Later On

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Archive for the ‘Healthcare’ Category

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

Politically, the US seems to have an autoimmune disease. Example: Wisconsin health-care worker intentionally spoiled more than 500 coronavirus vaccine doses

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An autoimmune disease results when the body’s immune systems attack the body instead of protecting it. From what I see, the US seems to be suffering from a kind of autoimmune disease.  A health-care worker destroys protective vaccines — and more generally, many people attack the measures epidemiologists and public heath authorities put in place to protect them. Police regularly (and with impunity) brutalize and even kill citizens they have sworn to protect. “Conservative” (but actually radical) politicians attack and attempt to destroy election results when they don’t like what voters chose. One party (the GOP) makes it an explicit goal to prevent the other party (Democrats) from accomplishing anything, and in fact simply refuses to do its actual duty (the Merrick Garland nomination, the presidential transition process). The US seems intent on destroying itself.

Andrea Salcedo and Isaac Stanley-Becker report in the Washington Post:

An employee at a hospital outside Milwaukee deliberately spoiled more than 500 doses of coronavirus vaccine by removing 57 vials from a pharmacy refrigerator, hospital officials announced Wednesday, as local police said they were investigating the incident with the help of federal authorities.

Initiating an internal review on Monday, hospital officials said they were initially “led to believe” the incident was caused by “inadvertent human error.” The vials were removed Friday and most were discarded Saturday, with only a few still safe to administer at Aurora Medical Center in Grafton, Wis., according to an earlier statement from the health system. Each vial has enough for 10 vaccinations but can sit at room temperature for only 12 hours.

Two days later, the employee acknowledged having “intentionally removed the vaccine from refrigeration,” the system, Aurora Health Care, said in a statement late Wednesday.

The employee, who has not been identified, was fired, Aurora Health said. Its statement did not address the worker’s motive but said “appropriate authorities” were promptly notified.

Wednesday night, police in Grafton, a village of about 12,000 that lies 20 miles north of Milwaukee, said they were investigating along with the FBI and the Food and Drug Administration. In a statement, the local police department said it had learned of the incident from security services at Aurora Health Care’s corporate office in Milwaukee. The system serves eastern Wisconsin and northern Illinois, and includes 15 hospitals and more than 150 clinics, according to its website.

Leonard Peace, an FBI spokesman in Milwaukee, . . .

Continue reading. There’s more.

Later in the report:

The tampering will delay inoculation for hundreds of people, Aurora Health officials said, in a state where 3,170 new cases were reported and 40 people died Wednesday of covid-19, the disease caused by the coronavirus, according to The Washington Post’s coronavirus tracker.

“We are more than disappointed that this individual’s actions will result in a delay of more than 500 people receiving the vaccine,” the health system said in a statement.

Written by LeisureGuy

31 December 2020 at 12:31 pm

“Those of Us Who Don’t Die Are Going to Quit”: A Crush of Patients, Dwindling Supplies and the Nurse Who Lost Hope

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J. David McSwane reports in ProPublica:

Nurse Kristen Cline was working a 12-hour shift in October at the Royal C. Johnson Veterans Memorial Hospital in Sioux Falls, South Dakota, when a code blue rang through the halls. A patient in an isolation room was dying of a coronavirus that had raged for eight months across the country before it made the state the brightest red dot in a nation of hot spots.

Cline knew she needed to protect herself before entering the room, where a second COVID-19 patient was trembling under the covers, sobbing. She reached for the crinkled and dirty N95 mask she had reused for days.

In her post-death report, Cline described how the patient fell victim to a hospital in chaos. The crash cart and breathing bag that should have been in the room were missing. The patient wasn’t tethered to monitors that could have alerted nurses sooner. He had cried out for help, but the duty nurse was busy with other patients, packed two to a room meant for one.

“He died scared and alone. It didn’t have to be that way. We failed him — not the staff, we did everything we could,” she said. “The system failed him.”

The system also failed her. Since the pandemic’s early weeks, Cline had complained that the Department of Veterans Affairs, which runs the nation’s largest hospital system, wasn’t doing enough to protect its front-line health care workers. She had filed complaints about inadequate personal protective equipment with the agency’s inspector general and the Occupational Safety and Health Administration, but they had done nothing. Many months into a pandemic, they were still having to ration masks and being asked to reuse them for as many as five shifts.

From Cline’s perspective and that of other health care workers I spoke with from the VA hospital in Sioux Falls, the lack of masks was a symptom of larger failures at the agency overseeing the medical care of 9 million veterans. The hospitals lacked staff and scrounged to find gowns, medical supplies, ventilators — everything needed to battle COVID-19.

While every American hospital was stretched by the pandemic, the VA’s lack of an effective system for tracking and delivering supplies made it particularly vulnerable, according to a recent examination by the federal Government Accountability Office. When the pandemic hit, the agency relied on a few big contractors to supply everything from N95 masks to needles to isolation gowns. Those few big contractors fell victim to a global shortage of masks. And the VA had no reliable tracking system to tell officials what hospitals have, what they need or what was expired. At the Sioux Falls facility, things got so desperate, the supply chain for masks relied on a guy named Steve who gave them out one at time from a nearby warehouse, employees said.

As COVID-19 overwhelmed the antiquated system, VA leadership asked employees at more than 170 hospitals to enter inventory by hand into spreadsheets every day and did “not have insight” into how resources were being deployed, the report said. In other words, the local Best Buy or Walgreen’s had more efficient ways of managing inventory to get supplies to the right place.

The resulting scramble, which ProPublica has investigated over the past eight months, was a disorganized, poorly overseen effort to buy masks and other supplies from just about anyone who said they could deliver. Hoping to compensate for a disastrous lack of preparation, the VA awarded more than 100 contracts worth over $120 million to vendors with whom it had never done business.

