Archive for the ‘Healthcare’ Category
Some good news, reported in Mother Jones by Kevin Drum:
The decision last week by United Healthcare to drop out of Obamacare got a lot of attention, but the truth is that UH was a pretty small player in the exchanges. What’s more important—but hasn’t gotten much attention—is the fact that more and more Obamacare insurers are getting close to profitability. Richard Mayhew comments:
2014 was a year where there were only guesses about both the Exchange population, the market structure, and federal policy structure (specifically the risk corridor revenue neutrality restrictions. 2015 had a bit more clarity on who was coming into the market, what was working and what was not working, and what federal policy on risk corridors would actually be. 2016 is the first year where the policies are priced on functionally decent real information and some of the amazingly dumb strategic decisions have been unwound through either course changes or through exiting the market.
As a simple reminder, competitive markets should see some companies make money and some companies that offer more expensive and less attractive products lose money. I would be extremely worried if everyone was making money after three years, just like I would be extremely worried that everyone was losing money after three years of increasingly better data.
Obamacare critics have spent a lot of energy trying to pretend that premiums on the exchanges have skyrocketed, but that’s never been true. What is true is . . .
I don’t wish to appear apocalyptic, but things in general seem to be breaking down badly, and few are being honest about it. (For example, Cleveland pays $6 million as a settlement with Tamir Rice’s family but admits no wrongdoing, which seems inane: was the $6 million nothing more than a gift in a spirit of generosity? Quite clearly Cleveland believes that there was wrong-doing, else they would not write a $6 million check.)
Eyal Press has a shocking story in the New Yorker:
Shortly after Harriet Krzykowski began working at the Dade Correctional Institution, in Florida, an inmate whispered to her, “You know they starve us, right?” It was the fall of 2010, and Krzykowski, a psychiatric technician, had been hired by Dade, which is forty miles south of Miami, to help prisoners with clinical behavioral problems follow their treatment plans. The inmate was housed in Dade’s mental-health ward, the Transitional Care Unit, a cluster of buildings connected by breezeways and equipped with one-way mirrors and surveillance cameras. “I thought, Oh, this guy must be paranoid or schizophrenic,” she said recently. Moreover, she’d been warned during her training that prisoners routinely made false accusations against guards. Then she heard an inmate in another wing of the T.C.U. complain that meal trays often arrived at his cell without food. After noticing that several prisoners were alarmingly thin, she decided to discuss the matter with Dr. Cristina Perez, who oversaw the inpatient unit.
Krzykowski, an unassuming woman with pale skin and blue eyes, was thirty at the time. The field of correctional psychology can attract idealists who tend to see all prisoners as society’s victims and who distrust anyone wearing a security badge—corrections officers call such people “hug-a-thugs.” But Krzykowski, who had not worked at a prison before, believed that corrections officers performed a difficult job that merited respect. And she assumed that the prison management did not tolerate any form of abusive behavior.
Perez was a slender, attractive woman in her forties, with an aloof manner. When Krzykowski told her that she’d heard “guys aren’t getting fed,” Perez did not seem especially concerned. “You can’t trust what inmates say,” she responded. Krzykowski noted that complaints were coming from disparate wings of the T.C.U. This was not unusual, Perez said, since inmates often devised innovative methods to “kite” messages across the facility.
Krzykowski mentioned that she had overheard security guards heckling prisoners. One officer had told an inmate, “Go ahead and kill yourself—no one will miss you.” Again, Perez seemed unfazed. “It’s just words,” she said. Then, as Krzykowski recalls it, Perez leaned forward and gave her some advice: “You have to remember that we have to have a good working relationship with security.”
Not long after this conversation, Krzykowski was working a Sunday shift, and a guard told her that, because of a staff shortage, T.C.U. inmates would not be allowed in the prison’s recreation yard. The yard, a cement quadrangle with weeds sprouting through the cracks, had few amenities, but for many people in the T.C.U. it was the only place to get fresh air and exercise. Overseeing this activity was among Krzykowski’s weekend responsibilities.
The following Sunday, access was denied again. The closures continued for weeks, and the explanations increasingly sounded like pretexts. When Krzykowski pressed a corrections officer about the matter, he told her, “It’s God’s day, and we’re resting.” In an e-mail to Perez, Krzykowski expressed her concern.
