Later On

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Archive for the ‘Healthcare’ Category

Disparate responses from disparate experience

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There’s an old saw that goes, “If you can keep your head when everyone around you is losing his, then you probably don’t understand the situation.” For example:

In the previous post (on my morning shave) I gave a  low-voltage example of this sort of error, which was my dismissing the practice of “blooming” the shaving soap because, when I tried it, it did nothing — blooming the soap or not made no difference. But I was limited by my experience (shaving with soft water) and did not understand what those who had to use hard water experienced.

That dissonance in that case is relatively mild, but in other situations a lack of insight due to (a) lack of experience and (b) not truly listening, can be devastating. The NY Times recently had a book review by Janice Nimura that discusses a disgraceful history of one long-running example of this type of error. She writes:

UNWELL WOMEN
Misdiagnosis and Myth in a Man-Made World
By Elinor Cleghorn

In order to recognize illness, you have to know what health looks like — what’s normal, and what’s not. Until recently, medical research generally calibrated “normal” on a trim white male. Such a patient, arriving in an emergency room clutching his chest as they do in the movies — and in the textbooks — would be immediately evaluated for a heart attack. But heart disease in women, inconveniently, doesn’t always come with chest pain. A woman reporting dizziness, nausea and heart-pounding breathlessness in that same E.R. might be sent home with instructions to relax, her distress dismissed as emotional rather than cardiac.

Heart disease has clear markers and proven diagnostic tools. When a woman’s symptoms are less legible or quantifiable — fatigue, vertigo, chronic pain — the tendency to be dismissive grows. In “Unwell Women,” the British scholar Elinor Cleghorn makes the insidious impact of gender bias on women’s health starkly and appallingly explicit: “Medicine has insisted on pathologizing ‘femaleness,’ and by extension womanhood.”

Cleghorn, framing her argument in terms of Western medicine, starts with Hippocrates, the Greek physician of antiquity who refocused medical science on the imbalances of the body rather than the will of the gods. Hippocrates understood that women’s bodies were different from those of men, but in his view, and for millenniums to come, those differences could be reduced to a single organ: the uterus. A woman’s purpose was to procreate; if she wasn’t well, it was probably her womb that was to blame. One Roman writer described the uterus as “an animal within an animal,” with its own appetites and the capacity to wander through the body in search of satisfaction. Most female afflictions could be reduced to “hysteria,” from the Greek word for womb. “The theory that out-of-work wombs made women mad and sad was as old as medicine itself,” Cleghorn notes. The standard cure was marriage and motherhood. As Hippocratic medicine was refracted through the lens of Christianity, the female anatomy was additionally burdened with the weight of original sin.

Moving steadily through the centuries, Cleghorn lays out the vicious circles of women’s health. Taught that their anatomy was a source of shame, women remained in ignorance of their own bodies, unable to identify or articulate their symptoms and therefore powerless to contradict a male medical establishment that wasn’t listening anyway. Menstruation and menopause were — and often still are — understood as illness rather than aspects of health; a woman’s constitution, thus compromised, could hardly sustain the effort required for scholarship or professional life. A woman with the means and the talents to contemplate such ambitions soon bumped up against the rigid shell of the domestic sphere. Her frustration and despair could cause physical symptoms, which her doctor would then chalk up to her unnatural aspirations. Conversely, a perfectly healthy woman who agitated for radical change — a suffragist, say — was clearly suffering from “hysteric morbidity.”

Though hormones eventually replaced wandering wombs as central to understanding women’s health, “old ideas about women’s bodies being naturally defective and deficient still pulsed through endocrinological theories,” Cleghorn writes. The marketing for early forms of hormone replacement therapy to relieve the discomforts of menopause was often directed at men. One horrifying magazine ad showed a radiant older woman laughing alongside male companions, with the tagline “Help Keep Her This Way.” Was hormone replacement therapy a way of liberating women from their reproductive biology, or keeping them cheerful for their husbands? And, as questions grew about estrogen and cancer, at what cost?

The intersection of class and race complicates things further. As early as 1847, the Scottish physician James Young Simpson argued in favor of anesthesia during labor and delivery, contradicting the age-old belief that the pain of birth was part of God’s judgment. (To this day, women who opt for an epidural instead of “natural childbirth” can feel a nagging sense of failure.) But even liberal-minded men like Simpson believed that what he called the “civilized female” needed his revolutionary innovation more than her less privileged sisters. Black women were thought to be less sensitive to pain and working-class women were considered hardier in general; certainly no one worried about whether these women could work while menstruating.

Each scientific advance came with its own shadow. Margaret Sanger may have  . . .

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Written by Leisureguy

18 June 2021 at 9:34 am

Some Hospitals Kept Suing Patients Over Medical Debt Through the Pandemic

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There is something deeply wrong with the US healthcare system. Jenny Deam reports in ProPublica:

Last year as COVID-19 laid siege to the nation, many U.S. hospitals dramatically reduced their aggressive tactics to collect medical debt. Some ceased entirely.

But not all.

There was a nearly 90% drop overall in legal actions between 2019 and the first seven months of 2020 by the nation’s largest hospitals and health systems, according to a new report by Johns Hopkins University. Still, researchers told ProPublica that they identified at least 16 institutions that pursued lawsuits, wage garnishments and liens against their patients in the first seven months of 2020.

The Johns Hopkins findings, released Monday in partnership with Axios, which first reported the results, are part of an ongoing series of state and national reports that look at debt collections by U.S. hospitals and health systems from 2018 to 2020.

During those years more than a quarter of the nation’s largest hospitals and health systems pursued nearly 39,000 legal actions seeking more than $72 million, according to data Johns Hopkins researchers obtained through state and county court records.

More than 65% of the institutions identified were nonprofit corporations, which means that in return for tax-exempt status they are supposed to serve the public rather than private interest.

The amount of medical debt individuals owe is often a small sliver of a hospital’s overall revenue — as little as 0.03% of annual receipts — but can “cause devastating financial burdens to working families,” the report said. The federal Consumer Financial Protection Bureau has estimated medical debt makes up 58% of all debt collection actions.

The poor or uninsured often bear the brunt of such actions, said Christi Walsh, clinical director of health care and research policy at Johns Hopkins University. “In times of crisis you start to see the huge disparities,” she said.

Researchers said they could not determine all of the amounts sought by the 16 institutions taking legal action in the first half of 2020, but of those they could, Froedtert Health, a Wisconsin health system, sought the most money from patients — more than $3 million.

Even after Wisconsin Gov. Tony Evers declared a public health emergency on March 12, 2020, hospitals within the Froedtert Health system filed more than 100 cases from mid-March through July, researchers reported, and 96 of the actions were liens.

One lien was against Tyler Boll-Flaig, a 21-year-old uninsured pizza delivery driver from Twin Lakes, Wisconsin, who was severely injured June 3, 2020, when a speeding drag racer smashed into his car. Boll-Flaig’s jaw was shattered, and he had four vertebrae crushed and several ribs broken. His 14-year-old brother, Dominic Flaig, tagging along that night, was killed.

Days after the crash, their mother, Brandy Flaig, said she got a call from a hospital billing office asking for her surviving son’s contact information to set up a payment plan for his medical bills.

Then on July 30 — less than two months later — Froedtert Hospital in Milwaukee filed a $67,225 lien against Boll-Flaig. It was one of seven liens the hospital filed the same day, totaling nearly a quarter of a million dollars, according to the Wisconsin Circuit Court Access website used by researchers and reviewed by ProPublica.