The COVID-19 pandemic came at a tough moment for the agency, which was more than a year into a massive reorganization by the administration of President Donald Trump that left hundreds of jobs empty and sent the VA scrambling to hire contract positions to help with, among other things, procurement of supplies.

Kevin Lyons, an associate professor and supply chain expert at Rutgers Business School, said nothing the VA did before or during the pandemic showed it had a handle on its own purchase and delivery of supplies, let alone prepare for a global shortage. His research is exploring how the Trump administration’s purge of hundreds of VA staff members created a path to disaster.

VA Secretary Robert Wilkie had boasted about across-the-board staff cutbacks in November 2019, just weeks before the first confirmed U.S. COVID-19 case, noting that he had “relieved people as high as network directors to people at the other end of our employee chain.”

Lyons, an Air Force veteran, told me top VA officials have been able to claim all’s well — even as nurses and doctors describe continued shortages and rationing — because bureaucrats who awarded contracts did little or nothing to track how they worked out. He said the rapid-fire approval of contracts gave “the appearance that we’re doing something. But there was no connection between the nurses and the doctors who actually need it.”

“All they really care about is, you know, signing a contract, and then crossing your fingers and hoping that stuff comes,” Lyons said. “And that’s just not the way that supply chain is supposed to happen.” . .

Continue reading. There’s much more.

Written by LeisureGuy

30 December 2020 at 4:40 pm

When ‘The American Way’ Met the Coronavirus

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Bryce Covert writes in the NY Times:

The end of the year has been awkward for Gov. Andrew Cuomo. As he promotes his new, self-congratulatory book about navigating New York through its first coronavirus wave of in the spring, he is also battling a new surge of cases.

He’s not been too happy. At a news conference in late November, he lashed out at his constituents.

“I just want to make it very simple,” he said. “If you socially distanced and you wore a mask, and you were smart, none of this would be a problem. It’s all self-imposed. It’s all self-imposed. If you didn’t eat the cheesecake, you wouldn’t have a weight problem.”

His blunt rhetoric exemplifies how political leaders — in Washington and in red and blue states — are responding to the Covid-19 crisis. They’ve increasingly decided to treat the pandemic as an issue of personal responsibility — much as our country confronts other social ills, like poverty or joblessness.

Yes, it’s absolutely critical that we wear masks and continue to keep our distance. But these individual actions were never meant to be our primary or only response to the pandemic.

Instead, more than 10 months into this crisis, our government has largely failed to act. There is no national infrastructure for testing or tracing. States have been put in a bind by federal failure, but even so, many governors have dithered on taking large-scale actions to suppress the current surge.

As Governor Cuomo excoriated New Yorkers about mask-wearing, he took no responsibility for not shutting down indoor dining for weeks, well into the new spike.

“We’re putting a lot of faith in individual actions and individual collective wisdom to do the right thing,” Rachel Werner, the executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, told me, “but it’s without any leadership.”

It’s no great mystery what the government could do to control the virus. Every expert I spoke to agreed on the No. 1 priority: testing.

“The primary thing we really should have had is ubiquitous testing, and the government has just not chosen to do that,” said Ashish Jha, the dean of the School of Public Health at Brown University and an early adviser to the White House Covid task force.

States can do only so much with their limited resources to roll out a testing regime; it requires the resources and heft of the federal government. And while the year-end relief legislation provides more money for testing, it’s not nearly enough, particularly for producing and sustaining rapid testing.

Dr. Jha said that early in his time on the task force there was a lot of interest in building a robust testing system. “But it was killed by the political leadership in the White House,” he said.

Then, the Trump administration allowed financial aid to businesses and households to dry up during some of the worst months of the pandemic — and only just struck a last-minute deal to partly revive it.

The inconsistent aid had a cascading effect. Governors like Mr. Cuomo, who don’t have the budgetary ability of the federal government to extend substantial business relief, ended up in a difficult situation as the virus surged in late summer and fall. New York had to keep high-risk businesses open, it was argued, so that they could earn whatever meager revenue they could. But what is “the economy” worth if it comes at the cost of our physical well-being, our very lives?

Calling Covid restrictions “Orwellian,” Kayleigh McEnany, the White House press secretary, said on “Fox & Friends” in late November that “the American people are a freedom-loving people” who “make responsible health decisions as individuals.” That, she said, is “the American way.”

I agree with her on one point: It is the American way to champion individualism over collective obligation. In 2019, 34 million Americans officially lived below the poverty line in this country, with many millions more struggling just above it — and that number has only increased since then. We could lift every family out of poverty by sending out regular checks; other countries use taxes to fund benefits that significantly reduce their poverty rates. Poverty, then, is a policy choice.

The pandemic gave us a crystal-clear window into this. The government’s initial response kept poverty from rising. But once stimulus checks and enhanced unemployment benefits started expiring, millions of people were pushed into destitution. It took Congress months to reach a deal to send more help, and even so, the latest relief bill cut back on stimulus spending and slashed supplementary federal unemployment benefits in half.

“We’ve basically had a complete abdication of the federal response,” Gregg Gonsalves, an assistant professor in epidemiology of microbial diseases at Yale, told me when asked about the interplay between public health and economic struggles.

If we want people to take individual actions to help curb the spread of the virus, we also need to invest in their ability to do so. The government could send every household masks — a plan the Trump administration nixed early on. It could pay Americans to stay home if they feel sick, test positive or work for a business that should close for public health reasons, to avoid choosing between their health and their bills.

