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The Cynicism Behind Graham-Cassidy Is Breathtaking

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Kevin Drum notes:

It’s hard to know how to react to the cynicism of the Graham-Cassidy health care bill. For starters, of course, it’s as bad as all the other Republican repeal bills. Tens of millions of the working poor will lose insurance. Pre-existing conditions aren’t protected. Medicaid funding is slashed. Subsidies are slashed.

But apparently that’s not enough. Republican senators (and President Trump, of course) obviously don’t care what’s in the bill. Hell, they’re all but gleeful in their ignorance. Nor is merely repealing Obamacare enough. Graham-Cassidy is very carefully formulated to punish blue states especially harshly. And if even that’s not enough, after 2020 it gives the president the power to arbitrarily punish them even more if he feels like it. I guess this makes it especially appealing to conservatives. Finally, by handing everything over to the states with virtually no guidance, it would create chaos in the health insurance market. The insurance industry, which was practically the only major player to stay neutral on previous bills (doctors, nurses, hospitals, and everyone else opposed them) has finally had enough. Even if it hurts them with Republicans, Graham-Cassidy is a bridge too far:

The two major trade groups for insurers, the Blue Cross Blue Shield Association and America’s Health Insurance Plans, announced their opposition on Wednesday to the Graham-Cassidy bill….“The bill contains provisions that would allow states to waive key consumer protections, as well as undermine safeguards for those with pre-existing medical conditions,’’ said Scott P. Serota, the president and chief executive of the Blue Cross Blue Shield Association.

….America’s Health Insurance Plans was even more pointed. The legislation could hurt patients by “further destabilizing the individual market” and could potentially allow “government-controlled single payer health care to grow,” said Marilyn B. Tavenner, the president and chief executive of the association. Without controls, some states could simply eliminate private insurance, she warned.

Literally nobody in the health insurance industry likes this bill. The chaos and misery it would unleash are practically undebatable. It’s being passed for no reason except that Republicans have screwed up health care so epically that they have only a few days left to pass something, and Graham-Cassidy is something.

If there’s any silver lining at all to this mess, it comes from AHIP’s Marilyn Taverner:  . . .

Continue reading.

Written by LeisureGuy

21 September 2017 at 8:26 am

A set of articles on the heroin crisis. Read about it. It’s worse than you think.

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From David Pell’s newsletter NextDraft:

“Once a bustling industrial town, Huntington, West Virginia has become the epicenter of America’s modern opioid epidemic, with an overdose rate 10 times the national average. This flood of heroin now threatens this Appalachian city with a cycle of generational addiction, lawlessness, and poverty.” The new Netflix documentary Heroin(e) (produced in collaboration with my friends at the excellent Center for Investigative Journalism) tells the story of three women on the front lines of the battle to save small towns from the perfect storm of America’s opioid/heroin disaster. It’s only thirty minutes. Take the time to watch it. Below, I’ve shared a collection of articles to frame this pressing story.

+ Cincinnati Enquirer: Seven days of heroin: This is what an epidemic looks like.

+ “Often omitted from the conversation about the epidemic is the fact that it is also inflicting harm on the American economy, and on a scale not seen in any previous drug crisis.” Even if politicians are not moved by the moral issue, they should be moved by the economic factors. The New Yorker on the cost of the opioid crisis.

+ “Distributors have fed their greed on human frailties and to criminal effect. There is no excuse and should be no forgiveness.” From the Charleston Gazette-Mail: Drug firms poured 780M painkillers into WV amid rise of overdoses.

+ What can a company like Purdue Pharma do to make ends meet when the domestic market finally gets hit with regulations? The family behind the company decided to follow in the deadly footsteps of big tobacco. From the LA Times: OxyContin goes global.

+ Bloomberg: Big Pharma’s Tobacco Moment as Star Lawyers Push Opioid Suits.

+ When American states started to legalize marijuana, drug cartels saw the writing on the wall. They knew they’d need a new source of income, and the opioid crisis provided them with a market of addicts suddenly facing a legal crackdown on pain pill mills. From the great Don Winslow: El Chapo and The Secret History of the Heroin Crisis.

+ And for a look at the rise of pill mills (a hurricane that hit Florida long before Irma), check out the book American Pain, by John Temple.

Written by LeisureGuy

13 September 2017 at 2:00 pm

The media gets the opioid crisis wrong. Here is the truth.

