. But the cruel hoax is that the reduction will amount to as much as $1600 when the beneficiary is older, poorer, and sicker. Many seniors already have a tough time paying for food, rent, and medical care.

Even worse, reductions in beneficiaries’ incomes may well cost government more for potentially preventable hospital and long-term care. Senator Elizabeth Warren and other New England lawmakers should be lauded for splitting from Democratic representatives and the Administration regarding this ill-conceived proposal.

Many senior citizens are already vulnerable to economic hardship. A recent US Census analysis that counts rising medical expenses found that over 1 in 6 elderly people live in poverty, unable to meet basic living expenses, and almost 20% more are living just above the poverty line. Social Security is the only or largest source of income for about 70% of seniors; the average monthly check is only about $1200.

The typical retirement savings of seniors is a paltry $50,000 — barely enough to get through several years’ living expenses, let alone 20-30 years of retirement. This is not the result of cavalier actions by the older generation; these are the Americans whose home values have plummeted, whose defined-benefit pension plans have been decimated or disappeared, and whose retirement accounts were eviscerated by the Wall Street meltdown of the last decade. Yet the current proposal punishes these Americans as if they were at fault for their poverty.

Fidelity Investments has estimated that the average retired couple will need more than $200,000 to pay their out-of-pocket medical expenses during retirement, and that figure is probably conservative.

The arithmetic of Social Security benefit reductions just doesn’t fit with this reality.

Why “Liking” Your Plan Is Not the Point

Dec 6, 2013• 34

By Daniel Skinner

In recent weeks, President Barack Obama has been appropriately raked over the coals for saying, multiple times, “If you like your health care plan, you’ll be able to keep it.” He shouldn’t have said it. The problem is, he shouldn’t have said it for entirely different reasons than most Americans think.

Let’s begin with a basic question: What does it mean to “like” one’s plan? And what is the value of this statement? All of this came to a head at an October 30 Congressional hearing with the Secretary of the Department of Health and Human Services, Kathleen Sebelius.

At the hearing, in a cantankerous challenge to Sebelius’s credibility, Tennessee Rep. Marsha Blackburn highlighted two constituents, Mark and Lucinda, who “like their plans,” but were being told they could not keep them because of the Patient Protection and Affordable Care Act (ACA), so-called “Obamacare.” A long-entrenched individualist rhetoric provided the framework for Blackburn’s point, namely that we should allow Mark and Lucinda to keep their plans in the name of individual freedom, just because they “like” them.

For purposes of argument, let’s assume that what Mark and Lucinda’s insurers are saying—that the cancellations are a result of the ACA—is true. But, as we do this, let’s also keep in mind that just because insurers claim premium hikes and cancellations are because of the ACA doesn’t mean that it’s true. In fact, it seems to be true only rarely and, even then, often as a half-truth.

But, anyway, let’s assume it is true. The question then becomes: why is it true? The problem is that this individual freedom is made possible by the assurances of a social safety net. This brings us back to the existential foundation of the ACA, namely that the choice to not carry health insurance—or to carry poor health insurance that individuals may find out, at some point, doesn’t cover something important—simply dumps those individuals into social institutions such as emergency rooms and local care centers, and does so in an extremely wasteful way. This returns us to the problem we started with and a question of whether or not ACA opponents are concerned with solving the problem of building a sustainable health care system.

In other words, Blackburn’s logic, as inspirational as it might be to some, bathed as it is in the rhetoric of freedom, is not premised on an analysis or understanding of health insurance, but deference to Mark and Lucinda to make their own choices, consequences be damned.

Healthism: The New Puritanism

Dec 4, 2013• 6

By Saurabh Jha, MD

Here is a thought experiment. Assume that every hour you run you extend your life by an hour.

I have chosen a one-to-one ratio between the increase in longevity from running and the time running because higher ratios lead to the immortality paradox. Lazarus aside, the all-cause mortality for Homo sapiens is 100 % and will remain so for the foreseeable future.

This arithmetic means that at one point you will literally be running for your life: your life being extended precisely by the time spent running. But ignore this logical fallacy.

You run an hour every day for 40 years. Your life is extended by 1.67 years. Your costs are a new pair of running shoes every three months, which might even be covered at zero co-payment by insurance if USPSTF gave running a grade A or B recommendation.