“If you want people to do the right thing you have to make it easy, and we’ve made it hard,” Dr. Gonsalves noted. States, too, have been told they’re on their own, with Congressional Republicans refusing to agree to the money Democrats want to send to help fill the vast hole left by the pandemic. In response, some governors seem to be prioritizing businesses over public health, handing out ineffectual curfews to restaurants and bars rather than just shutting them down.

But to help . ..

Continue reading.

The meme of the independent individual, beholding to no one, going his or her own way without no community, no responsibilities to anyone save himself, is constantly promoted in movies, in books, and in stories — think of the Serge Leone/Clint Eastwood westerns as an archetype.

Written by LeisureGuy

29 December 2020 at 12:28 pm

Dr. David Suzuki on the covid-19 vaccine

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An interesting comment posted in Facebook:

Recently the Suzuki Elders received an email asking if we knew what Dr David Suzuki thought about the Covid 19 vaccine(s). The person asked “My husband and I are debating whether or not to have the corona virus vaccine administered to our family. We wondered “What would David Suzuki do?” Here, written in his usual fulsome manner, is David Suzuki’s response. We then asked for permission to post this letter to the larger public through our Elder Facebook page and Dr Suzuki agreed.

December 10 2020

I have a couple of responses to your query about the COVID vaccine. Vaccination, like antibiotics, is one of the great innovations of medicine and the story of how it came to be is a wonderful one. You may know it, but basically smallpox has been a terrible disease that practically wiped-out Indigenous people who had not encountered it before. In the 1700s it had been reported that milkmaids contracted cowpox from milking cows. They would get lesions on their hands and arms but would recover but never contracted smallpox that was a deadly disease, killing between 20 – 60% of its victims while 1/3 of the survivors went blind and almost all had disfiguring scars from the pox. Edward Jenner deliberately infected a boy with cowpox and when he recovered, Jenner injected smallpox (something that would never be done today) and the boy was immune.

That began vaccination that has saved millions of lives and in 1980 smallpox was eradicated worldwide. It’s now extinct. Now a big push is on to do the same with polio.

So, I am a big admirer of vaccination. It involves using the body’s own mechanism of immunity by injecting an antigen, usually a coat protein of a virus or sometimes a heat killed virus itself. The body recognizes a foreign material and creates antibodies to eliminate it. So, we have inbuilt defenses that vaccination accelerates. There have been contaminants in the past resulting from the way antigens are processed chemically. After widespread use, the Salk vaccine was found to carry a live virus that was ultimately found to be harmless. And there have been trace amounts of chemicals like mercury. But the whole basis of the anti-vax movement was a report that has been proved to be bogus, yet it is repeated over and over.

The speed with which the new vaccines have been developed is astounding. After more than 40 years, there is still no vaccine for HIV. The reason it has taken so long to get approval for the new ones is that there is a very elaborate assessment process to ensure safety.

Now the Pfizer and Moderna vaccines are radically different from the traditional antigen injection. It involves injecting the gene (mRNA) specifying the coat protein (spike) and the gene gets into our cells where they produce the spike antigen and that, it turns out, is a very powerful way of getting our immune system to respond. The efficacy of this method is amazingly high. There might be some consequences that we can’t find until the treatment has gone on for years (esoteric issues like what happens to the mRNA, can it get into the nucleus of a cell and integrate into its DNA). What excites me is that this new approach could allow us to create vaccines very rapidly for any new viruses that emerge in future.

I’m sorry I’ve gone on so long. Most of medicine is about relieving symptoms when we are sick and depending on the healing capacity of the body, but vaccination is really a medical intervention that works. Would I take the new vaccine of Pfizer or Moderna? In a flash. I’m in a high-risk category and while I know I’m in the last part of my life, I don’t want to risk hurrying the end. Would I have any concerns about unexpected deleterious effect? Nothing is absolutely sure in medicine but I have no worries at all. Get it to me quick.

There is an aspect of anti-vaxxers (I know you’re not coming at it from conspiracy) that I have to rant about. A lot of folks are saying it’s their right to decide whether or not to get a shot. It’s all about freedom. The thing that bugs me is that freedom comes with responsibility otherwise it’s just license to do anything. If people resist mandated vaccination as a constitutional right, what about the right of everyone else who is sharing the same air? I hope they have a complete airtight case around them so they only breathe their own air. And they should not be allowed to use public medical facilities if they do get sick because they’ve opted out of the system by abrogating their responsibilities.

Thank you for your query. Please know I am not a medical doctor.

– – – David Suzuki

Written by LeisureGuy

28 December 2020 at 10:41 am

Congress helped with US medical fees — and reminded us of how bad it is

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Paul Waldman writes in the Washington Post:

In the 5,593 pages of the covid-19 relief and spending bill that will soon become law, there are some awful things and some wonderful things. And at least one provision is both.

It’s a provision that protects patients from “surprise medical bills,” just one of many horrors unique to the American health care system. It’s wonderful that the relief bill addresses the problem. It’s awful that it was even necessary.

Here’s how surprise medical bills work. You have an injury or an accident or some other kind of medical crisis, and since you don’t want to get hit with a huge bill, you go to the emergency room of a hospital in your network. Then a few weeks later you get a bill for hundreds, thousands or even tens of thousands of dollars, because unbeknownst to you, someone who treated you wasn’t in your network. Surprise!

Maybe it was the doctor in the ER; it could have been someone who showed up when you were unconscious, so even if you had the presence of mind to ask every person in the room “Are you in my network?” as you were bleeding all over the place, you still wouldn’t have avoided the bill.

As The Post notes, “A study this year by the Kaiser Family Foundation of millions of insurance claims found that nearly 1 in 5 emergency room visits nationwide led to at least one unexpected bill for care outside the patient’s insurance network.”

