Category: Health Policy

All Three Legs of the Obamacare Stool Are Working Well

Feb 15, 2023• 3

BY GEORGE HALVORSON

When the Affordable Care Act was passed, the politics were so intense and the debates were so filled with rhetoric in all directions that most people actually didn’t understand that there were three major component parts to the strategy and program that function very directly as a package, and should be looked at now in the context of several years of implementation to see how each part of that law is currently doing.

Medicaid was our first priority.

The first component part — and the one that had the highest need for passage when the law was passed because we were doing such a horrible job as a country in providing coverage to our children and to our low-income people — was Medicaid expansion.

We were the only country in the industrialized world that did not have health care available to our low-income children, and that deficiency damaged so many people and was so terrible as a reality that we needed to correct it as soon as we could.

That program is on the right track.

Most states have now used the full Medicaid package and we now have a total of 90 million people enrolled in Medicaid. About 41 million of the members are in the CHIPS program, and a majority of the births in a majority of the states are now Medicaid births.

The states have all used a number of modern care improvement tools to provide and deliver significantly better care than the old Medicaid programs that are far too often delivered to their beneficiaries.

What Scientists and Historians Understand: Without Truth, Progress Is An Impossibility

Feb 6, 2023

BY MIKE MAGEE

“This too will pass, honey!” That’s what my mother used to say when any of my eleven brothers and sisters or I seemed to be overwhelmed by whatever. And largely, now, three quarters of a century since my birth, she was mostly right. Whether in personal lives or the life of our nation, over a span of time, the slope has been slight, but upward.

But there are weeks, like this past one, where we are forced to witness the beating death of an innocent 29 year old black man at the hands of police in the very city where Martin Luther King was slaughtered 55 years ago, when it would be easy to lose hope. Why not, as Trumpets actively promote, just lie? Why not create “alternate realities?”

Witness Gov. Ron DeSantis. What he fails to realize, in his attempts to white wash Black History from Florida schools, is that the accurate and full disclosure and discussion of our complicated American history ultimately supports progress and optimism. This is because the record shows that we have the capacity (admittedly in very small steps) to improve ourselves and our ability to manage self-governance.

Science has a long history of opposition to politicians who oppose truth-telling. Louis Pasteur famously urged fellow scientists to “worship the spirit of criticism.” When challenged to provide a rationale for his faith in full disclosure, he replied, because “everything is fallible.”

There was another scientist of the same era who was born with an iron spine and a love for honest learning. Her mother had emigrated from Wales shortly after our Civil War. Born into a farming family on January 29,1881, Alice Evans lived to be 94. Along the way she became the first women scientist to work as a bacteriologist for the U.S. Department of Agriculture, and the founding president of the Society of American Bacteriologists (American Society for Microbiology).

Descriptions of her include an “unending intellectual curiosity, independent spirit, and unflinching integrity.” She received her education at Cornell’s College of Agriculture and at the University of Wisconsin’s College of Agriculture. After working on improving the flavor of cheddar cheese for three years, she headed to Washington D.C. to join the new federal Dairy Division. She had applied as A. Evans at the urging of her male mentors knowing the federal government had no taste for female scientists. As she was later quoted, “I was on my way to Washington where I had not wanted to go and where I was not wanted.”

Practicing Medicine without a License: When Patients and Politicians Play Doctor

Feb 1, 2023• 1

BY MICHAEL KIRSCH

We’ve all heard the adage, leave it to the professionals. It’s typically used when an individual has wandered out of his lane. How many folks go beyond their knowledge and skills with home projects, for example, who must then hire a real professional to mop up the mistakes? Luckily for me, the only tools that I – a gastroenterologist – know how to use are a colonoscope and an endoscope, so there’s no chance that I will be tempted to perform any plumbing or electrical tasks at home.

Although patients are not medical professionals, they routinely bring me results of their own medical research which suggest possible diagnoses and treatments. Often, these are patients whom I am meeting for the first time. I applaud patients who strive to be informed participants in their care. Indeed, there have been instances when a patient has brought me a valuable suggestion that I had not considered. But these are uncommon occurrences. A few computer clicks by a patient is not equivalent to the judgment and experience of a seasoned medical professional. It’s unlikely, for example, that I will agree that a patient’s elevated temperature is caused by malaria, despite this appearing on a patient’s internet search on the causes of fever.