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Anne Case, the Alexander Stewart 1886 professor of economics and public affairs emeritus at Princeton University, and Angus Deaton, the Dwight D. Eisenhower professor of economics and international affairs emeritus at Princeton University and the 2015 Nobel laureate in economics, write in the Washington Post:

Lawmakers and the media have devoted much of their attention recently to deaths from opioid overdoses, as well as to the broader “deaths of despair” that include suicides and deaths from alcoholic liver disease and cirrhosis. But despite the intense focus on the topic, misinformation about the epidemic runs rampant.

By conventional wisdom, tackling this crisis would require extending Medicaid and improving how it functions, cracking down on prescription painkillers and getting more health-care resources into rural communities.

But that’s not exactly right. To correct the record, here are four points to bear in mind:

Medicaid isn’t the problem (and isn’t the solution). Critics of Medicaid argue that the program enables the epidemic by paying for prescription opioids. In fact, Princeton University researchers Janet Currie and Molly Schnell calculate that only 8 percent of all opioid prescriptions from January 2006 to March 2015 were paid for by Medicaid, based on data from QuintilesIMS, a leading health-care information company.

Medicaid can help addicts by providing a range of evidence-based therapies. This is correct and, like many others, we think treatment is a good idea. As such, we are also concerned about the effects that reductions in Medicaid could have on the epidemic. But Medicaid proponents often greatly overstate what can be expected from treatment in general, and Medicaid in particular. Many addicts deny their addiction and either do not seek or do not adhere to treatment once started. “Evidence-based” typically means there has been a randomized, controlled trial that has demonstrated effectiveness. But trials include only those who seek treatment — and say nothing about those who avoid it. A trial is deemed successful when the treatment is proved better than nothing (or at least a placebo) — even if only a few people end up benefiting from it.

It is not all about opioids. Policymakers often speak as if the epidemic will be over as soon as we tackle both legal and illegal opioids. Better control of opioids is essential, but, even without opioid deaths, there would still be as many or more deaths from suicide and liver diseases. Opioids are like guns handed out in a suicide ward; they have certainly made the total epidemic much worse, but they are not the cause of the underlying depression. We suspect that deaths of despair among those without a university degree are primarily the result of a 40-year stagnation of median real wages and a long-term decline in the number of well-paying jobs for those without a bachelor’s degree. Falling labor force participation, sluggish wage growth, and associated dysfunctional marriage and child-rearing patterns have undermined the meaning of working people’s lives as well.

The crisis has hit men and women about equally.  . .

Continue reading.

Also note: “Here’s How Big Pharma Helped Set New Pain Guidelines,” by Kevin Drum, on the origins of the crisis we now face.

Written by LeisureGuy

12 September 2017 at 3:44 pm

In Huge Surprise, Study Confirms That Cutting Obamacare Advertising Will Cut Obamacare Enrollment

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When talking about the GOP, it’s difficult to avoid the word “evil.” Kevin Drum has a post worth reading in full. From that post:

. . . That’s a drop of 14 percent, which is huge. But this might still understate the problem. Trump is planning to stop advertising and outreach at the same time he’s shortening the open enrollment period. A lot of people who think they can wait to enroll until the end of December—or even the end of January—are going to be unpleasantly surprised when they head over to on December 27th and discover that they’ve missed the brand new deadline of December 15. I wouldn’t be surprised if this ended up affecting half a million people or more, who find themselves unexpectedly unable to buy health insurance for 2018.

The remarkable thing about all this isn’t just how callous it is, but how obviouslycallous it is. The cutbacks will save a little over $100 million, which is a pittance for a $100 billion program. There’s plainly no reason to eliminate this spending except as a way of deliberately trying to undermine the program and keep poor people from signing up. But Republicans don’t care if everyone knows it. Voters probably won’t figure it out, after all. . .

Written by LeisureGuy

5 September 2017 at 9:06 pm

The Real Reason the U.S. Has Employer-Sponsored Health Insurance

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Aaron Carroll writes in the NY Times:

The basic structure of the American health care system, in which most people have private insurance through their jobs, might seem historically inevitable, consistent with the capitalistic, individualist ethos of the nation.

In truth, it was hardly preordained. In fact, the system is largely a result of one event, World War II, and the wage freezes and tax policy that emerged because of it. Unfortunately, what made sense then may not make as much right now.

Well into the 20th century, there just wasn’t much need for health insurance. There wasn’t much health care to buy. But as doctors and hospitals learned how to do more, there was real money to be made. In 1929, a bunch of hospitals in Texas joined up and formed an insurance plan called Blue Cross to help people buy their services. Doctors didn’t like the idea of hospitals being in charge, so some in California created their own plan in 1939, which they called Blue Shield. As the plans spread, many would purchase Blue Cross for hospital services, and Blue Shield for physician services, until they merged to form Blue Cross and Blue Shield in 1982.