This worked out great for the health care industry, as long as it didn’t attract too much attention. Insurers could avoid some costs, and as the New York Times reports, “Some private-equity firms have turned this kind of billing into a robust business model, buying emergency room doctor groups and moving the providers out of network so they could bill larger fees.” What an inspiring story of entrepreneurial creativity.

Now the responsibility has been taken off the backs of patients. But Congress excluded ambulance rides, which are usually not in-network and cost hundreds of dollars. And the new rules won’t take effect for another year.

To repeat: It’s great that Congress addressed this problem, even if imperfectly. And it’s absolutely insane that we have a health care system that victimizes us this way in the first place.

You probably know the basic problem: America pays far more than any other country on earth for health care, yet we have tens of millions of people with no insurance at all, and our health outcomes are no better than countries that spend much less. We spend twice as much per capita as the average country in the Organization for Economic Cooperation and Development, yet we have the lowest life expectancy among those advanced countries.

Underneath that broad reality is an orgy of exploitation and victimization in ways large and small, ranging from the bill that’s merely annoying to the one that drives you into bankruptcy.

That the industry has convinced us that we can do no more than tinker around the edges of this system has to count as one of the great propaganda triumphs in history. Wendell Potter, an insurance industry whistleblower, will be happy to explain how he and others spread the lie that the Canadian health care system is a nightmare when it’s superior to ours in almost every way, to convince people that serious reform is impossible and they should be happy with what they have.

Yet if you asked someone from anywhere else in the industrialized world how their country handles surprise medical bills, they’d answer, “What now?” That’s because they don’t have them. Nor do they have “medical debt.” Or “the uninsured.” Or “networks” a provider could be in or out of. It’s just not a thing.

That’s because while there are many different health care models — Britain’s is different from Canada’s, which is different from Germany’s, which is different from Japan’s — all start from the premise that everyone deserves care they can afford. When that requires strong government to make sure prices stay reasonable and patients are protected — even if it means your orthopedist might drive a Volkswagen and not a Porsche — that’s what they use.

Our system, on the other hand, is based on the premise that health care is, at its heart, a business that should continue to generate massive profits, with some regulation that curbs its worst excesses. The result is not only that we have to pay so much for a system with so many holes, but that periodically we learn about some horrific practice like surprise billing, which continues until it gets enough attention that Congress resists industry lobbying and gets rid of it. . .

Continue reading. There’s more.

Written by LeisureGuy

22 December 2020 at 4:17 pm

Impatience: a deep cause of Western failure in handling the pandemic

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Branko Milanovic writes at Global Inequality:

 In  October 2019, Johns Hopkins University and the Economist Intelligence Unit published the  Global Epidemic Preparedness Report (Global Health Security Report). Never was a report on an important global topic better timed. And never was it more wrong.

The report argued that the best prepared countries are the following three: the US (in reality, the covid outcome, as of mid-December 2020, was almost 1000 deaths per million), UK (the same), and the Netherlands (almost 600). Vietnam was ranked No. 50 (while its current covid fatalities per million are 0.4), China was ranked 51st (covid fatalities are 3 per million), Japan was ranked 21st (20). Indonesia (deaths: 69 per million) and Italy (almost 1100 deaths per million) were ranked the same; Singapore (5 deaths per million) and Ireland (428 deaths per million) were ranked next to each other. People who were presumably most qualified to figure out how to be best prepared for a pandemic have colossally failed.

Their mistake confirms how unexpected and difficult it is to explain the debacle of Western countries (where I include not only the US and Europe, but also Russia and Latin America) in the handling of the pandemic. There was no shortage of possible explanations produced ever since the failure became obvious: incompetent governments (especially Trump), administrative confusion, “civil liberties”, initial underestimation of the danger, dependence on imports of PPE…The debate will continue for years. To use a military analogy: the covid debacle is like the French debacle in 1940. If one looks at any objective criteria (number of soldiers, quality of equipment, mobilization effort), the French defeat should have never happened. Similarly, if one looks at the objective criteria regarding covid, as the October report indeed did, the death rates in the US, Italy or UK are simply impossible to explain: neither by the number of doctors or nurses per capita, by health expenditure, by the education level of the population, by total income, by quality of hospitals…

The failure is most starkly seen when contrasted with East Asian countries which, whether democratic or authoritarian, have had outcomes that are not moderately but several orders of magnitude superior to those of Western countries. How was this possible? People have argued that it might be due to Asian countries’ prior exposure to epidemics like SARS, or Asian collectivism as opposed to Western individualism.

I would like to propose another deeper cause of the debacle. It is a soft cause. It is a speculation. It cannot be proven empirically. It has never been measured and perhaps it is impossible to measure with any degree of exactness. That explanation is impatience.

When one looks at Western countries’ reaction to the pandemic, one is struck by its stop-and-go character. Lockdown measures were imposed, often reluctantly, in the Spring when the epidemic seemed to be at the peak, just to be released as soon as there was an improvement. The improvement was perceived by the public as the end of the epidemic. The governments were happy to participate in that self-deception. Then, in the Fall, the epidemic came back with vengeance, and again the tough measures were imposed half-heartedly, under pressure, and with the (already once-chastened) hope that they could be rescinded for the holidays.

Why did not governments and the public go from the beginning for strong measures whose objective would not have been merely to “flatten the curve” but to either eradicate the virus or drive it out to such an extent, as it was done in East Asia, so that only sporadic bursts might remain? Those flare ups could be dealt again using drastic measures as in June when Beijing closed its largest open market, supplying several million people, after a few cases of covid were linked to it.