A back of the envelope calculation, assuming the shoes cost $ 80, yields cost per life year of roughly $7664. There is, of course, more nuance. I am not including injuries that may result from running. I am not discounting time: I am assuming we value an hour now the same as an hour 40 years from now.

I am also not factoring the costs avoided of treating late stage cardiovascular disease, which must be balanced against the additional social security checks that the individual will draw because of living longer, not to mention the costs of treating diseases of extended longevity such as cognitive impairment, Alzheimer’s disease, recurrent falls.

But please continue to indulge my approximation. The point is not precision of economic calculations but a principle.

$7664 for an additional life year. Compared to the benchmark of $50, 000 per quality-adjusted life year that’s a bargain!

Was it worth it then?

What Public Insurance Exchanges Will Look Like 5 Years From Now

Dec 4, 2013• 1

By Rich Gallun

When envisioning what public insurance exchanges of the future can and should look like when it comes to technology and structure, one only needs to look at the successful private exchanges that have paved the way over the past several years.

This experience has taught those who administer private exchanges that open enrollment—the phase that the federal government’s Health Insurance Marketplace is struggling through currently—is only the beginning. Public exchanges could benefit from lessons already mastered by private exchanges—starting with open enrollment but extending to even more complex technology-based transactions.

There are 10 scenarios that vendors must be able to handle.

1. Life Events. In today’s individual Health Insurance marketplace, consumers can generally add or drop coverage for themselves or their dependents anytime they want. In other words, it’s a relatively “rule-free world.” In January 2014, that world changes to look more like the current group health marketplace in which many rules are defined by the federal government’s existing tax code (e.g., Section 125) and HIPAA requirements, and consumers must select and “lock in” their coverage once a year for the following 12 months, unless they experience a qualified life event.

As a result, each qualified life event – e.g., marriage, divorce, birth of a child, loss of spouse’s coverage and many more – must be configurable within the Exchange technology to enforce the appropriate rules. For example, if a person gets married, is that person allowed to drop coverage or change plans and carriers? How about with the birth of a child? Or with a loss of spouse’s coverage? For a truly scalable Exchange technology, thousands of scenarios must be configured in advance to enable consumers to make enrollment choices online without administrator involvement.

The T-Rex Takes on Healthcare Reform

Dec 4, 2013• 7

By Michael Turpin

His emails arrive at night and land like scud missiles. He is an Old Testament retired CEO who is appalled at the state of America and as a thirty year healthcare system veteran and dutiful son, I am expected to interpret the complicated tea leaves of the Affordable Care Act ( ACA) and warn him if Armageddon (any form of change) is imminent. He needs three hours notice to hide his coin collection.

Today, his instant messaging is in large case font; He has forwarded an email that was forwarded to him from a friend of a friend of a friend – all retirees convinced that our current President is an operative for a hostile foreign government. I have to give high scores to his email chain author for his/her detail, veracity and creativity. Many of the stories are purportedly authored by retired Generals, Navy Seals, and in one case, a dead President.

I often scroll down these emails to see if I can find its genesis and author – perhaps it is Karl Rove or someone incarcerated for white-collar crime.

The email offers me “the truth about Benghazi” or a grainy photo of the President giving out nuclear codes to Al Qaeda operatives behind a District of Columbia Stop & Shop. I am not always inclined to believe these missives but I love my Dad and his loyal concern for America. At 83, his draconian solutions are not always politically feasible and carry a decent chance of arrest if one actually tried to act on them. However, he has a 140 IQ and understands economics.

Are Smokers Really the ACA’s Biggest Losers?

Dec 1, 2013• 23

By Al Lewis & Vik Khanna

Facing thousands in extra insurance costs, smokers appear to be the Affordable Care Act’s (ACA) biggest losers. Employers are allowed charge smokers up to 50% more for their medical coverage than nonsmokers , starting in 2014.

On November 25, Fox News put it best: “Obamacare Policies Slam Smokers,” , noting that “smokers are the only group with a pre-existing condition that Obamacare penalizes.” THCB itself has headlined: Smokers Face Tough New Rules under Obamacare.

And these headlines are absolutely accurate — meaning that, with the possible exception of the e-cigarette, ACA is the best thing that has happened to employed smokers ever.