Most insurance in the first half of the 20th century was bought privately, but few people wanted it. Things changed during World War II.

In 1942, with so many eligible workers diverted to military service, the nation was facing a severe labor shortage. Economists feared that businesses would keep raising salaries to compete for workers, and that inflation would spiral out of control as the country came out of the Depression. To prevent this, President Roosevelt signed Executive Order 9250, establishing the Office of Economic Stabilization.

This froze wages. Businesses were not allowed to raise pay to attract workers.

Businesses were smart, though, and instead they began to use benefits to compete. Specifically, to offer more, and more generous, health care insurance.

Then, in 1943, the Internal Revenue Service decided that employer-based health insurance should be exempt from taxation. This made it cheaper to get health insurance through a job than by other means.

After World War II, Europe was devastated. As countries began to regroup and decide how they might provide health care to their citizens, often government was the only entity capable of doing so, with businesses and economies in ruin. The United States was in a completely different situation. Its economy was . . .

Continue reading.

Written by LeisureGuy

5 September 2017 at 7:37 pm

Make Pot Legal for Veterans With Traumatic Brain Injury

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Thomas James Brennan writes in the NY Times:

The explosion that wounded me during a Taliban ambush in Afghanistan in 2010 left me with a traumatic brain injury and post-traumatic stress. In 2012 I was medically retired from the Marine Corps because of debilitating migraines, vertigo and crippling depression. After a nine-year career, I sought care from the Department of Veterans Affairs.

At first, I didn’t object to the pills that arrived by mail: antidepressants, sedatives, amphetamines and mood stabilizers. Stuff to wake me up. Stuff to put me down. Stuff to keep me calm. Stuff to rile me up. Stuff to numb me from the effects of my wars as an infantryman in Iraq and Afghanistan. Stuff to numb me from the world all around.

The T.B.I. brings on almost daily migraines, and when they come, it’s as if the blast wave from the explosion in Afghanistan is still reverberating through my brain, shooting fresh bolts of pain through my skull, once again leaving me incapacitated. Initially the prescriptions helped — as they do for many veterans. But when I continued to feel bad, the answers from my doctors were always the same: more pills. And higher dosages. And more pills to counteract the side effects of those higher dosages. Yet none of them quite worked.

One thing did. In 2013, a friend rolled a joint and handed it to me, urging me to smoke it later. It will relieve your symptoms, he promised. That night I anxiously paced around my empty house. I hesitated to light it up because I’d always bought into the theory of weed as a “gateway drug.” But after a few tokes, I stretched out and fell asleep. I slept 10 hours instead of my usual five or six. I woke up feeling energized and well rested. I didn’t have nightmares or remember tossing or turning throughout the night, as I usually did. I was, as the comedian Katt Williams puts it, “hungry, happy, sleepy.”

With the help of my civilian psychiatrist, I began trading my pill bottles for pipes and papers. I also began to feel less numb. I started to smile more often. I thought I had found a miracle drug. There was just one problem: That drug was illegal.

In 21 states, including North Carolina, where I live, any use of marijuana is forbidden under state law. The current punishments for those who possess or cultivate cannabis — even for medical purposes — may include a felony conviction and imprisonment, loss of child custody and permanent damage to their livelihood. The V.A. encourages veterans to discuss their cannabis use with their doctors, but because cannabis is also prohibited under federal law, the V.A. cannot prescribe it in any form — thereby denying countless veterans relief to many mental health symptoms and other service-connected disabilities.

The medical benefits of marijuana for the more than 360,000 post-Sept. 11 veterans who have brain injuries are not universally recognized. (As many as one in five veterans are thought to have post-traumatic stress.) But medical experts like Dr. Frank Ochberg, a psychiatrist and former associate director of the National Institute of Mental Health, believe that “medical marijuana absolutely belongs in the pharmacy for post-traumatic stress and brain injury treatment.” The V.A., Dr. Ochberg said, “is failing veterans by not making cannabis a treatment option.”

In recent years, the V.A. has worked to reduce the number of opioids prescribed to veterans and increase the promotion of alternative therapies such as yoga and mindfulness, and it has made significant improvements in access to health care. Dr. David Shulkin, the V.A. secretary,has publicly supported the evaluation of emerging cannabis research, acknowledging that patients may benefit from marijuana use. But the department is prohibited from prescribing medical cannabis for veterans even in states where it is legal. (In those states, veterans can get prescriptions from private doctors, but at their own expense.)