The public, and thus I think, the governments were unwilling to take the East Asian approach to the pandemic because of a culture of impatience, of desire to quickly solve all problems, to bear only very limited costs. That delusion however did not work with covid.

I think that impatience can be related to  . . .

Continue reading.

Written by LeisureGuy

16 December 2020 at 2:30 pm

The deadliest days in US history

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Today (Wednesday, December 9) more than 3,034 deaths from coronavirus were reported across the US, according to Johns Hopkins. That’s more than the death toll from 9/11. The daily death toll from Covid-19 is likely to increase as the illness progresses in those who were infected at Thanksgiving gatherings.

And the President is completely ignoring this disaster and instead is spending his time trying to overturn an election he lost, an election whose results have been certified after being checked and double-checked.

Written by LeisureGuy

9 December 2020 at 8:39 pm

Iowa shows what happens when government abandons its role in protecting public health

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I lived in Iowa City for many years, and all three of my children were born there. It once was a pretty good state. Elaine Godfrey reports in the Atlantic:

IOWA CITY, IOWA—Nick Klein knew the man wasn’t going to make it through the night. So the 31-year-old nurse at the University of Iowa ICU put on his gown, his gloves, his mask, and his face shield. He went into the patient’s room, held a phone to his ear, and tried hard not to cry while he listened to the man’s loved ones take turns saying goodbye. When they were finished, Klein put on some music, a muted melody like you might hear in an elevator. He pulled up a chair and took the man’s hand. For two hours that summer night, there were no sounds but soft piano and the gentle beep beep beep of the monitors. Klein thought about how he would feel if the person in the bed were his own father, and he squeezed his hand tighter. Around midnight, Klein watched as the man took one last, ragged breath and died.

“I still don’t know if I’ve fully processed everything that’s going on,” Klein told me the day before Thanksgiving, as we talked about what the past few weeks and months at the hospital have been like. And with COVID-19 infections skyrocketing in his state, he added, “I don’t know when I will.”

To visit Iowa right now is to travel back in time to the early days of the coronavirus pandemic in places such as New York City and Lombardy and Seattle, when the horror was fresh and the sirens never stopped. Sick people are filling up ICUs across the state. Health-care workers like Klein are being pushed to their physical and emotional limits. On the TV in my parents’ house in Burlington, hospital CEOs are begging Iowans to hunker down and please, for the love of God, wear a mask. This sense of new urgency is strange, though, because the pandemic isn’t in its early days. The virus has been raging for eight months in this country; Iowa just hasn’t been acting like it.

The story of the coronavirus in this state is one of government inaction in the name of freedom and personal responsibility. Iowa Governor Kim Reynolds has followed President Donald Trump’s lead in downplaying the virus’s seriousness. She never imposed a full stay-at-home order for the state and allowed bars and restaurants to open much earlier than in other places. She imposed a mask mandate for the first time this month—one that health-care professionals consider comically ineffectual—and has questioned the science behind wearing masks at all. Through the month of November, Iowa vacillated between 1,700 and 5,500 cases every day. This week, the state’s test-positivity rate reached 50 percent. Iowa is what happens when a government does basically nothing to stop the spread of a deadly virus.

“In a lot of ways, Iowa is serving as the control group of what not to do,” Eli Perencevich, an infectious-disease doctor at the University of Iowa Hospitals and Clinics, told me. Although cases dropped in late November—a possible result of a warm spell in Iowa—Perencevich and other public-health experts predict that the state’s lax political leadership will result in a “super peak” over the holidays, and thousands of preventable deaths in the weeks to come. “We know the storm’s coming,” Perencevich said. “You can see it on the horizon.”

Warnings from doctors like perencevich are what prompted my visit to Iowa City, a college town in eastern Iowa that serves as a sort of liberal sanctuary in a mostly red state. The city is home to the University of Iowa, and also to its public teaching hospital, which employs 7,000 people and has more adult ICU beds than most other state hospitals. I spent two days there just before Thanksgiving, interviewing doctors and nurses outside the brick walls of the hospital in the frigid November weather, standing six feet apart in the front garden or, when it rained, near a vent shooting out warm air on the building’s south side. Through the glass windows of the lobby, I watched as nurses in face shields pushed sick people around in wheelchairs. Once, I stepped inside to thaw and was startled by how quiet it was, and how the silence belied the suffering going on just a few floors above.

The first cases of the coronavirus in Iowa were recorded here in early March, when a group of infected locals returned home from an Egyptian cruise. As cases rose, Reynolds closed schools for the rest of the school year and most businesses for about two months. But by May 15, she’d allowed gyms, bars, and restaurants in all of Iowa’s 99 counties to open up again. She did not require Iowans to wear a mask in public, ignoring requests from local public-health officials and the White House Coronavirus Task Force and arguing that the state shouldn’t make that choice for its people. “The more information that we give them, then personally they can make the decision to wear a mask or not,” Reynolds said in June. She also wouldn’t require face coverings in public schools, where she ordered that students spend at least 50 percent of their instructional time in classrooms. When Iowa City and other towns began to issue their own mask requirements, Reynolds countered that they were not enforceable, undermining their authority. (The governor’s office did not respond to multiple requests for comment for this story.)

The rest of the summer and early fall brought on a mix of business closings and reopenings in counties around the state. (Complicating the picture, a data glitch at the Iowa Department of Public Health deflated case numbers in late summer.) Infections exploded in meatpacking plants, where managers were allegedly taking bets on how many workers would get sick. After students returned to schools and universities in the early fall, Iowa had the highest rate of COVID-19 infections in the country. In October, when Iowa was in the thick of community spread, Reynolds showed up, maskless and smiling, at a campaign rally for Trump at the Des Moines airport. (Her let-them-get-sick attitude toward the pandemic hasn’t been unusual among Republican governors, though there have been exceptions, including Mike DeWine of Ohio and Larry Hogan of Maryland.)