“It’s during the pandemic, we’re still grieving, and they go after Tyler?” Flaig said. “It’s predatory.” Tyler Boll-Flaig declined to be interviewed.

Froedtert Hospital is the largest in the Froedtert Health system, which includes five full-service hospitals, two community hospitals and more than 40 clinics. The health care system reported more than $53 million in operating income during the quarter ending Sept. 30, 2020 — double the amount from the previous year, according to its financial filings. It has also received $90 million in federal CARES Act money to help with its COVID-19 response and operating costs, a spokesperson said.

Only Reedsburg Area Medical Center, a nonprofit hospital in Reedsburg, Wisconsin, pursued more legal actions in the spring and summer of 2020, with 139 lawsuits and 22 wage garnishments, the study showed. Medical center officials did not respond to a request for comment.

In contrast, Advocate Aurora Health, the top-suing health network in the state before the pandemic, dropped to zero court filings after February 2020, the report found.

Stephen Schoof, a Froedtert Health spokesperson, said in an email he . . .

Continue reading.

Written by Leisureguy

15 June 2021 at 2:17 pm

Margaret Mead on the first archeological evidence of a civilization

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An interesting observation from Margaret Mead:

Years ago, anthropologist Margaret Mead was asked by a student what she considered to be the first sign of civilization in a culture. The student expected Mead to talk about fishhooks or clay pots or grinding stones.

But no. Mead said that the first sign of civilization in an ancient culture was a femur (thighbone) that had been broken and then healed. Mead explained that in the animal kingdom, if you break your leg, you die. You cannot run from danger, get to the river for a drink or hunt for food. You are meat for prowling beasts. No animal survives a broken leg long enough for the bone to heal.

A broken femur that has healed is evidence that someone has taken time to stay with the one who fell, has bound up the wound, has carried the person to safety and has tended the person through recovery. Helping someone else through difficulty is where civilization starts, Mead said.”

We are at our best when we serve others. Be civilized.

Ira Byock

Written by Leisureguy

10 June 2021 at 6:58 pm

He Bought Health Insurance for Emergencies. Then He Fell Into a $33,601 Trap Created by the Trump Administration.

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Jenny Deam reports in ProPublica:

In the spring of 2019, Cory Dowd suddenly found himself without health insurance for the first time. A self-employed event planner, he had just finished a Peace Corps stint that provided health benefits, but he was still more than a year away from starting a graduate program that would provide coverage through his university.

So, like countless others in an online world, he went insurance shopping on the internet.

But the individual insurance market he was about to enter was one dramatically changed under President Donald Trump’s push to dismantle Obamacare, offering more choices at cheaper prices.

Dowd is well-educated and knew more than most about how traditional health insurance works. But even he did not understand the extent to which insurers could offer plans that looked like a great deal but were stuffed with fine print that allowed companies to deny payment for routine medical events.

Not bound by the strict coverage rules of the Affordable Care Act, the short-term plans that Dowd signed up for have been dubbed “junk insurance” by consumer advocates and health policy experts. The plans can deny coverage for people with preexisting conditions, exclude payments for common treatments and impose limits on how much is paid for care.

Dowd, like millions of other Americans who have flocked to such plans in the past three years, only saw what looked like a great deal: six-month coverage offered through an agency called Pivot Health, whose website touts the company as a “fast-growing team obsessed with helping you find the right insurance for your needs.”

Monthly premiums for the two short-term plans he bought were surprisingly cheap at around $100 a month each, with reasonable co-pays for routine doctor visits and treatments. Best of all, the first plan he bought promised to cover up to $1 million in claims, the second up to $750,000. That should more than do it, he thought. Dowd was 31 and healthy but wanted protection in case of a medical emergency. He signed up and began paying his premiums without closely reading the details.

Then he was hit with the very kind of emergency he had feared. And he wasn’t protected after all.

Short-term plans have been around for decades, and are meant to temporarily bridge coverage gaps. Under the Affordable Care Act they were limited to three months. But when the Trump administration allowed them to be extended to nearly a year, they became a fast-growing and lucrative slice of the insurance industry.

Because these plans are not legally bound by the strict rules of the ACA, not only do they come with hefty restrictions and coverage limitations, but insurers can search through patients’ past medical histories to find preexisting conditions.

All companies selling short-term plans have to do is acknowledge that they are not ACA-compliant and may not cover everything — a disclosure the insurers insist they do.

Still, the Biden administration faces a challenge on what to do about the proliferation of such plans.

Once in office, President Joe Biden quickly moved to make enrolling in comprehensive ACA coverage easier and make plans more affordable. On Thursday, the Department of Health and Human Services announced 940,000 people had signed up for ACA plans this spring after enrollment was reopened in February. In many states, enrollment will run through the summer.

Yet, while health policy experts say ACA expansion is important, it does not specifically address those who remain in plans outside the health care law and could be at risk for financial ruin.

“The Biden administration is going to have to find a way to put the genie back in the bottle,” said Stacey Pogue, a health policy analyst for Every Texan, an Austin-based advocacy group.

True numbers of how many people have noncompliant plans remain elusive, as such plans often fly under regulatory radar and industry tracking. Still, an investigation last year by the U.S. House Committee on Energy and Commerce concluded that at least 3 million consumers had short-term limited duration plans in 2019, the last year for which information was available. That was a 27% jump from the previous year, when deregulation began in earnest, the investigation found.

“I would not be surprised if  . . .

Continue reading.

Written by Leisureguy

8 May 2021 at 10:24 am

Vaccine skepticism stems not from ignorance but from beliefs and values

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Sabrina Tavernise reports in the NY Times:

For years, scientists and doctors have treated vaccine skepticism as a knowledge problem. If patients were hesitant to get vaccinated, the thinking went, they simply needed more information.

But as public health officials now work to convince Americans to get Covid-19 vaccines as quickly as possible, new social science research suggests that a set of deeply held beliefs is at the heart of many people’s resistance, complicating efforts to bring the coronavirus pandemic under control.

“The instinct from the medical community was, ‘If only we could educate them,’” said Dr. Saad Omer, director of the Yale Institute for Global Health, who studies vaccine skepticism. “It was patronizing and, as it turns out, not true.”

About a third of American adults are still resisting vaccines. Polling shows that Republicans make up a substantial part of that group. Given how deeply the country is divided by politics, it is perhaps not surprising that they have dug in, particularly with a Democrat in the White House. But political polarization is only part of the story.

In recent years, epidemiologists have teamed up with social psychologists to look more deeply into the “why” behind vaccine hesitancy. They wanted to find out whether there was anything that vaccine skeptics had in common, in order to better understand how to persuade them.

They borrowed a concept from social psychology — the idea that a small set of moral intuitions forms the foundations upon which complex moral worldviews are constructed — and applied it to their study of vaccine skepticism.

What they discovered was a clear set of psychological traits offering a new lens through which to understand skepticism — and potentially new tools for public health officials scrambling to try to persuade people to get vaccinated.

Dr. Omer and a team of scientists found that skeptics were much more likely than nonskeptics to have a highly developed sensitivity for liberty — the rights of individuals — and to have less deference to those in positions of power.

Skeptics were also twice as likely to care a lot about the “purity” of their bodies and their minds. They disapprove of things they consider disgusting, and the mind-set defies neat categorization: It could be religious — halal or kosher — or entirely secular, like people who care deeply about toxins in foods or in the environment.

Scientists have found similar patterns among skeptics in Australia and Israel, and in a broad sample of vaccine-hesitant people in 24 countries in 2018.