Most of the major veterans groups, including the American Legion, Iraq and Afghanistan Veterans of America, Veterans of Foreign Wars and Disabled American Veterans, support regulated research into the medical uses of cannabis. But the research is slow in coming: Since 1968, the University of Mississippi has been home to the only licensed facility to produce cannabis for clinical research. In March it was reported that the university’s cannabis was contaminated with lead, yeast and mold — substances that jeopardize research efficacy and patient safety. . .

Continue reading.

Written by LeisureGuy

1 September 2017 at 11:29 am

Why Giving Birth Is Safer in Britain Than in the U.S., which claims to have the best healthcare in the world

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Kate Womersley reports in ProPublica:

At 11:58 p.m. this past June 25, Helen Taylor gave birth to her first baby, a boy, at West Suffolk Hospital in the east of England. At 11:59 p.m., with 15 seconds to spare before midnight, his sister was born. The obstetrician and her team were pleased; the cesarean section was going smoothly, fulfilling Helen’s wish that her twins share a birthday.

But 40 minutes later, Helen had lost over a third of her blood.

Enraptured by new motherhood, she barely noticed when the obstetrician’s head appeared around the surgical drape. “We need to give you a drug to help stop the bleeding, is that OK?” Helen nodded. Ten minutes passed before the question came again. Then again. The fourth time, Helen realized something was seriously wrong.

During pregnancy, the uterine blood vessels that nourish the fetus are wide open. Once the baby is delivered and the placenta removed, these vessels should constrict and close. If they don’t, as with Helen, the mother can bleed profusely. She may reach a point where her body can no longer compensate for the blood loss. The extent of the flow can be unpredictable and sometimes catastrophic. The surgical team’s response must be meticulous. And fast.

Helen’s team — an experienced obstetrician with her resident in training, a pediatrician, an anesthesiologist with an assistant, two nurses (one scrubbed-in, one fetching equipment), and three midwives — responded to her developing hemorrhage with a routine ingrained from rehearsal and real life.

“We are like a Formula One race team at a pit stop,” the anesthesiologist had reassured Helen by way of introduction.

The key to this well-oiled machine is standardization. It used to be that every obstetrician in the U.K. had his or her own signature strategy to manage an emergency. In the U.S., that still sometimes happens. But these days, every British doctor, whether newly qualified or approaching retirement, is required to follow the same guidelines for many aspects of maternity care, including treatment of bleeding. Postpartum hemorrhage guidelines are regularly updated by the Royal College of Obstetricians and Gynecologists and The National Institute for Health and Care Excellence, and then written into local protocols for practice in every National Health Service hospital. You don’t need to be a doctor to read the guidelines: They are freely available online. Women can find out exactly what standard of care to expect.

Helen’s was the kind of deceptively complex case that shows why a consistent approach is desirable. Her hemorrhage flared from minor (over 500 millimeters) to major (over 1 liter) to massive (over 2 liters) in less than an hour. First, the team gave her IV fluids to help replace the lost volume. After checking for bits of retained placenta, the obstetrician massaged Helen’s uterus to encourage its natural ability to contract, but her bleeding continued. The anesthesiologist lifted the surgical drapes to inject Helen’s thigh with a drug containing syntocinon, which stimulates the uterine muscle to tighten the blood vessels. The same medication was then given by a drip.

But there’s a catch: Drugs that narrow arteries can increase blood pressure. During her third trimester, Helen had developed preeclampsia, a type of hypertension induced by pregnancy that can lead to seizures and strokes. Not only does preeclampsia complicate treatment for bleeding, it makes hemorrhage more likely in the first place.

The immediate danger of more blood loss outweighed the risk of raising the blood pressure. The anesthesiologist followed protocol and administered two more drugs to intensify uterine contraction, with several minutes of watching and waiting in between. Still the blood flowed. The final step would be a transfusion.

Then, just as the team was about to dial up units of O-negative from the blood bank, the obstetrician noticed that her absorbent surgical swabs were taking longer to soak through with red. The uterus felt firmer, more like a bicep than loose tissue. Helen’s bleeding was under control. Due to the guidelines, a more serious crisis was averted. A transfusion wouldn’t be needed after all.

As a medical student at the University of Cambridge in England, I got to know Helen on the ward. This account of her pregnancy, labor and medical emergency is based on my observations and interviews with Helen, her partner Marcus and caregivers at West Suffolk Hospital. The hospital approved my access to interview patients, and Helen gave full consent to share her experience. It’s a tale that highlights the profoundly different approaches in the U.K. and the U.S. to maternal care — and to saving mothers’ lives.