By late November, the number of new COVID-19 cases in Iowa was higher than at any other point in the pandemic, and as many as 45 Iowans were dying of the disease every 24 hours in a state of just 3 million people. Outbreaks were reported in 156 nursing homes and assisted-living facilities in Iowa, and the virus ran rampant in the state’s prisons.

Doctors have been warning for weeks that the state’s health-care system is close to its breaking point. The University of Iowa hospital reached a peak of 37 COVID-19 inpatients in April, but by Thanksgiving, it had 90. That number may not seem overwhelming until you consider that COVID-19 patients require dozens of staff and that many spend weeks or months in hospital care. To meet the demand, administrators have had to reschedule hundreds of nonessential surgeries and converted multiple wards into COVID-19 units. Doctors told me that they’re already short on ICU beds, and are having to decide which critically ill patients receive one. There are not enough specialists to oversee common life-support techniques, such as extracorporeal membrane oxygenation, or ECMO, for people with severe cases of COVID-19.

And the University of Iowa hospital is actually in a better position than many others in the state. Smaller institutions, which have fewer specialized doctors and fewer staff overall, are being overwhelmed across Iowa, and many face bankruptcy, in part because they’ve been forced to cancel elective procedures.

Worst of all, health-care workers are sapped. They are used to death. But patients don’t usually die at this pace. They don’t usually die in this way, with tubes sticking out of their throats and sucking machines clearing the mucus from their lungs. They don’t usually die all alone.

Joe English, a 37-year-old respiratory therapist, spends every day traveling between hospital units, hooking up seriously ill COVID-19 patients to ventilators or ECMO machines. When there’s nothing left to be done, English is the one who turns off those machines; he’s done so at least 50 times in the past few months. “What I’m seeing [among health-care workers] is just frustration, desperation,” English told me. “People have been acting like we’ve been fighting a war for months.”

There is a name for this feeling, says Kevin Doerschug, the director of the hospital’s medical ICU: moral distress, or the sense of loss and helplessness associated with health-care workers navigating limitations in space, treatment, and personnel. Just a few weeks ago, a man in his 30s with no medical problems arrived in Doerschug’s unit with a severe case of COVID-19. After a week on a ventilator, the man’s health had greatly improved. Nurses removed his breathing tube, and his vitals were stable. But just a few hours later, the man was dead. “Our whole team just sat down on the ground and cried,” Doerschug told me outside the hospital, his voice muffled by his mask and the sound of the heating vent. Trauma like that compounds when a hospital fills up with critically ill patients. “The sheer enormity of it—it’s just endless,” Doerschug said.

What makes all of this suffering and death exponentially more painful is the simple fact that much of it was preventable. A recent New York Times analysis clearly showed that states with the tightest COVID-19 restrictions have managed to keep cases per capita lower than states with few restrictions. Reynolds is in an admittedly complicated situation. She, like other governors, is facing enormous pressure to protect people’s livelihoods as well as their health. But a mask mandate is free. And failing to control the virus is, unsurprisingly, very bad for business. “We want to take care of people … It shouldn’t be this hard, and that makes us mad,” Dana Jones, a nurse practitioner in Iowa City, told me. “There are people to blame, and it’s not the patients.”

When Reynolds finally announced a spate of new COVID-19 regulations on November 17, the rules limited indoor gatherings to 25 people, and required that Iowans wear masks inside public places only under a very specific set of conditions. Four of the doctors and nurses I interviewed laughed—actually laughed—when I asked what they thought of the new regulations. The policies will do basically nothing to prevent the spread of the virus, they told me.

State lawmakers’ response to Reynolds’s handling of the pandemic breaks down along partisan lines. “She’s done a good job balancing people’s constitutional rights with a few restrictions that have been commonsense,” Representative Dave Deyoe, a Republican from central Iowa, told me, arguing that tighter restrictions in more liberal states haven’t led to lower death rates. Although this is a common argument among Iowa Republicans, it’s an unfair one. Many Northeast and West Coast states have had more total deaths because they were badly hit by the virus early in the pandemic, before strong measures were put in place. In the past seven days, Iowa’s death rate has been at least twice as high as that of New York, New Jersey, and California.

Democrats in Iowa believe that Reynolds’s inaction has always been about politics. Early on, . . .

Continue reading.

Written by LeisureGuy

3 December 2020 at 6:11 pm

Kevin Drum’s political wishlist

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Drum’s list is much like mine. He writes:

For no particular reason, it occurred to me the other day that one of the drawbacks of blogging is that readers never get a full sense of how I feel about various topics in the progressive firmament. If you’re a longtime reader you can probably put it all together from posts here and there, but not everyone is a longtime reader.

So here’s a super brief rundown. I’ve limited this list to domestic policies that are primarily addressed at the federal level. There are no explanations here; this list solely represents what I would do if I could wave a magic wand and get whatever I wanted without stoking a revolution. In real life, of course, I believe that change happens only incrementally and I’m always open to compromises that get me part of the way to my goals. But these are the goals.

If there’s anything I’ve left out, it’s not because I’m holding out on you. I just forgot. Feel free to ask about things in comments, but please make your asks fairly specific.