“At the root are these moral intuitions — these gut feelings — and they are very strong,” said Jeff Huntsinger, a social psychologist at Loyola University Chicago who studies emotion and decision-making and collaborated with Dr. Omer’s team. “It’s very hard to override them with facts and information. You can’t reason with them in that way.”

These qualities tend to predominate among conservatives but they are present among liberals too. They are also present among people with no politics at all.

Kasheem Delesbore, a warehouse worker in northeastern Pennsylvania, is neither conservative nor liberal. He does not consider himself political and has never voted. But he is skeptical of the vaccines — along with many institutions of American power.

Mr. Delesbore, 26, has seen information online that a vaccine might harm his body. He is not sure what to make of it. But his faith in God gives him confidence: Whatever happens is God’s will. There is little he can do to influence it. . .

Continue reading.

Written by Leisureguy

29 April 2021 at 12:04 pm

Parents Want Justice for Birth Injuries. Hospitals Want to Strip Them of the Right to Make That Decision.`

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Carol Marbin Miller and Daniel Chang, Miami Herald, report in ProPublica:

Ashley Lamendola was still a teen when medical staff at St. Petersburg General Hospital delivered the awful news that would change her life forever: Her newborn son, Hunter, had suffered profound brain damage and would do little more than breathe without help.

“It was like an atomic bomb went off in my life,” she said.

Lamendola believed the hospital was partly responsible for Hunter’s birth injuries. But Florida is one of two states that shield doctors and hospitals from most legal actions arising from births that go catastrophically wrong. Lamendola filed a lawsuit against St. Petersburg General anyway, and when it appeared she was gaining traction, the hospital advanced an extraordinary argument.

It suggested that Hunter’s mother was not acting in her son’s best interest and that a critical decision about his future care should be put in the hands of an independent guardian and a judge. Lamendola, attorneys said, was pursuing her own self-interest by refusing to participate in the quasi-government program that compensates the families of children injured at birth.

Under the program, known as the Birth-Related Neurological Injury Compensation Association, or NICA, the state provides $100,000 upfront and pays for “medically necessary” care for the child’s lifetime. In exchange, parents give up their right to sue hospitals and doctors, lawsuits that can result in judgments or settlements in the tens of millions of dollars.

By choosing to “pursue her own speculative, complicated civil lawsuit” rather than permitting her son to accept his “vested” NICA benefits, Lamendola was trying to profit from Hunter’s injuries, St. Petersburg General attorneys argued in a court filing. They underscored the words “her own.

Had she accepted Hunter’s inclusion in NICA, “the Mother would be unable to pursue her own civil lawsuit, seeking her own separate monetary damages for the Child’s injuries,” the lawyers added.

“You carry a child for nine months, and then you finally get to hold them — eventually in my case,” said Lamendola, who was employed as a customer service rep at an AutoZone when she gave birth. “And you take care of their every want and need, and you put a child before you. I mean, once you have a child, there is no more you. It’s them. It’s us. It’s that baby that needs you and needs everything from you.

“I didn’t understand how somebody who wasn’t me could know what he wants and needs. I knew every sound, every movement, every seizure that he had,” Lamendola said. “And to think that somebody thought they knew better than me. It was wild to me.”

The battle between parents like Lamendola and hospitals like St. Petersburg General can seem like a gross mismatch: Lamendola was a single mom who made $10.50 an hour and lived with her mother. HCA Healthcare, which owns St. Petersburg General, is one of the nation’s largest for-profit hospital chains, with 180 hospitals, 280,000 employees and revenues of $51.5 billion in 2020.

For hospitals facing stunningly high settlements or verdicts, NICA, the state’s no-fault program, is a valuable legal tool — a club to bat away expensive lawsuits. At the cost of $50 per live birth, hospitals can protect themselves from multimillion-dollar judgments.

Paolo Annino, who heads the Children’s Advocacy Clinic at the Florida State University College of Law, said attempts to restrict a parent’s authority through the appointment of a guardian are unusual: In child welfare disputes, for example, parents must be found unfit by a judge before being stripped of their right to decide what’s best for their children.

“What we have here is a scenario where there’s no allegation of offending parents at all,” he said. “The parent is, with very few exemptions, the one who makes the child’s health care decisions.”

NICA came under fire this month after  . . .

Continue reading.

Written by Leisureguy

26 April 2021 at 1:31 pm

Vietnam defied the experts and sealed its border to keep Covid-19 out. It worked.

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Julia Belluz reports in Vox:

This story is one in our six-part series The Pandemic Playbook. Explore all the stories here.

Every January or February, Le The Linh and his wife pack their children into their car and drive 80 miles to visit family in Haiphong, a port city east of Vietnam’s capital, Hanoi, for Lunar New Year. But this time, as they reached the last stretch of the Hanoi-Haiphong Highway, a police officer approached and pointed them toward a group of guards in face masks under a makeshift tent. It was one of 16 checkpoints erected around Haiphong to control travel into and out of the city ahead of the Tet Festival holiday.

They joined a lineup of other travelers, nervously waiting for their turn in the rain. When they reached the front, the officials asked for proof of their travel plans, residency, and Covid-19 status.

“Don’t worry!” Linh exclaimed tensely. He could show, with his identity card, that they lived in an area that had no coronavirus cases recently.

The family was among the lucky ones let through. Travelers from areas near Haiphong that had recently recorded Covid-19 cases got turned away; a group of young people on motorbikes who tried to circumvent the checkpoint were arrested; still others chose not to travel at all, opting to meet family over FaceTime or Zalo (Vietnam’s answer to WhatsApp).

As the pandemic took hold last year, travel restrictions quickly proliferated — they were the second-most-common policy governments adopted to combat Covid-19. According to one review, never in recorded history has global travel been curbed in “such an extreme manner”: a reduction of approximately 65 percent in the first half of 2020. More than a year later, as countries experiment with vaccine passportstravel bubbles, and a new round of measures to keep virus variants at bay, a maze of confusing, ever-changing restrictions remains firmly in place.

But few countries have gone as far as Vietnam, a one-party communist state with a GDP per capita of $2,700. The Haiphong checkpoints timed for Tet were the equivalent of closing off Los Angeles to Americans ahead of Thanksgiving — within a country that was already nearly hermetically sealed. Last March, the government canceled all inbound commercial flights for months on end, making it almost impossible to fly in, even for Vietnamese residents.

Today, flights are limited to select groups, like businesspeople or experts, from a few low-risk countries. Everybody who enters needs special government permission and must complete up to 21 days of state-monitored quarantine with PCR tests. (Positive cases are immediately isolated in hospitals, regardless of disease severity.)

This strict approach to travel, global health experts say, is directly connected to Vietnam’s seeming defeat of Covid-19. Thirty-five people have reportedly died in total, and a little more than 2,700 have been infected with the virus during three small waves that have all been quickly quashed. Even on the worst days of the pandemic, the country of 97 million has never recorded more than 110 new cases — a tiny fraction of the 68,000 daily case high in the United Kingdom, which has a population one-third smaller than Vietnam, or the record 300,000-plus cases per day only the US and India managed to tally.

Last year, Vietnam’s economy even grew 2.9 percent, defying economists’ predictions and beating China to become the top performer in Asia. .. .

Continue reading. There’s much more, including god photos.

The US, of course, chose another path. To date, the US has seen 32,725,095 cases and 584,942 deaths.