A few days later, Krzykowski was running a “psycho-educational group”—an hour-long session in which inmates gathered to talk while she observed their mood and affect. After a dozen inmates had filed into the room, she noticed that the guard who had been standing by the door had walked away. She was on her own. Krzykowski completed the session without incident, and decided that the guard must have been summoned to deal with an emergency. But later, when she was in the rec yard, the guard there disappeared, too, once more leaving her unprotected amid a group of inmates.
Around the same time, the metal doors that security officers controlled to regulate the traffic flow between prison units started opening more slowly for Krzykowski. Not infrequently, several minutes passed before a security officer buzzed her through, even when she was the only staff member in a hallway full of prisoners. Krzykowski tried not to appear flustered when this happened, but, she recalls, “it scared the hell out of me.”
In theory, the T.C.U. was designed to provide mentally ill inmates with a safe environment in which they would receive treatment that might allow them to return to the main compound. Krzykowski discovered, however, that many inmates were locked up in single-person cells. Solitary confinement was supposed to be reserved for prisoners who had committed serious disciplinary infractions. In forced isolation, inmates often deteriorated rapidly. As Krzykowski put it, “So many guys would be mobile and interactive when they first came to the T.C.U., and then a few months later they would be sleeping in their cells in their own waste.”
Not only did Krzykowski suspect that few inmates in the T.C.U. were getting better; she was certain that the guards were punishing her for the e-mail she had sent to Perez. But she was afraid to complain about her situation. She didn’t even tell her husband, Steven, fearing he would insist that she give notice. He was an unemployed computer-systems engineer, and they could not afford to forgo her modest paycheck. . .
Continue reading. And read it all.
Later in the article:
. . . Even at the height of the economic crisis, jobs in corrections were plentiful in Florida—the state has the third-largest prison population in the country, behind Texas and California. Insuring that inmates with mental illnesses receive psychiatric care is a constitutional obligation, according to Estelle v. Gamble, a 1976 case in which the Supreme Court held that “deliberate indifference to serious medical needs of prisoners” amounted to cruel and unusual punishment.
Around the same time, the Court ruled, in O’Connor v. Donaldson, that a Florida man named Kenneth Donaldson had been kept against his will in a state psychiatric hospital for nearly fifteen years. The ruling added momentum to a nationwide campaign to “deinstitutionalize” the mentally ill. Activists decried the existence of mental hospitals that were filled, as one account put it, with “naked humans herded like cattle.” During the next two decades, states across the country shut down such facilities, both to save money and to appease advocates pushing for reform. But instead of funding more humane modes of treatment—such as community mental-health centers that could help patients live independently—many states left the mentally ill to their own devices. Often, highly unstable people ended up on the streets, abusing drugs and committing crimes, which led them into the prison system.
By the nineties, prisons had become America’s dominant mental-health institutions. The situation is particularly extreme in Florida, which spends less money per capita on mental health than any state except Idaho. Meanwhile, between 1996 and 2014, the number of Florida prisoners with mental disabilities grew by a hundred and fifty-three per cent.
The Supreme Court failed to clarify how psychiatric care could be provided in an environment where the paramount concern is security. According to medical ethicists, prison counsellors and psychologists often feel a “dual loyalty”—a tension between the impulse to defer to corrections officers and the duty to care for inmates. Because guards provide crucial protection to staff, it can be risky to disagree with them. But, if mental-health professionals coöperate too closely with security officials, they can become complicit in practices that harm patients.
After Krzykowski met with Perez, she told herself, “Maybe I’m being too sensitive—boys will be boys.” Aware that she was a newcomer to the world of prisons, she decided that the corrections officers at Dade were far more qualified than she was to determine how to maintain order.
At a morning staff meeting in June, 2011, a psychotherapist at Dade named George Mallinckrodt aired a different view. The previous day, Mallinckrodt announced, an inmate had shown him a series of bruises on his chest and back. The injuries had been sustained, the inmate claimed, when a group of guards had dragged him, handcuffed, into a hallway and stomped on him. Several other inmates confirmed the account, Mallinckrodt told his colleagues. He accused Dade security officials of “sabotaging our caseload,” and said that action needed to be taken.