  • Climate change: Spend a truly vast amount of money on buildout and R&D. This should be funded partly by a large and growing upsteam tax on carbon emissions.
  • Social Security: Increase benefits for the bottom third by about 30 percent.
  • Health care: True national health care, including long-term nursing care, on something like the French model. Fund it with a combination of taxes on business, and modestly progressive income taxes.
  • Minimum wage: Raise the federal minimum wage to $12-13 and index it to inflation. States and cities, as always, would remain free to legislate higher minimums.
  • Forgiving student debt: Pretty regressive, pretty poor stimulus, and not well handled at the federal level anyway.
  • Prison sentencing: Reduce minimum sentences substantially. Encourage states to do the same.
  • Labor: I’m in favor of practically anything that revives private-sector unions.
  • Abortion: No regulation whatsoever, aside from normal medical regs that govern all outpatient procedures.
  • Guns: Ban everything except single-shot firearms.
  • National ID: Everyone gets a free national ID card.
  • Voting: Voting should be a right, similar to freedom of speech, that can be restricted only under . . .

Continue reading.

Written by LeisureGuy

1 December 2020 at 2:47 pm

Denying reality while dying: Delusion’s grip is strong when it’s anchored in the ego

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Jodi Doering has a powerful thread on Twitter. Read the whole thread. It begins with this tweet:

Written by LeisureGuy

16 November 2020 at 1:40 pm

Ron Klain, back in January: Coronavirus Is Coming—And Trump Isn’t Ready

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President-Elect Joe Biden has picked Ron Klain as his chief of staff. Klain wrote this in the Atlantic in January:

We all knew the moment would come. It could have been over Iran or North Korea, a hurricane or an earthquake. But it may be the new coronavirus out of China that tests whether President Donald Trump can govern in a crisis—and there is ample reason to be uneasily skeptical.

The U.S. government has the tools, talent, and team to help fight the coronavirus abroad and minimize its impact at home. But the combination of Trump’s paranoia toward experienced government officials (who lack “loyalty” to him), inattention to detail, opinionated rejection of science and evidence, and isolationist instincts may prove toxic when it comes to managing a global-health security challenge. To succeed, Trump will have to trust the kind of government experts he has disdained to date, set aside his own terrible instincts, lead from the White House, and work closely with foreign leaders and global institutions—all things he has failed to do in his first 1,200 days in office.

We do not know yet how grave a threat the new coronavirus will turn out to be. On the one hand, scientists have quickly sequenced the virus and are working on a vaccine. China has imposed draconian quarantines to slow the virus’s spread, and is rapidly building massive new hospitals to treat its victims. To date, the U.S. has seen only a handful of cases, all of them the product of travel to China, not transmission here. These are causes for concern, but not overwrought fear.

But on the other hand, there are some worrisome developments. Models suggest that the cases in China may number in the hundreds of thousands—many times what the government has reported. Perhaps a million or more people left Wuhan before the quarantines, and could be spreading the virus widely. Other countries are reporting cases of the virus among people who were not in China; there are even reports that individuals may be infectious before the onset of symptoms (a substantial complication to traditional public-health screening). And the economic impact of a massive epidemic in China on the global economy is difficult to predict.

What will Trump do about it? His track record offers us two data points, one horrible and one merely disappointing.

Trump briefly withdrew from politics after his “birther” campaign against President Barack Obama was discredited, but his next big public splash was a virulent, xenophobic, fearmongering outburst over the West African Ebola epidemic of 2014. Trump’s numerous tweets—calling Obama a “dope” and “incompetent” for his handling of the epidemic—were both wrongheaded and consequential: One study found that Trump’s tweets were the single largest factor in panicking the American people in the fall of 2014. How paranoid and cruel was Trump? He blasted Obama for evacuating an American missionary back to the United States when that doctor contracted Ebola while fighting the disease in Africa. Fortunately, Obama ignored Trump’s protests, and Kent Brantley was successfully treated in the U.S.; he continues doing good works today.

Obama’s strategy for combatting Ebola in West Africa—interventionist, aggressive, science-based—made a huge contribution to a global response that saved hundreds of thousands of lives, and protected the U.S. from an outbreak. Tom Friedman wrote that it was perhaps Obama’s “most significant foreign policy achievement, for which he got little credit precisely because it worked … [showing] that without America as quarterback, important things that save lives … often don’t happen.”

As president, Trump’s own handling of the second-worst Ebola outbreak in history—ongoing in Congo—has been more mixed. Regrettably, after four U.S. soldiers were killed in Niger in 2017, Trump imposed an isolationist edict that no U.S. personnel are allowed to be in harm’s way in fighting the disease. Top American experts who were in and near the disease “hot zone” in Congo have been withdrawn. Moreover, while the U.S. has sent aid, it has provided only a fraction of the assistance offered in past global-health emergencies, a step back from the leadership demonstrated by prior Democratic and Republican administrations. Within these constraints, however, Trump has allowed the experts at the U.S. Agency for International Development and the Centers for Disease Control to provide assistance; most surprisingly, Trump even allowed the medical evacuation of a possible Ebola case to the U.S. for treatment.

The record on the Congo response is uneven: As long as Ebola in Congo is not in the news, the White House allows the bureaucracy to do its job, albeit within a limited range of action and with less than robust U.S. participation. But escalation of the coronavirus epidemic, and the elevated level of public attention, may lead Trump to depart from his usual indifference to the functioning of government and choose to assume personal leadership of his administration’s response.

Some of the world’s leading infectious-disease experts continue to serve in the administration, led by the incomparable Tony Fauci at the National Institutes of Health, and the level-headed Anne Schuchat at the CDC. These two, along with other leaders at key science agencies (and scores of men and women working for them), have decades of experience serving under presidents of both parties, and are among the world’s best at what they do.