Written by Leisureguy

23 April 2021 at 4:06 pm

Vaccine Refusal Will Come at a Cost—For All of Us

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Edward Isaac-Dovere writes in the Atlantic:

Imagine it’s 2026. A man shows up in an emergency room, wheezing. He’s got pneumonia, and it’s hitting him hard. He tells one of the doctors that he had COVID-19 a few years earlier, in late 2021. He had refused to get vaccinated, and ended up contracting the coronavirus months after most people got their shots. Why did he refuse? Something about politics, or pushing back on government control, or a post he saw on Facebook. He doesn’t really remember. His lungs do, though: By the end of the day, he’s on a ventilator.

You’ll pay for that man’s decisions. So will I. We all will—in insurance premiums, if he has a plan with your provider, or in tax dollars, if the emergency room he goes to is in a public hospital. The vaccine refusers could cost us billions. Maybe more, over the next few decades, with all the complications they could develop. And we can’t do anything about it except hope that more people get their shots than those who say they will right now.

If the 30 percent of Americans who are telling pollsters they won’t get vaccinated follow through, the costs of their decisions will pile up. The economy could take longer to get back to full speed, and once it does, it could get shut down again by outbreaks. Variants will continue to spread, and more people will die. Each COVID-19 case requires weeks of costly rehabilitation. Even after the pandemic fades, millions of vaccine refusers could turn into hundreds of thousands of patients who need extra care, should they come down with the disease. Their bet that they’ve outsmarted the coronavirus or their insistence that Anthony Fauci and Bill Gates were trying to trick them will not stop them from going to the doctor when they’re having trouble breathing, dealing with extreme fatigue, or struggling with other lasting effects of COVID-19. (A new study found that 34 percent of COVID-19 survivors are diagnosed with a neurological or psychological condition within six months of recovering from the initial illness.)

The economic costs of vaccine refusal aren’t yet a major part of the political conversation. That’s likely to change as we move past the first year of the pandemic. “You have a liberty right, and that unfortunately is imposing on everyone else and their liberty right not to have to pay for your stubbornness. And that’s what’s maddening,” Jay Inslee, the governor of Washington, told me. Inslee is 70, and fully vaccinated. The three-term Democrat was in a good mood because he was on his way to see his baby granddaughter, whom he hadn’t hugged in a year. But after what he’s gone through since early 2020—the first American COVID-19 outbreak and the first explosion of COVID-denialist demonstrations were both in Washington—he’s angry and sad that so many people are refusing to get their shots.

He had the latest numbers: 15 Washingtonians had died of COVID-19 the day we spoke. More than 300,000 state residents who had been eligible for a vaccine for at least three months still hadn’t gotten one, including 27 percent of those over 65. Some of those people hadn’t been able to get appointments. Some may have been nervous, but would eventually get a vaccine. Some had just refused, and will continue to do so. Those people are “foisting [their] costs on the rest of the community,” Inslee said. “There’s a long, long economic tail of disease prevalence as a result of people who refuse to get vaccinated.” But, he stressed, “it pales in comparison to people losing their lives.”

Inslee read me some data he had gotten from the Republican messaging maven Frank Luntz, which the governor said was going to inform new public-awareness campaigns that the state is developing to break through to Republican men, the people most likely to say they won’t get vaccinated, according to polling. Two appeals seem to work best: First, the vaccines are safe, and they’re more effective than the flu vaccine. Second, you deserve this, and getting vaccinated will help preserve your liberty and encourage the government to lift restrictions. (That last idea is what Jerry Falwell Jr. focused on in the vaccination selfie he posted this week, captioned, “Please get vaccinated so our nutcase of a governor will have less reasons for mindless restrictions!”) Inslee hopes that emphasizing those points will persuade more Republican men to get their shots. But he’s not sure it will work.

The prospect of lower health-care costs has led conservatives to back health-related regulations in the past. In 1991, Pete Wilson, then the Republican governor of California, signed a law mandating helmets for motorcyclists, and made a conservative argument for the new regulation. “We don’t know exactly how much money and how many lives will be saved with this legislation,” Wilson said at the signing ceremony, which was held at a hospital in the state capital. “But we do know that the cost of not enacting it is too great for a civilized society to bear.” Then again, President Ronald Reagan was famously resistant to seatbelt and airbag laws, which also reduce health-care spending.

Though there are some notable vaccination holdouts among Republican officials, most in Congress and in state leadership positions have encouraged their constituents to get the shots. “I saw on some program last week that Republican men, curiously enough, might be reluctant to take the vaccine. I’m a Republican man, and I want to say to everyone: We need to take this vaccine,” Senate Minority Leader Mitch McConnell said at an event in Kentucky this week. Brad Wenstrup, who worked as a podiatrist before becoming a Republican congressman from Ohio, has been so eagerly promoting the vaccines that he got trained to administer them. But the Republican politics around COVID-19 remain treacherous, and when I reached out to several Republican members of Congress, telling their aides I’d be eager to have them make a Wilson-esque fiscally conservative argument for vaccination, I couldn’t find anyone willing to make that case to me.

Calculating the exact long-term costs is tricky; we have only a year’s worth of data on the lasting health consequences of COVID-19, and even less on the efficacy of the vaccines and Americans’ resistance to getting them. Krutika Amin, who conducts economic and policy research for the Kaiser Family Foundation, tried to sketch out what the taxpayer bill might be. Before the pandemic, about . . .

Continue reading. There’s more.

Written by Leisureguy

11 April 2021 at 11:17 am

Heart Stents and Upcoding: How Cardiologists Game the System

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Written by Leisureguy

7 April 2021 at 12:48 pm

Why tearing down Fauci is essential to the MAGA myth

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Michael Gerson was a speechwriter for George W. Bush and is currently a columnist. Here’s a recent column that appeared in the Washington Post that reflects the despair of traditional Republicans (among whom he counts himself) in the face of MAGA madness:

MAGA political philosophy is not systematic, but it is comprehensive. Right-wing populism offers a distorted lens to view nearly all of life.

Through this warped lens, progress toward equal rights is actually the oppression of White people. Free and fair elections, when lost, are actually conspiratorial plots by the ruthless left. But perhaps the most remarkable distortion concerns the MAGA view of covid-19.

We have all seen the basic outlines of pandemic reality. Experts in epidemiology warned that the disease would spread through contact or droplets at short distances, which is how it spread. The experts recommended early lockdowns to keep health systems from being overwhelmed, and the lockdowns generally worked. The experts said Americans could influence the spread of the disease by taking basic measures such as mask-wearing and social distancing. The disease was controlled when people did these things. The disease ran rampant when they did not, killing a lot of old and vulnerable people in the process.

There were, of course, disagreements along the way about the length of lockdowns and the form of mandates. But on the whole, American citizens have witnessed one of the most dramatic vindications of scientific expertise in our history. We have been healthier when we listened to the experts and sicker when we did not.

This is the context in which the MAGA right has chosen to make Anthony S. Fauci — the director of the National Institute of Allergy and Infectious Diseases since 1984 — the villain in their hallucinogenic version of pandemic history.

It is worth disclosing when a columnist has a personal connection to a public figure. I have known Fauci since I was in government during the early 2000s and watched him help create the President’s Emergency Plan for AIDS Relief. He is the best of public service: supremely knowledgeable, personally compassionate, completely nonpolitical, tenacious in the pursuit of scientific advancement and resolute in applying such knowledge to human betterment. He has no other ambition or agenda than the health of the country and world.

Yet slamming Fauci was a surefire applause line at the Conservative Political Action Conference in February. Former Trump administration officials continue to target him. Republican members of Congress vie with one another to put Fauci in his place.

