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Category: Health Policy

THCB 20th Birthday Classic: As I’ve always suspected, Health Care = Communism + Frappuccinos

By MATTHEW HOLT

Our 20th birthday continues with a few classics coming out. Back in 2005 I was really cutting a lyrical rug, and would never miss a chance to get that Cambridge training in Marxism into use. This essay about whether health care should be a public or private good has always been one of my favorites, even if I’m not sure Starbucks is still making Frappuccinos. And 18 years later the basic point of this essay remains true, even if many of you will not have a clue who Vioxx or Haliburton were or why they mattered back then!

Those of you who think I’m an unreconstructed commie will correctly suspect that I’ve always discussed Marxism in my health care talks. You’d be amazed at how many audiences of hospital administrators in the mid-west know nothing about the integral essentials of Marx’s theory of history. And I really enjoy bring the light to them, especially when I manage to reference Mongolia 1919, managed care and Communism in the same bullet point.

While I’ve always been very proud of that one (err.. maybe you have to be there, but you could always hire me to come tell it!), even if I am jesting, there’s a really loose use of the concept of Marxism in this 2005 piece (reprinted in 2009) called A Prescription for Marxism in Foreign Policy from (apparently) libertarian-leaning Harvard professor Kenneth Rogoff. He opens with this little nugget:

“Karl Marx may have suffered a second death at the end of the last century, but look for a spirited comeback in this one. The next great battle between socialism and capitalism will be waged over human health and life expectancy. As rich countries grow richer, and as healthcare technology continues to improve, people will spend ever growing shares of their income on living longer and healthier lives.”

Actually he’s right that there will be a backlash against the (allegedly) market-based capitalism — which has actually been closer to all-out mercantilist booty capitalism — that we’re seen over the last couple of decades. History tends to be reactive and societies go through long periods of reaction to what’s been seen before. In fact the 1980-20?? (10-15?) period of “conservatism” is a reaction to the 1930-1980 period of social corporatism seen in most of the western world. And any period in which the inequality of wealth and income in one society continues to grow at the current rate will eventually invite a reaction–you can ask Louis XVI of France about that.

But when Rogoff is talking about Marxism in health care what he really means is that, because health care by definition will consume more and more of our societal resources, the arguments about the creation and distribution of health care products and services will look more like the arguments seen in the debates about how the government used to allocate resources for “guns versus butter” in the 1950s. These days we are supposed to believe that government blindly accepts letting “the market” rule, even if for vast sways of the economy the government clearly rules the market, which in turn means that those corporations with political influence set the rules and the budgets (quick now, it begins with an H…).

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Naive Realism and the Legal Profession

By MIKE MAGEE

In 2002, psychologist Emily Pronin and her co-authors, in an article titled, You Don’t Know Me, But I Know You: The Illusion of Asymmetric Insight, laid out the concept of “Naive Realism.”

As she explained, “We insist that our ‘outsider perspective’ affords us insights about our peers that they are denied by their defensiveness, egocentricity, or other sources of bias. By contrast, we rarely entertain the notion that others are seeing us more clearly and objectively than we see ourselves. (We) talk when we would do well to listen…” Point well taken, but these (most would agree) are trying times.

The problem of our divisions is certainly worse now, two decades later, than when it was first labeled. 2023 headlines speak to “political polarization,” “division,” “factual inaccuracy,” and “loss of civility.”  And yet, we hold tight to the “rightness”of justice under the law, and set out to demonstrate with extreme confidence that our democratic institutions, under assault, have mostly held.

Madison was well aware of extreme labeling of opponents as “unreasonable, biased, or ill-motivated.” He warned on February 8, 1788 in Federalist 51 that “If men were angels, no government would be necessary. If angels were to govern men, neither external nor internal controls on government would be necessary. In forming a government which is to be administered by men over men, the great difficulty lies in this: you must first enable government to control the governed; and in the next place oblige it to control itself.” His solution? Our legal system, and  checks and balances.

Hamilton, in the first paragraph of Federalist 1, tees up the same issue, in the form of an unsettling warning. He writes, “It has been frequently remarked that it seems to have been reserved to the people of this country, by their conduct and example, to decide the important question, whether societies of men are really capable or not of establishing good government from reflection and choice, or whether they are forever destined to depend for their political constitutions on accident and force.”