However, even when I feel that a patient’s research results have no medical merit, the ensuing conversation is always valuable for both of us. I am in the room and can address the issue directly in real-time. I am the patient’s guardrail to protect him from careening off the road. I can explain right then the importance of being guided whenever possible by sound medical evidence. So, while I truly welcome the dialogue and recommendations from patients, I think that the maxim leave it to the professionals applies. Isn’t this why patients come to see us?

There’s a new player on the scene masquerading as medical professionals dispensing medical advice to the public. And in this case, there are no effective protective guardrails protecting patients as we doctors routinely do. I am not referring to middle of the night telemarketers or companies promising that probiotics are the panacea of our time.

As absurd as this sounds, politicians are now authorizing medical treatment for various diseases and conditions. Politicians? Could this be true?

The “Antebellum Paradox”: What is it and why it matters.

Jan 30, 2023

BY MIKE MAGEE

I recently made the case that “Health is foundational to a functioning democracy. But health must be shared and be broadly accessible to be an effective enabler of good government.” I also suggested that the pursuit of good health is implied and imbedded in the aspirational and idealistic wording of our U.S. Constitution, and that the active pursuit of health as a nation is essential if we wish to rise to Hamilton’s challenge in Federalist #1 and prove that we are “capable of establishing good government from reflection and choice.” So why are native white males lagging behind in health?

Our progress as a nation toward health was severely hampered from the start. The reality of self-government “of the people, by the people, and for the people” applied only to 6% of inhabitants, all white male land owners at the time. Health was never voiced as a priority, though modern day critics insist it is clearly implied in the promise of “life, liberty, and the pursuit of happiness.” But what was that promise worth in the late 18th century, in a nation that allowed slavery, disenfranchised women, and slaughtered and dislocated its indigenous brothers and sisters?

In those earliest years of the birth of this nation, in the first half of the 19th century, what was the state of health for enfranchised native born white citizens of this nation? Most may presume (as I did) that the general health and standard of living over the next two hundred years, as reflected in lifespan, was a straight (if gradual) upward slope. But what I learned from a bit of digging is that uncovering the facts on mortality, fertility, migration, and population growth during those early years of our nation is a complex venture at best.

Our federal government did conduct a census every ten years, but one hundred years passed before we reliably collected vital statistics including comprehensive birth and death registration. Beginning in 1850, age, sex, race, marital status, occupation and cause of death were supposed to be collected. But an audit in those years disclosed that mortality (for example) was 40% underreported.

Cardiology update: Should mRNA vaccine myocarditis be a contraindication to future COVID-19 vaccinations ?

Jan 26, 2023

BY ANISH KOKA

Myopericarditis is a now a well reported complication associated with Sars-Cov-2 (COVID-19) vaccinations. This has been particularly common with the messenger RNA (mRNA) vaccines (BNT162b2 and mrna-1273), with a particular predilection for young males.

Current guidance by the Australian government “technical advisory groups” as well as the Australian Cardiology Society suggest patients who have experienced myocarditis after an mRNA vaccine may consider a non-mRNA vaccine once “symptom free for at least 6 weeks”.

A just published report of 2 cases from Australia that document myopericarditis after use of the non-mRNA Novavax vaccine in patients that had recovered from mRNA vaccine myocarditis suggests this is a very bad idea.

The case reports

Case 1 involves a 26 year old man who developed pericarditis after the Pfizer vaccine. Pericarditis, an inflammation of the sac the heart lives in, developed about 7 days after the Pfizer vaccine. The diagnosis was made based on classic findings of inflammation on an electrocardiogram associated with acute chest pain. The symptoms lasted 3 months, and a total of 6 months after the first episode of pericarditis, he received a booster vaccination with the Novovax (NVX-CoV2373) vaccine. 2-3 days after this he developed the same sharp chest pain and shortness of breath with elevated inflammatory markers (CRP) as well as typical findings of pericarditis seen on ECG. To add insult to injury, he contracted COVID 2 months after the second episode of pericarditis, but had no recurrence of the symptoms of pericarditis.

