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Above the Fold

Calcium Scan and Subtractive Medicine

Apr 3, 2017

By SAURABH JHA MD

Being a radiologist, I rarely speak to patients, but I was asked to counsel Mrs. Patel (not her real name, so calm down HIPAA totalitarians), who was worried about the risks of radiation from cardiac calcium CT scan. Because of her risk factors for atherosclerosis, her cardiologist wanted her to take statins for primary prevention, but she was reluctant to start statins. They eventually reached a truce. If she had even a speck of calcium in her coronary arteries she would take statins. If her calcium score was zero she wouldn’t. This type of shared decision making is the most frequent reason why cardiologists order calcium scans at my institution.

Health Care: What Should a Populist Do Now?

Mar 31, 2017• 1

By CLARK HAVIGHURST

Why not a plan that would actually help the forgotten folks who voted for change—and even attract some liberals’ support?

How can the Trump administration and the Republican Party make history forget their embarrassing failure to “repeal and replace” Obamacare? Interestingly, their best strategy—if they can withstand the political heat from all those who prosper under health-care business-as-usual—would be to embrace an explicitly populist program aimed at correcting the numerous and serious economic injustices deeply embedded in American health care today. The victims of these injustices include many of the lower-income Americans who in 2016 voted against elite interests in both political parties and in favor of fundamental, not just incremental, change. A program to right their wrongs should appeal even to some liberals, specifically those whose principal concern is the welfare of the people themselves, not just aggrandizing government or restoring the Democratic Party’s rightful dominance.

The political chances of the reform program outlined below would depend on making a direct, explicitly populist appeal to the many millions of Americans whom the health-care system currently exploits economically almost entirely without their knowledge.

Health-Sector Monopolies and Those Who Pay Their Prices

In the great populist era around the turn of the last century, the people’s anger was directed not, as now, at political elites or government itself but at huge private monopolies, the “trusts.” Teddy Roosevelt’s trust-busting effort broke up large agglomerations of market power while also establishing competition as America’s fundamental mechanism for inducing private businesses to satisfy consumers. If today’s populists are truly serious about protecting ordinary Americans from abuse by elite interests, they should begin by declaring a similar war against monopoly in health-care markets. Liberals should be invited to join this effort.

The Child Sexual Abuse Conspiracy

Mar 31, 2017• 8

BY DAVID INTROCASO

(After this essay was submitted to THCB the Senate Judiciary Committee held a hearing on March 28th titled, “Protecting Young Athletes From Sexual Abuse.” USA Gymnastics refused to appear and provide testimony likely, in part, because USA Gymnastics’ President, Steve Penny, was forced to resign on March 16th. The issue was framed by Committee Chairman Chuck Grassley as a “heinous crime,” no health care or public health expert testified and the hearing and was reported in sports pages of the The New York Times and The Washington Post.)

If you do not read the sports page you may have missed the news that this past November, December and February Dr. Larry Nassar, a former USA Gymnastics and Michigan State physician, was charged with numerous counts of criminal sexual misconduct and for possessing 37,000 child pornography images and videos of him sexually molesting girls. Beyond these charges, there are at present another 80 and counting related police complaints and several related civil lawsuits filed against Nassar. 1 Before he retired in September 2015, Nassar served on the USA Gymnastics National Team’s medical staff for 29 years and before he was fired last October, he also worked as a physician at Michigan State where for two decades he treated, among others, members of the university’s women’s basketball, crew, field hockey, figure skating, gymnastics, soccer, softball, swimming and track and field teams. Dr. Nassar was also associated with a Lansing-area girls’ gymnastic club and a high school.

Trump’s Obamacare Debacle: Vanquished by a Ghost!

Mar 30, 2017• 30

By JEFF GOLDSMITH

Judging by the dazed expression on President Trump’s face at his Friday afternoon press conference, it is clear that he never saw his first major political defeat coming. It was as if he had stepped off the curb looking the other direction into the path of an uncoming bus.