In the days after the meeting, Krzykowski recalls thinking that “sabotaging” was “a pretty strong word—a loaded word.” Mallinckrodt was known to be on friendly terms with some of the patients in the T.C.U., and Krzykowski felt that he had become too aligned with the inmates—“too much on their side.” She told me, “I thought he’d become an advocate—you know, a hug-a-thug.”
Krzykowski tried to focus on providing good care, but she discovered that she had limited power to make decisions. State law mandated that prisons offer inmates twenty hours of activities a week, and when she was hired she was told that she would be responsible for insuring that this happened in the T.C.U. But every time she proposed an activity—yoga, music therapy—her superiors rejected it. Invariably, the reason cited was that it posed a “security risk,” even though the activities were meant to alleviate aggression.
One day, Krzykowski brought in a box of chalk, in the hope that inmates could draw on the pavement in the rec yard. On another occasion, she gave a rubber ball to an inmate who had schizophrenia; she thought that he would benefit from tactile play. An officer returned both items to her, ostensibly because they posed safety hazards. Krzykowski felt that she was being taught a lesson about knowing her place. “I kept getting the message that whatever security says goes,” she said.
Krzykowski had heard enough stories about inmates assaulting prison staff to know how dangerous it was to work without protection. One day in the rec yard, after a guard left her alone, an inmate sidled up to her and put his hands on her backside. The inmate was tall and imposing, and had been diagnosed as psychotic. Krzykowski thought of screaming for help, but she sensed that the guard who had vanished would not come rushing back if she did. Instead, she froze. After a moment, she hurried away without looking back. The inmate didn’t follow her. For days afterward, she was shaken. “He definitely could have overpowered me,” she said. “I could have been assaulted, raped—anything.” . . .
Somehow I don’t believe that the opposition is caused by concern for the patients and their health and convenience. Lee Fang reports in The Intercept:
The campaign in Colorado to create the nation’s first state-based “single payer” health insurance system, providing universal coverage and replacing insurance premiums with higher taxes, has barely begun.
But business interests in Colorado are not taking anything for granted, and many of the largest lobbying groups around the country and in the state are raising funds to defeat Amendment 69, the single-payer ballot question going before voters this November.
The Council of Insurance Agents & Brokers, a national trade group, is mobilizing its member companies to defeat single payer in Colorado. “The council urges Coloradans to protect employer-provided insurance and oppose Proposition 69,” the CIAB warns. The group dispatched Steptoe & Johnson, a lobbying firm it retains, to analyze the bill.
Lobby groups that represent major for-profit health care interests in Colorado, including hospitals and insurance brokers, are similarly mobilizing against Amendment 69. The Colorado Association of Commerce & Industry — a trade group led in part by HCA HealthOne, a subsidiary of HCA, one of the largest private hospital chains in the country — is soliciting funds to defeat single payer. The business coalition to defeat the measure also includes the state’s largest association of health insurance brokers.
The proposal calls for the Colorado legislature to pass new laws raising $25 billion a year from a mix of employer payroll taxes, a 3 percent tax on employee gross pay, and a new tax on self-employed net income. The money would be used for a new health care system that would cover all premiums and out-of-pocket costs for health and dental care. The state would also be charged with negotiating for better prices for drugs and with providers. Supporters of the plan say the system would save $4.5 billion a year.
I asked Sean Duffy, a spokesperson for “Coloradans for Coloradans,” an ad-hoc coalition against the single-payer ballot measure, how the state should address high health care costs and those struggling to afford health insurance premiums.
“We are focused on sharing with Coloradans the numerous questions, ambiguities, and concerns with Amendment 69,” said Duffy. He noted that “motivations for universal coverage are shared by many in Colorado” but that making Colorado a “one-state experiment, and the cost of doubling our state budget, potentially diminishing the accessibility and quality of care and creating an unaccountable, massive bureaucracy is just not a good idea for Colorado.”
The U.S. is the only wealthy nation without a publicly financed universal health care system — and spends far more than every other industrialized nation on health care costs. America also has one of the highest infant mortality rates of countries ranked by the Organization for Economic Co-operation and Development.
Patients using Medicare, the single-payer program for the elderly set up by President Lyndon Johnson, consistently tell pollsters that they prefer Medicare over private insurance. But expanding the system has proven difficult over . . .