Can Missouri Pass The Muster

Jan 24, 2023

BY MIKE MAGEE

A case has been made that a logical approach to reforming America’s violent and racist leanings would be to adopt the values and practices of Health Care for All. These include a commitment to compassion, understanding, and partnership; extending the linkages between individual, family, community and society; addressing fear and worry for individuals and populations; and promoting an optimistic and equitable future for all Americans.

Nurses and doctors and pharmacists and other health professionals pledge oaths and spend years training to exhibit and practice these values in the course of providing preventive and interventional care to select Americans. Imagine the effect of delivering these many benefits in an equitable way, in all communities, with the intent of making not only Americans, but also the American culture healthy.

Or we could simply continue to accept the values exhibited by the Missouri State Legislature, where misogyny and brass knuckles have risen to the top of their legislative calendar.

In June, 2021, a Missouri News-Press editorial commented that “one vote last week might strike some as a sign that Missouri’s lawmakers could use some help with time management and prioritization.” The Republican led body had soundly passed HB 1462 which included Section 571.020 and 571.107 which read “This act repeals prohibitions on the possession and selling of brass knuckles, firearm silencers, and switchblade knives.” The same act addressed the taxpayer burden for possession of their weaponry by providing “that all sales of firearms and ammunition made in this state shall be exempt from state and local sales taxes.”

Medicare Advantage UpCoding Has Been Eliminated by CMS Effective 2022

Jan 23, 2023• 2

By GEORGE HALVORSON

Medicare Advantage now enrolls almost exactly half the people enrolled in Medicare — and has both significant fans and hardline opponents in the health care policy circles who disagree about its performance.

The biggest attack point that comes from the critics deals with the issues of coding accuracy by the plans. The payment model for the program is capitation — and that capitation is based on the average cost of fee-for-service Medicare in every county. The people who designed the model believed that the country should use the average cost of fee-for-service Medicare in every county as the baseline number and should have the plans paid less than that average Medicare cost going forward every year in their capitation cash flow.

Medicare fee-for-service has a strict and consistent payment level based on a list of approved Medicare services — and they add up the cost of those services in every county and let the plans bid a lower number than that fee for service Medicare cost, if the plans believe they can offer all of the basic benefits and possibly add more benefits and additional services for that amount.

The fee-for-service Medicare cash flow and costs in each county tend to be very stable over time, with a continuous and steady increase in the actual functional cost for taking care of those fee-for-service patients for each year that they receive care. That total cost of fee-for-service Medicare care is a visible and clear baseline number that we can use each year with confidence and knowledge that it is what we are spending now on those Medicare members in the counties.

The direct capitation amount that is then paid to each of the plans is based on the age, gender, health status, and diagnosis profile of the Medicare Advantage members who enroll in the plans. The plans have been reporting those patient profile numbers to the government through the Risk Adjustment Processing System (RAPS) over a couple of decades to set up their payment levels and to create the monthly cash flow for each plan.

That’s where the upcoding accusations relative to the plans arise.

The plans get paid more if the patients have more expensive diagnoses — so the plans have had a strong and direct incentive to make sure that every diabetic enrollee is recorded and reported as being diabetic for their RAPS filings.

They also have a strong incentive to be sure that every congestive heart failure patient has their diagnosis recorded in their RAPS report.

Fighting the Wrong (Culture) War

Jan 20, 2023

By KIM BELLARD

News flash from the culture wars: they’re coming to take our gas stoves!

Well, actually, “they” are not, but the kind of people who got alarmed about it are a threat to our health, and to theirs.

The gas stove furor started with a Bloomberg News interview that Richard Trumka, Jr, a Consumer Product Safety Commission commissioner. “This is a hidden hazard,” he said. “Any option is on the table. Products that can’t be made safe can be banned.”

He was referring to the well known but little acknowledged fact that gas stoves emit various pollutants, especially nitrogen dioxide. Last year the AMA adopted resolutions about the risks of gas stoves, and urged migration efforts to electric stoves. Shelly Miller, a University of Colorado, Boulder, environmental engineer has said:

Cooking is the No. 1 way you’re polluting your home. It is causing respiratory and cardiovascular health problems; it can exacerbate flu and asthma and chronic obstructive pulmonary disease in children…you’re basically living in this toxic soup.