For Trump officials, including Donald Trump himself, this makes perfect sense. If Fauci has been right about covid, then playing down the disease, mocking masks, modeling superspreader events, denying death tolls, encouraging anti-mandate militias and recommending quack cures were not particularly helpful. If Fauci has been right, they presided over a deadly debacle.

When former Trump trade adviser Peter Navarro claims that Fauci is “the father of the actual virus” or former chief of staff Mark Meadows complains about Fauci’s indifference to the (nearly nonexistent) flow of covid across the southern border, the goal is not really to press arguments. It is to create an alternative MAGA reality in which followers are free from the stress of truth — a safe space in which more than half a million people did not die and their leader was not a vicious, incompetent, delusional threat to the health of the nation.

Metaphorically (but only barely metaphorically), there is a body on the floor with multiple stab wounds. The Trump administration stands beside it with a bloody knife in its hand. It not only claims to be innocent. It claims there is no blood. There is no body. There is no floor.

Congressional Republicans who criticize Fauci to prove their populist manhood are even more pathetic. Their self-abasement is voluntary. Watching Sen. Rand Paul (R-Ky.) debate science with Fauci during committee hearings is like watching Albert Einstein being disputed by his dry cleaner. Fauci is often reduced to making obvious points in a patient voice. Fauci deserves his Presidential Medal of Freedom just for his heroic forbearance.

All these critics of Fauci have chosen to attack the citadel of science at its strongest point. With squirt guns. While naked and blowing kazoos.

This useless exertion is somehow wrapped in the language of freedom. Freedom from the servitude of a piece of cloth on your face that might save your neighbor’s life. Freedom to light off fireworks below a potential avalanche. . .

Continue reading. The column concludes:

Fauci is practicing epidemiology. His critics are practicing idiocy. Both are very good at their chosen work.

Written by Leisureguy

6 April 2021 at 12:11 pm

The health-care industry doesn’t want to talk about this single word

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A clear example of the extent of systemic racism in the United States is offered in a Washington Post column by Ron Wyatt, co-chairof the Institute for Healthcare Improvement’s equity advisory group and faculty for the IHI Pursuing Equity Initiative. Wyatt was the first Black chief medical resident at the Saint Louis University School of Medicine. He writes:

When I write about health policy or speak with medical colleagues about barriers to care, there is one word — and one word only — that evokes a wide range of responses. Some respond with silence; others with avoidance. Some respond with anger and defensiveness.

The word appeared at the top of a paper I submitted to the Journal of the American Medical Association in 2015 with David R. Williams, a professor of public health and African American studies at Harvard University. The title: “Racism in Health and Healthcare: Challenges and Opportunities.”

The editor of the journal at that time, Howard Bauchner, advised us that the word could not be published and that “racial bias” would be substituted into the title before publication. Using “racism,” he said, would result in “losing readers.” As authors and scientists, we compromised. We agreed to the change, and the article was published.

Just a few weeks ago, six years after that decision to compromise, Bauchner and I spoke by phone. He apologized, saying that progress has been made since then.

Has progress been made? JAMA recently announced that following controversial comments on racism in medicine made by a deputy editor, Bauchner was placed on administrative leave on March 25 while an independent investigation is completed.

Entrenched systemic racism — and the deliberate omission of the word in patient safety circles — is the cause of an astonishing level of preventable harm and death among communities of color that have been devalued and discounted for more than 400 years.

The covid-19 pandemic has laid bare the racial inequities of the U.S. health-care system. Too many health-care executives still perpetuate the ahistoric perspective that our country’s model provides safe and equal care for all. Yet the disproportionate number of deaths to covid-19 among racial and ethnic minority groups exposes the systemic and lethal barriers to care.

Last month, a major health-care trade magazine accepted another article that I contributed to with three colleagues, once again with “racism” in the title. When our editor sent us the final authors’ agreement, we noticed the word had been removed from the title and replaced with “intolerance.” This time, we were not willing to compromise. Our editor later informed us that the article would not be published in the May/June issue as scheduled. We were not given a reason.

I have worked all over the United States and internationally as a champion of addressing health inequity. I can say without hesitation — both as a doctor and a citizen — that racism in the United States is a public health crisis.

Having lived in rural Alabama, my family experienced these inequities personally. When my great uncle, who was like a father to me, fell ill, he was taken to a clinic that was segregated by skin color, and was subsequently admitted to a hospital in Selma in 1973. He died one day later. In 2015, I learned he had a ruptured appendix and was never seen by a physician.

I have advised and worked with large, complex health-care systems in the United States, Britain, Australia and Africa. I have collaborated with organizations such as the American Medical Association, the American Hospital Association and the Joint Commission. I have even discussed race as a risk factor for death with White health leaders, such as former president of the Institute for Healthcare Improvement Don Berwick.

Yet, I still sometimes feel that survival mechanism kick in to compromise and veil the truth that structural and systemic racism is a root cause of preventable harm and death across U.S. health care. I have been warned that if I did not continue to compromise, I would be labeled an “angry Black man” and that colleagues would distance themselves from me.

The days of compromise are over.

Solving systemic racism in public health must start with naming it. We must publish the word. We must say the word. If health-care providers are to be competent in caring for communities that have been marginalized and oppressed for centuries, then they must understand the role racism plays in poor health. This includes . . .

Continue reading.

Racists don’t like it when you point out their racism.

Written by Leisureguy

5 April 2021 at 5:51 pm

Why Are Stents Still Used If They Don’t Work?

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Written by Leisureguy

5 April 2021 at 9:34 am

The Real Reason Republicans Couldn’t Kill Obamacare

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Adapted from The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage, St. Martin’s Press 2021, and quoted from the Atlantic:

The affordable care act, the health-care law also known as Obamacare, turns 11 years old this week. Somehow, the program has not merely survived the GOP’s decade-long assault. It’s actually getting stronger, thanks to some major upgrades tucked in the COVID-19 relief package that President Joe Biden signed into law earlier this month.

The new provisions should enable millions of Americans to get insurance or save money on coverage they already purchase, bolstering the health-care law in precisely the way its architects had always hoped to do. And although the measures are temporary, Biden and his Democratic Party allies have pledged to pass more legislation making the changes permanent.

The expansion measures are a remarkable achievement, all the more so because Obamacare’s very survival seemed so improbable just a few years ago, when Donald Trump won the presidency. Wiping the law off the books had become the Republicans’ defining cause, and Trump had pledged to make repeal his first priority. As the reality of his victory set in, almost everybody outside the Obama White House thought the effort would succeed, and almost everybody inside did too.

One very curious exception was Jeanne Lambrew, the daughter of a doctor and a nurse from Maine who was serving as the deputy assistant to the president for health policy. As a longtime Obama adviser, going back to the 2008 transition, Lambrew was among a handful of administration officials who had been most responsible for shaping his health-care legislation and shepherding it through Congress—and then for overseeing its implementation. Almost every other top official working on the program had long since left government service for one reason or another. Lambrew had stayed, a policy sentry unwilling to leave her post.

On that glum November 2016 day following the election, Lambrew decided to gather some junior staffers in her office and pass out beers, eventually taking an informal survey to see who thought Obama’s signature domestic-policy achievement would still be on the books in a year. Nobody did—except Lambrew.

Yes, Republicans had already voted to repeal “Obamacare” several times. But, she knew, they had never done so with real-world consequences, because Obama’s veto had always stood in the way. They’d never had to think through what it would really mean to take insurance away from a hotel housekeeper or an office security guard on Medicaid—or to tell a working mom or dad that, yes, an insurance company could deny coverage for their son’s or daughter’s congenital heart defect.