Here is how we arrive at this conclusion. The data is mixed on whether smokers incur much higher healthcare costs or just slightly higher healthcare costs during their working ages than non-smokers do. None of the data shows that their costs are lower, but let’s say there is no impact on health spending.

Nonetheless, the following is incontrovertible: smokers take smoking breaks.

Remarkably, there are no laws specifically governing smoking breaks, and like most other quantifiable human resources issues, no one has quantified them. But we all observe these breaks, and about a fifth of us participate in them. They reduce productivity. By definition, if you are outside smoking, you are not inside working.

Sure, some smokers make up the time by working harder when they aren’t smoking…but (1) many non-smokers work hard too and (2) some workplaces, such as inbound call centers, don’t offer the luxury of catching up later because they operate in real time. Lacking quantification, fall back on your imagination…and imagine what you would do if you ran a company in which non-smokers spent as much time mulling around outside as smokers do. That should give you an understanding of the impact of smoking breaks on productivity.

The Month of Anti-Deadlines

Nov 30, 2013• 2

By Billy Wynne

As we shake off the carb-coma and make our pre-resolutions, Congress and the Administration head into a sprint to the holiday recess fraught with health policy implications. Unlike every December in recent memory, there isn’t very much Congress actually has to do. Here are the top five things you need to know to follow the fun and prepare your organization for the changes afoot. A key theme to take home is that December 2013 is a month of anti-deadlines.

The Nov. 30/Dec. 1 “fix” to Healthcare.gov was set arbitrarily and has simply teed up another pivot point for opponents to pounce. We already know the wand hasn’t tapped the electro-synapses of the site yet to make the dang thing work like it should. Expect more incremental improvements through the month and enrollment numbers to come in above current rock-bottom expectations, with a healthy chunk coming from the proud, the few … the state-based exchanges.
The Dec. 13 deadline for budget conferees to produce a joint resolution is similarly fictional and self-imposed. While there are some burgeoning reports that co-chairs Murray and Ryan might be able to agree to FY14 funding levels and potentially alleviate some of the sequester, the buzz-o-sphere in Washington still has deep doubts. Even if the two negotiators come to agreement, House and Senate leadership have the bigger challenge of getting a bipartisan deal through their chambers.
Jan. 15 is the real deadline for a budget agreement and the real goal is writing a check to fund the government through Sept. 30. A budget resolution is helpful to give appropriators time to write actual spending policy, but it can be bypassed if the end-game is a continuing resolution that keeps current funding allocations in place. (Congress hasn’t passed an actual budget resolution since Democrats controlled both chambers.) At the end of the day, we’ll be back to the all-too-familiar roundtable of congressional leaders and Obama reps hatching a last-minute deal to avert a shutdown.

Stopping 23andMe Will Only Delay the Revolution Medicine Needs

Nov 29, 2013• 13

By Gholson Lyon

Genetic testing is a powerful tool. Two years ago, with the help of my colleagues, it was this tool that helped us identify a new disease. The disease, called Ogden Syndrome, caused the death of a four-month old child named Max. But the rules and regulations for genetic testing in the US, laid down in the CLIA (Clinical Laboratory Improvement Amendments), meant I could not share the results of the family’s genetic tests with them.

Since that time, I have advocated performing all genetic testing involving humans such that results can be returned to research participants. This I believe should extend beyond research, and some private companies, like 23andMe, are helping to do just that.

For as little as US $99, people around the world can send a sample of their saliva to 23andMe to get their DNA sequenced. Their Personal Genome Service (PGS) analyses parts of a person’s genome. This data is then compared with related scientific data and 23andMe’s own database of hundreds of thousands of individuals to spot genetic markers, which the company claims “reports on 240 health condition and traits”.

Earlier this month, however, as I had feared, the US Food and Drug Administration (FDA) has ordered 23andMe to stop marketing their service. In a warning letter, FDA said: “23andMe must immediately discontinue marketing the PGS until such time as it receives FDA marketing authorisation for the device.” By calling PGS “a device”, the FDA fears that people may self-medicate based on results they receive from 23andMe.

Somehow the US and UK governments find it acceptable to store massive amounts of data about their own citizens and that of the rest of the world. They are happy spending billions on such mass surveillance. But if the same people want to spend their own money to advance genomic medicine and possibly improve their own health in the process, they want to stop them.