The “force” on January 6 was no accident. Hours before the armed insurrection of Congressthat morning, USA Today published  “By the numbers: President Trump’s failed efforts to overturn the election.” The article led with, “Trump and allies filed scores of lawsuits, tried to convince state legislatures to take action, organized protests and held hearings. None of it worked…Out of the 62 lawsuits filed challenging the presidential election (in state and federal courts), 61 have failed…Some cases were dismissed for lack of standing and others based on the merits of the voter fraud allegations. The decisions have came from both Democratic-appointed and Republican-appointed judges – including federal judges appointed by Trump.”

By all accounts, our nation and her citizens, owe our Judicial branch (its judges, lawyers, and legal guideposts) a debt of gratitude.

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Population Health Management: SDOH Challenges and Solutions

By ARJUN GOSAIN

In the United States alone, one in ten people live in poverty, 10.2% of households are food insecure, and more than half of people living below the poverty line are transportation insecure. These statistics represent social determinants of health (SDOH) measures that describe a patient’s experience outside hospital walls. 

Health.gov defines SDOH as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” This definition argues that a patient’s experiences are just as crucial if not more telling than their biology.

And this makes sense as a person who is housing insecure may not have the same access to nutritional food, transportation, or social support. Additionally, some patients, in their efforts to maintain health, may experience discrimination based on their skin color or religious beliefs. 

Some studies have found SDOH can drive up to 80% of health outcomes. This means that the traditional healthcare model—hospitalization, healthcare delivery, and treatment—only affects a mere 20% of a person’s overall health. To tap into this 80%, healthcare professionals need data. However, SDOH data collection poses significant challenges.

SDOH Overview

Before we dive into data collection, let’s review the specific measures of SDOH and why they should take top priority among healthcare professionals. 

SDOH concepts include:

  • Employment insecurity: Measures whether the patient is employed and their current employment or unemployment experience. This includes whether they were harassed on the job or experiencing unequal pay. Employment insecurity can lead to financial stress, mental health problems, and reduced healthcare access. 
  • Psychological circumstances: Measures current events that are affecting the patient’s health. This encompasses a wide range from unwanted pregnancies to exposure to war or violence. Stress, anxiety, and other negative emotions can have a direct effect on a patient’s physical health and contribute to disease development.
  • Housing insecurity: Notes whether a patient has a consistent place to live or is forced to move regularly. Homelessness or housing insecurity can lead to exposure to the elements, mental health challenges, and increased vulnerability to infection.
  • Social adversity: Examines a patient’s social experience including any discrimination or persecution the individual may be facing. Increased social adversity can cause an individual to socially isolate and develop feelings of depression. 
  • Transportation: Observes the patient’s access to transportation including available public transport. Missed appointments can be the direct result of transportation inaccessibility which leads to a decrease in the quality of care. 
  • Food insecurity: Indicates whether a patient has adequate food access and safe drinking water access. Receiving adequate nutrition is essential for maintaining optimal physical health. For example, if a child is food insecure, it can lead to serious developmental issues and chronic disease.
  • Education and literacy: Observes a patient’s ability to read and comprehend hospital paperwork. Note that individuals with higher literacy and education rates typically make more informed health decisions.
  • Occupational risk: Examines how a patient’s current employment affects their overall health. Determines if their job site places them at risk of toxin exposure, physical harm, undue stress, or other hazardous conditions that can contribute to injuries or illnesses.
  • Economic insecurity: Measures a patient’s poverty level to determine if copays, rent, and hospital bills are manageable. A patient living with inadequate finances will face a greater barrier to quality care.
  • Lack of support: Notes whether a patient has reliable support when experiencing difficult circumstances such as the death of a loved one. If a patient has a present support network, they will be able to receive practical, emotional, and physical assistance in times of need. 
  • Upbringing: Takes a patient’s childhood, family, and upbringing into account to assess if a patient is carrying trauma from previous years. Adverse childhood experiences can increase the risk of chronic diseases and mental health issues later in life. 
  • Language: Examines any language or communication concerns, so that a patient can both communicate their issues and understand oral and written treatment. Miscommunications can lead to misdiagnoses and inadequate treatment. 

These contributing factors cannot be ignored since, as previously stated, they can directly impact up to 80% of health outcomes. Thus, organizations that choose to neglect SDOH factors are only focused on the 20%. 

This is why providers must find ways to address SDOH in a meaningful and productive manner, which is where SDOH data comes in. The collection and analysis of SDOH data can help providers identify at-risk populations to provide informed, effective interventions. Measures like patient needs assessments and population-level health disparity analysis can let providers get to the root cause without the guesswork. 