A repeal bill would likely have all of those effects. And although Republicans could try to soften the impact, every adjustment to legislation would force them to sacrifice other priorities, creating angry constituents or interest groups and, eventually, anxious lawmakers. GOP leaders wouldn’t be able to hold the different camps within their caucuses together, Lambrew believed, and the effort would fail.

All of those predictions proved correct. And that wasn’t because Lambrew was lucky or just happened to be an optimist. It was because she knew firsthand what most of the Republicans didn’t: Passing big pieces of legislation is a lot harder than it looks.

It demands unglamorous, grinding work to figure out the precise contours of rules, spending, and revenue necessary to accomplish your goal. It requires methodical building of alliances, endless negotiations among hostile factions, and making painful compromises on cherished ideals. Most of all, it requires seriousness of purpose—a deep belief that you are working toward some kind of better world—in order to sustain those efforts when the task seems hopeless.

Democrats had that sense of mission and went through all of those exercises because they’d spent nearly a century crusading for universal coverage. It was a big reason they were able to pass their once-in-a-generation health-care legislation. Republicans didn’t undertake the same sorts of efforts. Nor did they develop a clear sense of what they were trying to achieve, except to hack away at the welfare state and destroy Obama’s legacy. Those are big reasons their legislation failed.

Obamacare’s survival says a lot about the differences between the two parties nowadays, and not just on health care. It’s a sign of how different they have become, in temperament as much as ideology, and why one has shown that it’s capable of governing and the other has nearly forgotten how.

Democrats were so serious about health care that they began planning what eventually became the Affordable Care Act more than a decade earlier, following the collapse of Bill Clinton’s reform attempt in the 1990s. The ensuing political backlash, which saw them lose control of both the House and Senate, had left top Democrats in no mood to revisit the issue. But reform’s champions knew that another opportunity would come, because America’s sick health-care system wouldn’t heal itself, and they were determined not to make the same mistakes again.

At conferences and private dinners, on chat boards and in academic journals, officials and policy advisers obsessively analyzed what had gone wrong and why—not just in 1993 and 1994 but in the many efforts at universal coverage that had come before. They met with representatives of the health-care industry as well as employers, labor unions, and consumer advocates. Industry lobbyists had helped kill reform since Harry Truman’s day. Now they were sitting down with the champions of reform, creating a group of “strange bedfellows” committed to crafting a reform proposal they could all accept.

Out of these parallel efforts, a rough consensus on substance and strategy emerged. Democrats would put forward a plan that minimized disruption of existing insurance arrangements, in order to avoid scaring people with employer coverage, and they would seek to accommodate rather than overpower the health-care industry. The proposal would err on the side of less regulation, spending, and taxes—basically, anything that sounded like “big government”—and Democrats would work to win over at least a few Republicans, because that would probably be necessary in Congress.

Proof of concept came in 2006, in Massachusetts, when its Republican governor, Mitt Romney, teamed up with the Democratic state legislature to pass a plan that fit neatly into the new vision. It had the backing from a broad coalition, including insurers and progressive religious organizations. Ted Kennedy, the liberal icon and U.S. senator, played a key role, by helping secure changes in funding from Washington that made the plan possible. “My son said something … ‘When Kennedy and Romney support a piece of legislation, usually one of them hasn’t read it,’” Kennedy joked at the signing ceremony, standing at Romney’s side.

Kennedy’s endorsement said a lot about the psychology of Democrats at the time. No figure in American politics was more closely associated with the cause of universal health care and, over the years, he had tried repeatedly to promote plans that looked more like the universal-coverage regimes abroad, with the government providing insurance directly in “single-payer” systems that resembled what today we call “Medicare for All.” But those proposals failed to advance in Congress, and Kennedy frequently expressed regret that, in the early 1970s, negotiations over a more private sector-oriented coverage plan with then-President Richard Nixon had broken down, in part because liberals were holding out for a better deal that never materialized.

Kennedy was not alone in his belief that the champions of universal coverage would have to accept big concessions in order to pass legislation. The liberal House Democrats John Dingell, Pete Stark, and Henry Waxman, veteran crusaders for universal coverage who’d accrued vast power over their decades in Congress, were similarly willing to put up with what they considered second-, third-, and even fourth-best solutions—and they were masters of the legislative process, too. Waxman in particular was an expert at doing big things with small political openings, such as inserting seemingly minor adjustments to Medicaid into GOP legislation, expanding the program’s reach over time. “Fifty percent of the social safety net was created by Henry Waxman when no one was looking,” Tom Scully, who ran Medicare and Medicaid for the Bush administration in the early 2000s, once quipped.

Obama had a similar experience putting together health-care legislation in the Illinois state legislature—where, despite proclaiming his support for the idea of a single-payer system, he led the fight for coverage expansions and universal coverage by working with Republicans and courting downstate, more conservative voters. He also was a master of policy detail, and as president, when it was time to stitch together legislation from different House and Senate versions, he presided over meetings directly (highly unusual for a president) and got deep into the weeds of particular programs.

Obama could do this because the concept of universal coverage fit neatly within . . .

Continue reading. There’s much more.

Later in the column:

Another problem was a recognition that forging a GOP consensus on replacement would have been difficult because of internal divisions. Some Republicans wanted mainly to downsize the Affordable Care Act, others to undertake a radical transformation in ways they said would create more of an open, competitive market. Still others just wanted to get rid of Obama’s law and didn’t especially care what, if anything, took its place.

“The homework that hadn’t been successful was the work to coalesce around a single plan, a single set of specific legislative items that could be supported by most Republicans,” Price told me. “Clearly, looking at the history of this issue, this has always been difficult for us because there are so many different perspectives on what should be done and what ought to be the role of the federal government in health care.”

The incentive structure in conservative politics didn’t help, because it rewarded the ability to generate outrage rather than the ability to deliver changes in policy. Power had been shifting more and more to the party’s most extreme and incendiary voices, whose great skill was in landing appearances on Hannity, not providing for their constituents. Never was that more apparent than in 2013, when DeMint, Senator Ted Cruz of Texas, and some House conservatives pushed Republicans into shutting down the government in an attempt to “defund” the Affordable Care Act that even many conservative Republicans understood had no chance of succeeding.

The failure to grapple with the complexities of American health care and the difficult politics of enacting any kind of change didn’t really hurt Republicans until they finally got power in 2017 and, for the first time, had to back up their promises of a superior Obamacare alternative with actual policy. Their solution was to minimize public scrutiny, bypassing normal committee hearings so they could hastily write bills in the leadership offices of House Speaker Paul Ryan and, after that, Senate Majority Leader Mitch McConnell.

Written by Leisureguy

28 March 2021 at 4:52 pm

A grim view of the UK — and of the US

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Umair Haque views things through a dark lens, but he does make some good points. Rather than try to extract the essence, let me offer three of his recent columns for you to read, one after the other:

What Does it Look Like When a Society Commits Suicide? Brexit.

Can the World Resist Being Americanized?

Britain is Showing the World How Nationalism Implodes Into Fascism

I’m interested in hearing your thoughts after reading both.

If you want another, try one of these (from a search on “America failed state”).

Written by Leisureguy

17 March 2021 at 6:45 pm

First vaccine to fully immunize against malaria builds on pandemic-driven RNA tech

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Monisha Ravisetti writes in The Academic Times about some very good news indeed:

Consistently ranked as one of the leading causes of death around the world, malaria doesn’t have an eective vaccine yet. But researchers have invented a promising new blueprint for one — with properties akin to the novel RNA- based vaccine for COVID-19.