Robert Mackey reports on mass demonstrations in Israel to support the Army medic who shot and killed a wounded Palestinian who was lying on the ground and posed no threat:
Thousands of Israelis rallied in Tel Aviv’s Rabin Square on Tuesday in support of an army medic who was caught on video last month apparently executing a wounded Palestinian suspect following a knife attack in the occupied West Bank.
The medic, Sgt. Elor Azaria, 19, was charged with manslaughter by an Israeli military court on Monday for firing a single bullet into the head of Abdel Fattah al-Sharif, killing him, on March 24 in the city of Hebron. Sharif was one of two young Palestinians suspected of lightly wounding an Israeli soldier in an area of the city inhabited by Jewish settlers.
Crowd chants “Elor the hero” and “death to Arabs.” This seems more like a celebration of murder than anythingpic.twitter.com/2QHDpIT0LJ
— Dan Cohen (@dancohen3000) April 19, 2016
Video of the incident recorded by a Palestinian witness and posted online by B’Tselem, an Israeli human rights group, showed that Sharif was lying prone on the ground, already immobilized by previous gunshots, when Azaria cocked his gun and shot him.
Haaretz, the Tel Aviv daily, reported that his supporters shouted slogans including, “He’s a hero,” and “Release the soldier.” The soldier’s mother thanked the crowd of about 5,000, according to a police estimate, and reminded her son that, “From a young age, you wanted to be a combat soldier and give back to your country.” . . .
David Downs writes in Scientific American:
Speculation is growing about the possibility that the U.S. Drug Enforcement Administration (DEA) will review by summer its “Schedule I” designation of marijuana as equal to heroin among the world’s most dangerous drugs. Very few Americans know of or understand the DEA’s drug-ranking process, and a review of cannabis’s history as a Schedule I drug shows that the label is highly controversial and dubious.
Disgraced Attorney General John Mitchell of the Nixon administration placed marijuana in this category in 1972 as part of the ranking or “scheduling” of all drugs under the 1970 Controlled Substances Act. Schedule I drugs are deemed to have no medical use and a high potential for abuse. Cannabis has been there ever since. “As of today, marijuana has never been determined to be medicine,” says Russ Baer, staff coordinator in the Office of Congressional and Public Affairs at the DEA. “There’s no safe, effective medical use, and a high abuse potential, and it can’t be used in medical settings.” This determination has come to be insulated by a byzantine, Kafkaesque bureaucratic process now impervious to the opinion of the majority of U.S. doctors—and to a vast body of scientific knowledge—many experts say.
“Of course cannabis has medical uses,” says University of California, San Francisco integrative oncologist Donald Abrams, one of the few researchers who have been able to obtain extremely limited, government-approved supplies of research cannabis for human trials. “It’s pretty clear from anthropological and archaeological evidence that cannabis has been used as a medicine for thousands of years—and it was a medicine in the U.S. until 1942,” Abrams adds. “I’m an oncologist and I say all the time, not a day goes by when I’m not recommending cannabis to patients for nausea, loss of appetite, pains, insomnia and depression—it works.”
Marijuana’s placement in Schedule I did not happen in a vacuum, historians note. Overt racism, combined with New Deal reforms and bureaucratic self-interest are often blamed for the first round of federal cannabis prohibition under the Marihuana Tax Act of 1937, which restricted possession to those who paid a steep tax for a limited set of medical and industrial applications. (Cannabis was removed from the official U.S. Pharmacopeia in 1942.) “In segregated America newspapers were saying, ‘this stuff makes white women and black men have sex,’” notes historian Martin Lee, author of Smoke Signals: A Social History of Marijuana.
The American Medical Association initially opposed prohibition. Cannabis was medically useful, says William Woodward, association counsel. “Congress being what it was at the time, you could ram things through just by bullshitting,” Lee adds. “Who’s going to be stepping up to the plate [in 1937] to defend a drug that blacks, Latinos and jazz musicians use?”