SDOH Data Collection Challenges

SDOH data collection is a sensitive topic. After all, if a patient is experiencing abuse or is unemployed, they most likely would not disclose that information outright. Providers also have limited time to ask additional questions because many feel rushed during routine consultations and may not have the resources needed to collect SDOH data. 

Beyond SDOH data scarcity, there is the issue of standardization. How providers collect housing data, for instance, can vary across definitions and measurements, making quantifying data difficult. So, how can providers offer whole-person care with limited data and a lack of definitive measurements? The solution is three-fold. 

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Republican Misbehavior Promoted Health Professional Activism

By MIKE MAGEE

If you wanted to create a motto for the summer of 2023 – one that would stand the test of time from the medical exam room of Ohio to the gilded bathroom of Mar-a-lago – it would have to be Jack Smith’s “Facts matter!” If that is true on a national scale, it is equally true in states across the nation where doctors increasingly are coming out from behind a self-imposed clinical curtain and going public.

As reported in ProPublica last week, “Doctors who previously never mixed work with politics are jumping into the abortion debate by lobbying state lawmakers, campaigning, forming political action committees and trying to get reproductive rights protected by state law.”

A few examples:

1. One thousand Ohio doctors signed a full-page ad titled “A Message to our Patients on the loss of Reproductive Rights” in the Columbus Dispatch in response to actions of a state legislature highjacked by radicalized Republicans enacting a 6-week abortion ban post the Dobbs decision. This was after their coalition delivered a protest letter with 700,000 signatures earlier to the State House.

2. Dr. Damla Karsan, a Houston obstetrician, faced off Texas legislators  on July 20th, lending truth to power when she said , ““I feel like I’m being handicapped. I’m looking for clarity, a promise that I will not be persecuted for providing care with informed consent from patients that someone interprets is not worthy of the medical exception.”

3. In Nebraska, the doctor-led “Campaign for a Healthy Nebraska” raised $400,000 to hire political consultants to launch a women’s health rights campaign which helped the Nebraska Medical Society “find its inner voice” and openly oppose abortion restrictions in that state. State Senator Danielle Conrad was impressed. She said, “It’s really just incredible from my vantage point to see how these doctors have been able to not be hobbled by those decades of political baggage, to step forward with this fresh, clear medical perspective and be able to engage more people.”

4. A month earlier, Dr’s Katie McHugh, Gabriel Bosslet, Caroline Rouse and Tracey Wilkinson penned an Op-Ed in STAT in support of their colleague, Dr. Caitland Bernard, who had come to the rescue of a 10 year old Ohio rape victim who had fled to Indiana to gain access to an abortion. Caitlin was shamefully fined $3,000 by the Indiana State Licensing Board. Her colleagues wrote, “While a relatively minor punishment, this finding should send a chill through the medical community and beyond. But that chill shouldn’t be silencing.”

5. In Michigan, a doctor-led group, the Committee to Protect Health Care, teamed up with the ACLU, and successfully passed “Proposal 3”,  a “constitutional amendment to enshrine reproductive rights into the state constitution.” Dr. Rob Davidson declared, “This is a historic victory for reproductive rights in Michigan, and the Committee to Protect Health Care was proud to help get Proposal 3 across the finish line.”

Yesterday’s indictment of  Donald Trump, the citizen, squarely places him and his legislative enablers in Washington and Republican led state houses across our nation, on the wrong side of the truth. As reported, he is accused of “three conspiracies: one to defraud the United States; a second to obstruct an official government proceeding, the certification of the Electoral College vote; and a third to deprive people of a civil right, the right to have their votes counted.”

But what he and his Republican supporters in Washington and state houses across the nation are primarily guilty of, is not simply lying and deceit, but attempting to destroy our democracy and disenfranchise our voters. That is why prosecution under Civil Rights statutes employed in the past to address the savagery of the KKK, are totally appropriate here. Jack Smith’s “stand tall” leadership is a model for us all, and that includes our doctors and nurses.

As I have repeatedly argued, the health of our democracy is inseparably interwoven with the health of our system of caring for each other. At the helm of this system, our health professionals have survived the hurricane force winds of a pandemic, an inequitable and inefficient health delivery system, and a medical-industrial complex that is more focused on seizing patents than serving patients.

And yet, today we take heart. Our physicians, in growing numbers, are rediscovering their strength and their voices. Like Jack Smith, they are speaking up, in opposition to a small group of bitter and evil leaders, who have earned our active condemnation, and now must face the weight of the law.

Mike Magee MD is a Medical Historian, regular THCB contributor, and the author of CODE BLUE: Inside the Medical-Industrial Complex.