Making a vaccine for malaria is challenging because its associated parasite, Plasmodium, contains a protein that inhibits production of memory T-cells, which protect against previously encountered pathogens. If the body can’t generate these cells, a vaccine is ineective. But scientists recently tried a new approach using an RNA-based platform.

Their design circumvented the sneaky protein, allowed the body to produce the needed T-cells and completely immunized against malaria. The patent application for their novel vaccine, which hasn’t yet been tested on humans, was published by the U.S. Patent & Trademark Oce on Feb. 4.

“It’s probably the highest level of protection that has been seen in a mouse model,” said Richard Bucala, co-inventor of the new vaccine and a physician and professor at Yale School of Medicine.

The team’s breakthrough could save hundreds of thousands of lives, particularly in developing nations. In 2019 alone, there were an estimated 229 million cases of malaria and 409,000 deaths worldwide. Of those deaths, 94% were in Africa, with children being the most vulnerable.

“It aects societies and populations that have the least amount of resources and expertise to manage these infections well,” Bucala told The Academic Times. “We need new vaccines, and we need more tools.”

Novartis Pharmaceuticals and the National Institutes of Health funded the work. GlaxoSmithKline is an assignee on the patent, which if approved, will allow the company to produce the vaccine and make it available to the public.

At present, the only vaccine to prevent malaria is called RTS,S. Approved two years ago, this vaccine is the result of nearly two decades of research, but is only about 30% eective. And after four years, that gure drops to 15%.

“It doesn’t work very well,” Bucala said. “And the research studies all have the conclusion that the people who fail to mount a vaccine response, or who get reinfected, have poor memory T-cell responses.”

Along with Andrew Geall, a pharmaceutical researcher who developed the RNA platform that the duo used, Bucala found a way to prevent the unwanted protein in Plasmodium, called PMIF, from inhibiting T-cell generation.

“Our research studies indicate that . . .

Continue reading.

Written by Leisureguy

1 March 2021 at 5:18 pm

No, the Tuskegee Study Is Not the Top Reason Some Black Americans Question the COVID-19 Vaccine`

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April Dembosky reports for KQED:

As more surveys come out showing that Black Americans are more hesitant than white Americans to get the coronavirus vaccine, more journalists, politicians and health officials — from New York Gov. Andrew Cuomo to Dr. Anthony Fauci — are invoking the infamous Tuskegee syphilis study to explain why.

“It’s ‘Oh, Tuskegee, Tuskegee, Tuskegee,’ and it’s mentioned every single time,” says Karen Lincoln, a professor of social work at the University of Southern California. “We make these assumptions that it’s Tuskegee. We don’t ask people.”

When she asks the Black seniors she works with in Los Angeles about the vaccine, Tuskegee rarely comes up. People in the community are more interested in talking about contemporary racism and barriers to health care, she says, while it seems to be mainly academics and officials who are preoccupied with the history of Tuskegee.

“It’s a scapegoat,” Lincoln says. “It’s an excuse. If you continue to use it as a way of explaining why many African Americans are hesitant, it almost absolves you of having to learn more, do more, involve other people – admit that racism is actually a thing today.”

It’s the health inequities of today that Maxine Toler, 72, hears about when she talks to her friends and neighbors in LA about the vaccine. Toler is president of her city’s senior advocacy council and her neighborhood block club. She and most of the other Black seniors she talks to want the vaccine, but are having trouble getting it, she says, and that alone is sowing mistrust.

Those who don’t want the vaccine have very modern reasons for not wanting it. They tell Toler it’s because of religious beliefs, safety concerns or distrust for the former U.S. president and his relationship to science. Only a handful mention Tuskegee, she says, and when they do, they’re fuzzy on the details of what happened during the 40-year study.

“If you ask them what was it about and why do you feel like it would impact your receiving the vaccine, they can’t even tell you,” she says.

Toler remembers, and says the history is a distraction; it’s not relevant to what’s happening now.

“It’s almost the opposite of Tuskegee,” she says. “Because  . . .

Continue reading.

Written by Leisureguy

27 February 2021 at 12:16 pm

The power of capitalism: Private equity ownership is killing people at nursing homes

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The power is not so much that capitalism kills people for the sake of profits (cf. Texas power grid, pollution from industry, the requirement for government laws to keep workplaces safe (and the endless efforts of corporations to repeal or evade those laws)), but that capitalism is able to continue the practice without encountering more effective opposition.

Dylan Scott reports in Vox:

When private equity firms acquire nursing homes, patients start to die more often, according to a new working paper published by the National Bureau of Economic Research.

Private equity acquisitions of nursing homes is a pressing topic: Total private equity investment in nursing homes exploded, going from $5 billion in 2000 to more than $100 billion in 2018. Many nursing homes have long been run on a for-profit basis. But private equity firms, which generally take on debt to buy a company and then put that debt on the newly acquired company’s books, have purchased a mix of large chains and independent facilities — making it easier to isolate the specific effect of private equity acquisitions, rather than just a profit motive, on patient welfare.

Researchers from Penn, NYU, and the University of Chicago studied Medicare data that covers more than 18,000 nursing home facilities, about 1,700 of which were bought by private equity from 2000 to 2017, the sample period they studied.

Their findings are sobering.

The researchers studied patients who stayed at a skilled nursing facility after an acute episode at a hospital, looking at deaths that fell within the 90-day period after they left the nursing home. They found that going to a private equity-owned nursing home increased mortality for patients by 10 percent against the overall average.

Or to put it another way: “This estimate implies about 20,150 Medicare lives lost due to [private equity] ownership of nursing homes during our sample period,” the authors — Atul Gupta, Sabrina Howell, Constantine Yannelis, and Abhinav Gupta — wrote. That’s more than 1,000 deaths every year, on average.

What accounts for such a significant loss of life when private equity takes over a nursing home? The researchers advance a few possible explanations.

For one, they note, the increased mortality is concentrated among patients who are relatively healthier. As counterintuitive as that may sound, there may be a good reason for it: Sicker patients have more regimented treatment that will be adhered to no matter who owns the facility, whereas healthier people may be more susceptible by the changes made under private equity ownership.

Those changes include a reduction in staffing, which prior research has found is the most important factor in quality of care. Overall staffing shrinks by 1.4 percent, the study found, but more directly, private equity acquisitions lead to cuts in the number of hours that front-line nurses spend per day providing basic services to patients. Those services, such as bed turning or infection prevention, aren’t medically intensive, but they can be critical to health outcomes.

“The loss of front-line staff is most problematic for older but relatively less sick patients, who drive the mortality result,” the authors wrote.

The study also detected a 50 percent increase in the use of antipsychotic drugs for nursing home patients under private equity, which may be intended to offset the loss in nursing hours. But that introduces its own problems for patients, because antipsychotics are known to be associated with higher mortality in elderly people.

The combination of fewer nurses and more antipsychotic drugs could explain a significant portion of the disconcerting mortality effect measured by the study. Private equity firms were also found to spend more money on things not related to patient care in order to make money — such as monitoring fees to medical alert companies owned by the same firm — which drains still more resources away from patients.

“These results, along with the decline in nurse availability, suggest a systematic shift in operating costs away from patient care,” the authors concluded.