The Tax Act passed amid New Deal reforms, and the first marijuana peddlers were arrested and jailed that year. Science reared its head within a decade, though. In 1944 the La Guardia Committee report from the New York Academy of Medicine was the first in a long line of official bodies to question the prohibition. The committee found marijuana not physically addictive, not a gateway drug and that it did not lead to crime. But Harry Anslinger, head of the then–Federal Bureau of Narcotics, labeled the report unscientific and prohibition rolled on. “Every 10 years since then—although we’re a bit off schedule—some august governing body has reviewed the data and come up with the same finding [against prohibition],” Abrams says.
The Tax Act’s mode of federal cannabis prohibition became illegal in 1969 with the case Leary v. United States, which found that purchasing a marijuana tax stamp amounted to self-incrimination. The verdict spurred Congress to repeal the Tax Act and replace it with the more comprehensive Controlled Substances Act of 1970.
Marijuana was placed in Schedule I in 1971 provisionally, until the science could be assessed. But Pres. Richard Nixon saw pot prohibition as a way to destroy the antiwar left, according to clandestine recordings made by Nixon in the White House as well as statements from his staff to the press. Nixon convened The National Commission on Marihuana and Drug Abuse (what became known as the Shafer Commission) to engineer scientific support for cannabis’s Schedule I placement. “I want a goddamn strong statement on marijuana,” Nixon said in tapes from 1971. “Can I get that out of this sonofabitching, uh, domestic council? … I mean one on marijuana that just tears the ass out of them.”
The Shafer Commission found in 1972 that cannabis was as safe as alcohol, and recommended ending prohibition in favor of a public health approach. But by then the Federal Bureau of Narcotics had been removed from the Treasury Department and merged into the U.S. Department of Justice—where Nixon’s ally, Attorney General John Mitchell, placed cannabis in Schedule I in 1972; that same year he resigned to head Nixon’s re-election committee. (He later stood trial in 1974 over the Watergate scandal and served 19 months of a prison sentence for conspiracy, perjury and obstruction of justice.] “You want to know what this was really all about?” Nixon aid John Ehrlichman told journalist Dan Baum in 1994, according to an article published in Harper’s Magazine in 2016. “The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I’m saying? We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”
Anyone can petition the DEA to reschedule any drug, Baer says. The DEA takes advice from the U.S. Food and Drug Administration, Department of Health and Human Services, the DEA’s administrative law judges, along with others, but “the buck stops here. We have final scheduling authority,” he says. “Really it comes down to science. That’s the foundation of the argument. We’re bound by that scientific and medical evaluation.”
Many would disagree. Decades ago the DEA’s own administrative law judge, Francis Young, recommended unscheduling cannabis in response to a petition from activist groups. Young ruled in 1988 that “marijuana, in its natural form, is one of the safest therapeutically active substances known to man. By any measure of rational analysis marijuana can be safely used within a supervised routine of medical care.” The DEA denied the petition anyway.
In 1999, in response to California medical legalization, the Institute of Medicine found that marijuana had medical uses and a relatively low potential for abuse, leading to another round of petitioning. The DEA denied a petition again in 2011, citing a lack of available research specifically on smoked marijuana in the U.S.
Researchers say this represents a classic catch-22, as the paucity of research is the direct result of a federal blockade on such research by the DEA and the National Institute on Drug Abuse (NIDA). . .
Paul Krugman points out the impossibility of the task the GOP has assigned itself: to formulate a conservative alternative to Obamacare. (Liberal alternatives are easy, as he points out: a single-payer system, for instance, or a national health service). He posts in his blog:
Hype springs eternal — certainly when it comes to Paul Ryan, whose media image as a Serious, Honest Conservative and policy wonk seems utterly impervious to repeated demonstrations that he is neither serious nor honest, and that he actually knows very little about policy. And here we go again.
But what really amazes me about the latest set of stories is the promise that Ryan will finally deliver the Republican Obamacare alternative that his colleagues in Congress have somehow failed to produce after all these years. No, he won’t — because there is no alternative.
Or maybe I should say that there is no alternative to the right. Alternatives to the left do exist. True socialized medicine — an American NHS — would be feasible economically; so would single-payer, in the form of Medicare for all. The reasons we aren’t doing those are political.
But on the right, is there a more free-market, more privatized system that could replace the Affordable Care Act without causing the number of uninsured to soar? No, as some of us have tried to explain many times.
Once again: a useful starting point is the problem of people with pre-existing conditions. . .
That’s from this article in Motherboard by Sarah Emerson, which has more details.