“Ultimately, it’s a story I didn’t think I’d get to tell,” Helen said.

For a pregnant woman in the 1950s, the two childbirth complications most likely to prove fatal were hemorrhage and preeclampsia. Whether American or British, one in every 1,000 expectant and new mothers died.

British health authorities recognized this number was unacceptably high, given that nearly half of the deaths were considered preventable. Starting in the late 1940s, a national commitment was made to standardize maternity care across the NHS, assess each maternal fatality, and learn how it might have been avoided.

That campaign has succeeded. Today, the average mother in the U.K. receives more comprehensive and consistent care, ranging from earlier prenatal appointments to closer monitoring after she gives birth, than does her American counterpart. And if a mother dies, the U.K. investigates and tries to learn from it. Medical authorities in the U.K. view maternal deaths as public health failures that underscore deficiencies in health care systems. In the U.S., maternal deaths are too often treated as disconnected, private tragedies. If they are scrutinized by hospitals or regulators at all, the findings typically prompt institutional rather than national reforms.

Underlying these contrasts is a different view of the medical responsibility to mother and child. In the U.S., laudable aspirations for infant safety have intensified focus on the fetus — more sonograms, continuous fetal heart monitoring and granting rights to the unborn. But these measures may at times distract attention from the mother’s health.

By contrast, British medical professionals are legally required to prioritize a mother’s wellbeing if both she and her baby are in danger. They’re trained to stabilize mom first, and then tend to baby. “That sense that the woman (while the fetus is in utero) is the agent in charge is in place. I think that’s the right way,” said Denis Walsh, a midwife and associate professor in midwifery at the University of Nottingham. “Otherwise you start undermining individual women’s autonomy and then you go down a slippery slope.”

The numbers reflect the difference in national priorities. Today in the U.K., 8.9 women for every 100,000 live births die from complications of pregnancy or childbirth, according to the Institute for Health Metrics and Evaluation. In the U.S., this figure declined in tandem with Britain’s until 1990. It then reversed course, rising to 25.1 women per 100,000 in 2015, almost three times higher than the U.K., and among the worst in the Western world.

These U.S. deaths are not spread equally. Women who are poor, African American or live in a rural area are more likely to die during and after pregnancy. . .

Continue reading. There’s a lot more. Later in the report:

. . . Ironically, the centerpiece of the U.K.’s strategy to reduce maternal mortality is an American import. In 1949, the British Congress on Obstetrics and Gynecology suggested adopting a new method for reviewing maternal deaths that was already practiced in some parts of the U.S. Fatalities in those regions were assessed by local committees of experts, who published reports in medical journals to educate the profession. The British minister of health agreed to try it. The result was the Report on Confidential Enquiries into Maternal Deaths in England and Wales, established in 1952.

The confidential inquiry has far outstripped its American forebears. Now run by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the United Kingdom), its report drives training, assessment and practice in British obstetrics — including the types of treatment protocols that saved Helen Taylor’s life. Crucially, hospitals can neither opt out of MBRRACE’s surveillance nor ignore its recommendations. . .

In the meantime, the GOP is working hard to makes sure that as many as Americans as possible don’t have healthcare insurance. See, for example, the NY Times report today, “Trump Administration Sharply Cuts Spending on Health Law Enrollment,” by Abby Goodnough and Robert Pear. It begins:

The Trump administration is slashing spending on advertising and promotion for enrollment under the Affordable Care Act, a move some critics charged was a blatant attempt to sabotage the law.

Officials with the Department of Health and Human Services, who insisted on not being identified during a conference call with reporters, said on Thursday that the advertising budget for the open enrollment period that starts in November would be cut to $10 million, compared with $100 million spent by the Obama administration last year, a drop of 90 percent. Additionally, grants to about 100 nonprofit groups, known as navigators, that help people enroll in health plans offered by the insurance marketplaces will be cut to a total of $36 million, from about $63 million. . .

Read the whole thing.

This step follows the failure of the GOP Senate to repeal the Affordable Care Act. The idea now is to sabotage the Affordable Care Act to ensure that it fails. Apparently making sure Americans have access to healthcare is undesirable to the GOP.

See also “Trump officials slash advertising, grants to help Americans get Affordable Care Act insurance,” by Amy Goldstein, in the Washington Post.

Written by LeisureGuy

31 August 2017 at 4:51 pm

Posted in Government, Healthcare

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