Health Care, Disagree Better

BY KIM BELLARD

On one of the Sunday morning news programs Governors Spence Cox (UT) and Jared Polis (CO) promoted the National Governors Association initiative Disagree Better. The initiative urges that we practice more civility in our increasingly civilized political discourse. It’s hard to argue the point (although one can question why NGA thinks two almost indistinguishable, middle-aged white men should be the faces of the effort), but I found myself thinking, hmm, we really need to do that in healthcare too.  

No one seems happy with the U.S. healthcare system, and no one seems to have any real ideas about how to change that, so we spend a lot of time pointing fingers and deciding that certain parties are the “enemy.”  That might create convenient scapegoats and make good headlines, but it doesn’t do much to solve the very real problems that our healthcare system has. We need to figure out how to disagree better.

I’ll go through three cases in point:

Health Insurers versus Providers of Care

On one side, there are the health care professionals, institutions, organizations that are involved in delivering care to patients, and on the other side there are health insurers that pay them.  Both sides think that the other side is, essentially, trying to cheat them.

For example, prior authorizations have long been a source of complaint, with new reports coming out about its overuse in Medicaid, Medicare Advantage, and commercial insurance.  Claim denials seem equally as arbitrary and excessive.  Health insurers argue that such efforts are necessary to counter constantly rising costs and well documented, widespread unnecessary care

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Matthew’s tidbits: Obesity Summer

Every time I get around to sending out the THCB READER I add a short & usually not to sweet commentary on some aspect of health care.–Matthew Holt


I saw the obesity crisis up close this week. And by that I’m not just referring to my addiction to Salted Caramel with Pretzel Ice Cream, bad though it is. Instead I felt thin because I went to Disneyland. But while I tip the scales at a BMI of 30 if I’m lucky, I genuinely felt that looking around Disneyland more than 50% of the crowd were obese and many morbidly so.

The rest of my trip to Southern California was quite a contrast because I’ve been watching a girls water polo tournament. Those young women and most of their families, as you’d expect, look very different. In this crowd I am definitely on the other end of the spectrum.

Obviously there’s a big socio-economic difference between the Disneyland attendees and a crowd centered around a sport largely played by rich, white kids. But at a time where we are arguing about whether Ozempic and its fellow anti-obesity drugs should be available via insurance, we seem to have no other strategies to fight the nation’s slide to obesity.   

You’ve probably seen those photos of people on the beach in the 1960s where everyone is thin. I won’t claim to understand the science of what happened but clearly the prevalence of high fructose corn syrup and other highly processed food has much to do with it. As does the free rein food companies have had to advertise what are addictive products. I don’t know how we get to be a nation where everyone eats and exercises like a water polo player. But clearly we need significant changes in our agriculture and nutrition policies. We did it with smoking, so we know it can be done. If you don’t think we need it, I recommend a trip to Disneyland (and that’s the only reason I recommend one!)

The Sweet Spot of Health Care Cost Containment

BY BEN WHEATLEY

As health care continues to move in the direction of unaffordability, policy makers are considering a range of options to bring down health care costs. The Health Affairs Committee on Health Care Spending and Value has identified four broad areas for reform, including administrative savings, price regulation and supports for competition, spending growth targets, and value-based payment. These measures appropriately target health care’s supply side and the excesses that exist in the health care system.

In this blog, I would like to highlight another avenue for savings: one that focuses on the demand side of the equation. It is possible to reduce health care expenditures by reducing the demand for care. This is distinct from rationing, which is the denial of needed care. I’m referring to genuine health improvements that make health care less necessary in the first place. This type of health improvement is the sweet spot of health care cost containment, benefiting both patients and purchasers.

In a previous blog, I posed the question: in an ideal world, how much would we spend on health care? I posited that in a perfect world, we would spend zero on health care because no one would be sick. While such a perfect world may be unachievable, having the goal in mind can serve to guide our way in the present moment—like entering a destination into GPS.  

Measures that promote genuine health improvement can alleviate the burden of illness while at the same time reducing the cost of care. They move us in the direction we want to go. In this blog I provide several such examples.

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No, the Poor Don’t Always Have to Be With Us

BY KIM BELLARD

OK, for you amateur (or professional) epidemiologists among us: what are the leading causes of death in the U.S.?  Let’s see, most of us would probably cite heart disease and cancer.  After that, we might guess smoking, obesity, or, in recent years, COVID.  But a new study has a surprising contender: poverty.   