The key to any political victory is situational awareness- clarity about your goals and mastery of the details. There were warning signs of a potentially fatal disengagement, for example, in Trump’s periodic references to “the healthcare” when discussing the issue.

It doesn’t make Trump’s political pain any more bearable to know that he was mugged by a ghost, by a potent political symbol nourished by the Obama administration. The stunningly rapid political failure of the American Health Care Act more resembled a botched exorcism than a serious exercise in health policy.

From his successful campaign, Trump knew that repealing and replacing ObamaCare was the most reliable thunderous applause line in his stump speech. This visceral connection moved the issue to the top of his political agenda. To Trump’s political base, repealing ObamaCare was striking a blow against a paternalistic all-knowing federal government, against interference in citizens’ private lives, against confiscation and redistribution of peoples’ wealth, to a new “entitlement” program, but most of all, against a President they reviled.

Dr. Smith Goes to Washington

Mar 29, 2017• 8

By NIRAN AL-AGBA, MD

Last week, the AHCA was pulled from the House floor after not enough votes could be secured in favor of its passage. A Washington Post article reported President Trump’s thoughts on the matter. “We couldn’t get one Democrat vote, not one. They [Democrats] own Obamacare. So when it explodes…we make one beautiful deal for the people.”

Journalist Robert Costa asserted “there was little evidence that either Trump or House Republicans made a serious effort to reach out to Democrats.”

Well Robert, I sure did. And I did not get very far.

In the interest of full disclosure, over the past 20+ years, I have been a Democrat, Republican, and just about everything in between. I recently reached out to lawmakers on both sides of the aisle, yet the responses were lopsided. A recent entry myself into the political physician realm, I gave a presentation last week on lowering Medicare drug costs to the National Physicians’ Council for Healthcare Policy (NPCHP), in the Energy and Commerce Committee Hearing Room in Washington DC. This phenomenal group of physicians was assembled by Congressman Pete Sessions (R) from Texas; and they are innovative, engaged, and working to improve the lives of their patients and fellow physicians.

Did Medical Darwinism Doom the GOP Health Plan?

Mar 29, 2017• 9

By MICHAEL L. MILLENSON

“We are now contemplating, Heaven save the mark, a bill that would tax the well for the benefit of the ill.”

Although the quote reads like it could be part of the Republican repeal-and-replace assault against the Affordable Care Act (ACA), it’s actually from a 1949 editorial in The New York State Journal of Medicine denouncing health insurance itself.

Indeed, the attacks on the ACA seem to have revived a survival-of-the-fittest attitude most of us thought had vanished in America long ago. Yet, again and again, there it was in plain sight, as when House Speaker Paul Ryan (R-WI) declared: “The idea of Obamacare is that the people who are healthy pay for the people who are sick.” Contemporary language, but the same thinking that sank President Harry Truman’s health care plan almost seven decades ago.

Ryan’s indignation highlighted a fundamental divergence in attitudes that repeatedly turned the health care debate into a clash over the philosophy behind Obamacare-style health insurance. To some, the communal pooling of financial risk of medical expenses seems too often an unacceptable risk to personal responsibility.

As a researcher who has documented this approach to health care, I’ve been startled to see the debate over the AHCA reignite a political philosophy and policy approach that seemed to be have been discredited – and be in sharp decline.

After the American Health Care Act

Mar 26, 2017• 17

BY JOHN IRVINE

We asked THCB’s editors and bloggers for their reactions to Friday’s news. Here are their first impressions.

DANIEL STONE, MD

The late UCLA Professor Richard Brown, once commented that the Clinton healthcare initiative failed because the status quo was everyone’s second choice. Some of that logic applies to today’s failure to vote on the AHCA. Additionally, no one ever lost money betting against the rollback of an established entitlement program.

The Republicans opponents of the ACA have not yet faced the fact that the reason coverage is so expensive is because the care is so expensive. You can’t have cheap insurance for expensive services. So, something “better and cheaper” was a never more than a slogan. That slogan showed the AHCA to be the bait and switch that it was.