The researchers make a point in their opening to stipulate that private equity may prove successful in other industries. But, they warn, it may be dangerous in health care, where the profit motive of private firms and the welfare of patients may not be aligned:

For example, patients cannot accurately assess provider quality, they typically do not pay for services directly, and a web of government agencies act as both payers and regulators. These features weaken the natural ability of a market to align firm incentives with consumer welfare and could mean that high-powered incentives to maximize profits have detrimental implications for consumer welfare. . . .

Continue reading.

Written by Leisureguy

22 February 2021 at 1:53 pm

This town of 170,000 replaced some cops with medics and mental health workers. It’s worked for over 30 years.

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The question that immediately came to mind: Given that it worked, why has the approach not been widely replicated over that 30-year period? What are the barriers to learning? It’s a good model and a successful model, but people did not learn from it. Resistance to learning strikes me as a serious problem, one for which solutions should be found — and quickly.

Update: Resistance to change is an old problem. An example: After it was discovered that patients did much better after surgery (that is, they did not sicken and die nearly so often) when the surgeon washed his hands before performing surgery, the practice did not become common until an entire generation of surgeons of non-hand-washing surgeons had been replaced by a new generation for whom washing hands before surgery was normal. /update

Scottie Andrew reports for CNN:

Around 30 years ago, a town in Oregon retrofitted an old van, staffed it with young medics and mental health counselors and sent them out to respond to the kinds of 911 calls that wouldn’t necessarily require police intervention.

In the town of 172,000, they were the first responders for mental health crises, homelessness, substance abuse, threats of suicide — the problems for which there are no easy fixes. The problems that, in the hands of police, have often turned violent.

Today, the program, called CAHOOTS, has three vans, more than double the number of staffers and the attention of a country in crisis.

CAHOOTS is already doing what police reform advocates say is necessary to fundamentally change the US criminal justice system — pass off some responsibilities to unarmed civilians.

Cities much larger and more diverse than Eugene have asked CAHOOTS staff to help them build their own version of the program. CAHOOTS wouldn’t work everywhere, at least not in the form it exists in in Eugene.

But it’s a template for what it’s like to live in a city with limited police.

It’s centered on a holistic approach

CAHOOTS comes from White Bird Clinic, a social services center that’s operated in Eugene since the late 1960s. It was the brainchild of some counterculture activists who’d felt the hole where a community health center should be. And in 1989, after 20 years of earning the community’s trust, CAHOOTS was created.

“CAHOOTS” stands for “Crisis Assistance Helping Out On The Streets” and cheekily refers to the relationship between the community health center that started it and the Eugene Police Department.

Most of the clients White Bird assisted — unsheltered people or those with mental health issues — didn’t respond well to police. And for the many more people they hadn’t yet helped, they wanted to make their services mobile, said David Zeiss, the program’s co-founder.

“We knew that we were good at it,” he said. “And we knew it was something of value to a lot of people … we needed to be known and used by other agencies that commonly encounter crisis situation.”

It works this way: 911 dispatchers filter calls they receive — if they’re violent or criminal, they’re sent to police. If they’re within CAHOOTS’ purview, the van-bound staff will take the call. They prep what equipment they’ll need, drive to the scene and go from there.

The program started small, with a van Zeiss called a “junker,” some passionate paraprofessionals and just enough funding to staff CAHOOTS 40 hours a week.

It always paired one medic, usually a nurse or EMT, with a crisis responder trained in behavioral health. That holistic approach is core to its model.

Per self-reported data, CAHOOTS workers responded to 24,000 calls in 2019 — about 20% of total dispatches. About 150 of those required police backup.

CAHOOTS says the program saves the city about $8.5 million in public safety costs every year, plus another $14 million in ambulance trips and ER costs.

It had to overcome mutual mistrust with police

White Bird’s counterculture roots ran deep — the clinic used to fundraise at Grateful Dead concerts in the West, where volunteer medics would treat Deadheads — so the pairing between police and the clinic wasn’t an immediately fruitful one.

There was “mutual mistrust” between them, said Zeiss, who retired in 2014.

“It’s true there was a tendency to be mistrustful of the police in our agency and our culture,” he said. “It was an obstacle we had to overcome.”

And for the most part, both groups have: Eugene Police Chief Chris Skinner called theirs a “symbiotic relationship” that better serves some residents of Eugene.

“When they show up, they have better success than police officers do,” he said. “We’re wearing a uniform, a gun, a badge — it feels very demonstrative for someone in crisis.”

It seeks to overturn a disturbing statistic

And a great many people in Eugene are in crisis. . .

Continue reading. There’s much more.

Later in the article:

Most of CAHOOTS’ clients are homeless, and just under a third of them have severe mental illnesses. It’s a weight off the shoulders of police, Skinner said.

“I believe it’s time for law enforcement to quit being a catch-base for everything our community and society needs,” Skinner said. “We need to get law enforcement professionals back to doing the core mission of protecting communities and enforcing the law, and then match resources with other services like behavioral health — all those things we tend to lump on the plate of law enforcement.”

Written by Leisureguy

15 February 2021 at 1:17 pm

Two different approaches to Covid relief: Democratic and Republican

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Just as a reminder: the specific and explicit mission statement of the Federal government is stated in the Preamble to the US Constitution:

We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.

I have put the relevant phrase in boldface.

As of this morning, the number of American deaths due to Covid is 459,712. The total number of American combat deaths for all wars from 1900 to the present — 121 years, including WWII, WWI, the Korean War, the Vietnam War, the Iraq Wars, the Afghanistan War, and others — is 427,214.

And those who survive are facing grievous economic hardship 2— not the very wealthy, of course, which is the segment of the public the Republican party serves, but the great majority of the American public, who have had to struggle with the impact of the pandemic and the lockdowns needed to contain it. They need help, and the Federal government’s mission is to help them.

Written by Leisureguy

2 February 2021 at 9:42 am

A thought about the Schwarzenegger video

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After sleeping on it, I had a few thoughts on Arnold Schwarzenegger’s video that I blogged yesterday. Let me quote some of what he said:

 I was born in 1947, two years after the Second World War. Growing up, I was surrounded by broken men drinking away their guilt over their participation in the most evil regime in history.

My father would come home drunk once or twice a week, and he would scream, and hit us, and scare my mother. I didn’t hold him totally responsible because our neighbor was doing the same thing to his family, and so was the next neighbor over.

I heard it with my own ears and saw it with my own eyes. They were in physical pain from the shrapnel in their bodies and in emotional pain for what they saw or did. It all started with lies, and lies, and lies, and intolerance.

It struck me that those insights into the reasons for his father’s behavior are not the insights of Arnold had when he was a child, being abused (physically, emotionally, and psychologically). Children have little experience or knowledge, so they tend to accept that what happens to them is just the way things are — especially if the same thing is happening in the houses of neighbors.

I think Schwarzenegger’s description of the causes of his father’s behavior reflects an understanding that came much later. I strongly suspect Schwarzeneger came to see that explanation through some extended psychotherapy and counseling, probably undertaken to examine and understand his own behavior and feelings. Psychotherapy generally includes a look back at one’s childhood family environment since that influences and shapes one’s worldview and behavior strategies. A better, deeper understanding of what was really going on in the family at the time — what was causing the behavior one saw — can help a lot in untying any psychic knots causing current problems for the adult that child became.

The statements I quote above strike me as realizations that were facilitated by a good therapist — for example, the realization that his father was not “evil,” but was acting as he did because he did know how else to deal with what had happened to him and what he had done.

Obviously, I have no direct knowledge, but I’ve done some therapy myself, and that reading certainly is consistent with my experience.

Written by Leisureguy

11 January 2021 at 9:40 am

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