So one can see why the CPSC might be concerned. But the outcry about Mr. Trumka’s comments were immediate and vociferous. “I’ll NEVER give up my gas stove. If the maniacs in the White House come for my stove, they can pry it from my cold dead hands. COME AND TAKE IT!!” Rep. Ronny Jackson (R-TX) tweeted. The Atlantic further reported:

Governor Ron DeSantis tweeted a cartoon of two autographed—yes autographed—gas stoves. Representative Jim Jordan of Ohio declared simply, “God. Guns. Gas stoves.” Naturally, Tucker Carlson got involved. “I would counsel mass disobedience in the face of tyranny in this case,” he told a guest on his Fox News show.

Almost as immediately, Mr. Trumka clarified: “To be clear, CPSC isn’t coming for anyone’s gas stoves. Regulations apply to new products.” CPSC Chair Alexander Hoehn-Saric issued a statement making it clear that, while “emissions from gas stoves can be hazardous…I am not looking to ban gas stoves and the CPSC has no proceeding to do so.” The White House issued its own denial. Case closed, right?

The Danger of Stroking a Tiger

Jan 17, 2023• 1

By MIKE MAGEE

On the evening of December 29, 1940, with election to his 3rd term as President secured, FDR delivered these words as part of his sixteenth “Fireside Chat”: “There can no appeasement with ruthlessness…No man can tame a tiger into a kitten by stroking it.”

Millions of Americans, and millions of Britons were tuned in that evening, as President Roosevelt made clear where he stood while carefully avoiding over-stepping his authority in a nation still in the grips of a combative and isolationist opposition party.

The Germans were listening as well and sent a different type of message as the Luftwaffe, in concert with the address, launched their largest yet raid on the financial district of London. Their “fire starter” group, KGr 100, initiated the attack with incendiary bombs that triggered fifteen hundred fires that began a conflagration ending in what some labeled the “Second Great Fire of London.”

There was nothing happenstance about the timing or methods of the attack. The night was moonless, keeping RAF fighters lacking air-to-air radar grounded. There were high winds to fan the flames that night. High explosive bombs were used to target water mains to hamper fire fighters, and the Thames was at low tide making accessing it for a water supply neigh impossible.

Combined with Roosevelt’s words, the actions of December 29, 1940, now 82 years later, highlight two truisms when confronting evil orchestrated at the hands of racist, autocratic leaders.

First, appeasement does not work. It expands the vulnerability of a majority suffering the “tyranny of the minority.”

Second, the radicalized minority will utilize any weapon available, without constraint, to maintain and expand their power.

The battle to save democracy in these modern times has not been won. As was FDR at the time of his address, we are in the early years of this deadly serious conflict, and still in catch-up mode, awakened from a self-induced slumber on January 6, 2020.

Healthcare, Meet Southwest

Jan 3, 2023

BY KIM BELLARD

Customers experiencing long, often inexplicable delays, their experiences turning from hopeful to angry to afraid they’ll never get back home. Staff overworked and overwhelmed. IT systems failing at the times they’re most needed. To most people, that all probably sounds like Southwest Airline’s debacle last week, but, to me, it just sounds like every day in our healthcare system.

Southwest had a bad week. All the airlines were hit by a huge swath of bad weather the weekend before Christmas, but most airlines recovered relatively quickly. Southwest passengers were not so lucky; the airline’s delays and cancellations numbered in the thousands and stretched into days. Overnight, it seemed, Southwest went from being one of the most admired airlines – loyal customers, on-time service, happy employees, consistent profitability – to one with “its reputation in tatters.”

CEO Bob Jordan has had to do his mea culpas, and he’s not done.

Some pointed to Southwest’s reliance on point-to-point flight schedules, in contrast to other airlines’ use of hub-and-spoke models, but most seem to agree that the root problem was that its IT infrastructure was not up to task – particularly its employee scheduling system, which told its employees who needed to be where when and how to accomplish that. Casey A. Murray, president of the Southwest Airlines Pilots Association, told The New York Times: “Once one card falls, the whole house falls here at Southwest. That’s our problem. We couldn’t keep up with the cascading events.”