It’s the kind of thing you might expect to find in developing countries, not in the world’s leading economy, the most prosperous country in the world. But amidst all that prosperity, the U.S. has the highest rates of poverty among developed countries, which accounts in no small part for our miserable health outcomes.  The new data on poverty’s mortality should come as no surprise.

The study, by University of California Riverside professor David Brady, along with Professors Ulrich Kohler and Hui Zheng, estimated that persistent poverty – 10 consecutive years of uninterrupted poverty – was the fourth leading cause of death, accounting for some 295,000 deaths (in 2019). Even a single year of poverty was deadly, accounting for 183,000 deaths.  

“Poverty kills as much as dementia, accidents, stroke, Alzheimer’s, and diabetes,” said Professor Brady. “Poverty silently killed 10 times as many people as all the homicides in 2019. And yet, homicide firearms and suicide get vastly more attention.” 

The study found that people living in poverty didn’t start showing increased mortality until in their 40’s, when the cumulative effects start catching up.  The authors note that these effects are not evenly distributed: “Because certain ethnic and racial minority groups are far more likely to be in poverty, our estimates can improve understanding of ethnic and racial inequalities in life expectancy.”

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Health Tech’s Magic Wand: The Anti-Social Bent of Modern Medicine

BY MIKE MAGEE

In George Packer’s classic 2013 New Yorker article titled “Change the World: Silicon Valley transfers its slogans – and its money – to the realm of politics,” there is a passage worth a careful reread now a decade latter.

Packer shares an encounter with a 20-something techie critiquing his young colleagues who said, “Many see their social responsibility fulfilled by their businesses, not by social or political action. It’s remarkably convenient that they can achieve all their goals just by doing their start-up. They actually think that Facebook is going to be the panacea for many of the world’s problems. It isn’t cynicism—it’s arrogance and ignorance.”

Packer’s assessment at the time was “When financiers say that they’re doing God’s work by providing cheap credit, and oilmen claim to be patriots who are making the country energy-independent, no one takes them too seriously—it’s a given that their motivation is profit. But when technology entrepreneurs describe their lofty goals there’s no smirk or wink.”

Or, as others might say, “They believe their own bull shit.” Where many of us are currently focused on issues of values, fairness and justice, those in the shadows of Silicon Valley see the challenge to be inefficiency and incompetence, and the solution amenable to technologic engineering.

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HHS Again Suspends Disbelief: The Medicaid Program Will Ignore the Greatest Health Threat to Medicaid Beneficiaries

BY DAVID INTROCASO

In May the Centers for Medicare and Medicaid Services (CMS) simultaneously published two proposed Medicaid rules (here and here) intended to improve moreover access and quality.  Both discussed at length the agency’s commitment to “addressing health equity.”  The first sentence in both identified health equity as a Medicaid program priority.  The proposed “ensuring access” rule stated CMS “takes a comprehensive approach to . . . better addressing health equity issues in the Medicaid program.”  CMS went on to state “we are working to advance health equity by designing, implementing, and operationalizing policies and programs” by “eliminating avoidable differences in health and quality of life outcomes experienced by people who are disadvantaged or underserved.”

Nevertheless, CMS’ interest in health equity is entirely performative.  It is impossible to believe the agency is legitimately interested in “eliminating avoidable differences” because leadership is well aware the greatest health equity threat to Medicaid – and Medicare – beneficiaries is the climate crisis.  This is because the most climate vulnerable Americans are Medicaid and Medicare populations.  Yet, the climate crisis is never addressed much less mentioned in either proposed Medicaid rule.  The word “climate” never appears in 291 Federal Register pages. 

This is explained by the fact that despite the Biden administration’s “government-wide approach” approach to “tackle” the climate crisis, HHS has refused to address the threat the climate crisis poses by regulating the healthcare industry’s massive carbon footprint.

Children, 36 percent of whom are Medicaid beneficiaries, are uniquely vulnerable.  Fine respirable particles resulting from fossil fuel combustion are particularly harmful because children breathe more air than adults relative to their body weight.  Research published last year concluded the health effects to the fetus, infant and child include preterm and low-weight birth, infant death, hypertension, kidney and lung disease, immune-system dysregulation, structural and functional changes to the brain and a constellation of behavioral health diagnoses.   

Medicare beneficiaries, already compromised due to higher incidence rates of co-morbidities, are at even greater risk related to arthropod-borne, food-borne and water-borne diseases because the climate crisis can increase the severity of over half of known human pathogenic diseases.  Extreme heat episodes are particularly deadly.  Over the past 20 years heat-related mortality among seniors has increased 54%

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