Health insurance has evolved to serve two purposes; to protect against health related financial catastrophe and to finance care. The ACA, with its high deductibles does a better job with the former than the latter. (Although opponents give short shrift to the mitigation provided by the provision of preventive services without charge.) It will be hard to satisfy the diverse collection of stakeholders with anything much different.

This is another illustration of the fact that anything approaching universal coverage is challenging for the developed world’s outlier on healthcare cost. Medicare has around 15% lower costs than commercial plans. The only practical way out of the cost vs access quandary is to harness the commercial insurance overhead/waste/profit and direct it toward coverage.

So, to paraphrase Keynes, in the long run, we’re in both single payer and dead. It’s just a question of whether we’re all dead first or just some of us.

JOHNATHAN HALVORSON

My immediate reaction is that now they are going to nibble at the ACA for 4 years. I’d actually have preferred the House passed this monster of a bill, which the Senate would have rejected, and then had to answer for it in 2018.

Energy and Commerce committee is not going to rewrite the AHCA now and is instead turning to CHIP reauthorization (where they may sneak in ACA cuts) and exchange stabilization.

MICHAEL MILLENSON

I think Jonathan Chait’s piece in NY Magazine addresses a lot of the substantive issues very well, particularly noting high up the opposition of a broad array of conservative experts.

Let me comment briefly on a small political point. Trump issued an ultimatum asking for a vote, just like you’d do if you last paid attention to how Congress works during 8th-grade civics class. But, clearly, when it became clear they would lose, Trump Congressional allies who are more sophisticated explained to the White House why you didn’t want to expose GOP House members to casting a potentially toxic vote in a sure-to-lose cause, and so the president “requested” that the vote not be held; i.e., put the onus on himself, not Ryan.

Translation: Trump is learning how politics really works and is adjusting to reality. That will likely help him in the future.Continue reading…

Repealed and Misplaced

Mar 26, 2017• 1

By KIP SULLIVAN

Like Joe, Michael and others, I find myself wondering what, if anything, Trump learned from the demise of the AHCA last Friday. But I’m also wondering what Democrats and other Republicans are thinking. The question I would like to ask all Republicans is: Is it clear to you now that merely saying no to any Democratic proposal to lower the uninsured rate is bad for your party? The question I would like to ask all Democrats who supported the Affordable Care Act is: Is it clear to you now that that the managed care nostrums in the ACA cannot lower costs, and that attempting to lower the uninsured rate without cutting costs is bad for your party?

Evidence-Based Health Reform

Mar 26, 2017• 13

By MARGALIT GUR-ARIE

President Trump campaigned on making health care better, cheaper and available to all Americans, regardless of ability to pay. Once Mr. Trump was safely in the White House, the Republican thought leaders in Congress were quick to supply him with plans to repeal and replace Obamacare. Most were written in protest to President Obama’s policies and were never meant to be implemented.

When scrutinized by the rank and file of the Republican Party, it turned out that the Ryan/Price American Health Care Act was neither repealing enough for some, nor replacing enough for others.

Now What, Mr. President? Here’s What.

Mar 26, 2017• 7

By STEVEN FINDLAY

In the wake of the AHCA’s demise, most lawmakers and policy experts agree that Congress will put repeal and replace aside for the rest of 2017.

As House Speaker Paul Ryan acknowledged on Friday that means the ACA/Obamacare remains the law for the “foreseeable future.”

Thus, as was widely reported over the weekend, that begs the question: how will the Trump administration administer the law and when might be the right time to return to the issue of fixing and improving it (however you want to label that.)

This is unknowable at the moment. The President, although inconsistent in his remarks, threatened to let the ACA “explode” this year and in 2018, thus forcing Democrats, in his mind, to beg him to fix it. At the same time, he said maybe the legislation’s demise was the “best thing” that could have happened since it would allow him to work with Democrats to craft an ACA replace or fix bill that would win their votes, bypassing the hard-right Freedom Caucus block in the House.