But Trump’s war on government has decimated crucial functions in other key agencies. Smart and effective border screening will be a key tool in the response; there is scarcely a single competent or experienced leader left at the Department of Homeland Security. While USAID is in solid hands under Administrator Mark Green, it is stuck inside Mike Pompeo’s State Department, which has been purged of the many skilled administrators who play a role in facilitating foreign-disaster response. Trump’s poor choices for many ambassadorial posts, and harsh treatment of the Foreign Service, may create holes in our on-the-scene leadership as the disease spreads: During the West African Ebola epidemic, career Foreign Service ambassadors were important players in the response.

The biggest gap, of course, is at the White House itself.

At the end of the West African Ebola epidemic in 2015, President Obama accepted my recommendation to set up a permanent directorate at the National Security Council to coordinate government-wide pandemic preparedness and response. For the first year of his presidency, Trump kept that structure, and put the widely respected Admiral Tim Ziemer, a veteran of the George W. Bush administration, in charge of the unit. But in July 2018, John Bolton took over the NSC, disbanded the unit, and relegated Ziemer to a staff job at the State Department. The administration described that as a move to “streamline” the NSC, while critics charged that Bolton was too focused on hard-power threats.

To date, the Trump administration has resisted reversing this decision—either permanently, or on an ad hoc basis for the coronavirus response. Standing up a unit at NSC would require bringing in career staff to work there, and Trump’s paranoia about having such government veterans in the White House weighs against the move. But perhaps just as important, greater White House involvement in managing the response to pandemics would likely mean greater personal involvement by Trump. And in that regard, senior officials in government agencies may have a view of presidential engagement not unlike Fiddler on the Roof’s prayer for the czar: “May the Lord bless and keep him … far away from us.”

In his press conference on Tuesday,  . . .

Continue reading.

Written by LeisureGuy

12 November 2020 at 1:12 pm

Conservatives backed the ideas behind Obamacare, so how did they come to hate it?

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Christopher Robertson, Professor of Law, Boston University, and Wendy Netter Epstein, Professor of Law and Faculty Director of the Jaharis Health Law Institute, DePaul University, write in The Conversation:

The Affordable Care Act is back before the U.S. Supreme Court in the latest of dozens of attacks against the law by conservatives fighting what they now perceive to be a government takeover of health care.

Yet, in an odd twist of history, it was Newt Gingrich, one of the most conservative speakers of the House, who laid out the blueprint for the Affordable Care Act as early as 1993. In an interview on “Meet the Press,” Gingrich argued for individuals’ being “required to have health insurance” as a matter of social responsibility.

Over time, he drew on ideas from the conservative Heritage Foundation and Milton Friedman to suggest “that means finding ways through tax credits and through vouchers so that every American can buy insurance, including, I think, a requirement that if you’re above a certain level of income, you have to either have insurance or post a bond.”

If Gingrich laid the blueprint for the ACA, how did the law become a punching bag for right-wing politicians and their appointees in the courts? As experts (Robertson | Epstein) on health law and policy, we will be watching the Supreme Court’s oral arguments on the ACA. If the court strikes it down, we expect that it will force Congress to someday enact a single-payer system, which will be legally invincible. Let us explain.

A bipartisan consensus

In 1986 President Ronald Reagan signed a law called EMTALA – the Emergency Treatment and Active Labor Act – recognizing that uninsured Americans would get sick and would show up at emergency rooms needing health care.
Reagan and his Republican Senate majority, led by Bob Dole, agreed with their Democratic colleagues in the House that, as a society, we simply cannot turn away fellow Americans to die on the streets. So, to this day, EMTALA requires hospitals to provide emergency health care. But it provides no funding mechanism to do it. Hospitals can try to shift those costs to other payers, or try to go after the patients themselves, who often have no alternative but bankruptcy.

With EMTALA in place, conservatives began to embrace the goal of getting everyone into the insurance system. Conservatives viewed having insurance as a matter of personal responsibility, to avoid passing health care costs on to others.

Conservatives also turned to the Gingrich model, because they long feared the alternative of a single-payer system. What we now call Medicare for All would leave out insurance companies and instead rely on the federal government as the single insurer. Indeed, Reagan got his start in national politics during the 1960s campaigning against the enactment of Medicare. He claimed it would lead to a socialist dictatorship that would “invade every area of freedom we have known in this country.” So, with single-payer off the table, an individual mandate for private health insurance was the conservative solution.

The debate over preexisting conditions

Today, our society has made another moral commitment that insurers cannot turn away the sick. But the market cannot let people wait until they are sick to buy insurance. That would be like buying homeowners insurance when your house is already on fire. If insurers insured only sick people, premiums would have to be exorbitantly high. Rather, insurers must be able to spread the risk of any of us getting sick over a large base of healthy subscribers.

Accordingly, when Republican Mitt Romney was the governor of Massachusetts, he spearheaded a landmark reform that protected patients with preexisting conditions. He also recognized the need to pay for it. Through bipartisan legislative debate and bargaining emerged the individual mandate – a way to encourage people to buy insurance, even when they were healthy.

When Barack Obama was elected president, he initially resisted the idea of an individual mandate. But he lacked the votes for a single-payer approach. In the ACA, he settled on a weak mandate with a low monetary penalty for failure to comply, an expansion of Medicaid through the states, and subsidies so everyone could afford coverage on the private market, just as Newt Gingrich proposed so many years ago.

The right wing pivots

One might have imagined a round of conservative applause, but instead Republicans pivoted to attack mode. Even Gingrich started arguing that the individual mandate was “clearly unconstitutional.” The law ultimately passed with no Republican votes.

The first challenge to the ACA that reached the Supreme Court was in 2012, NFIB v. Sebelius. The issues were the constitutionality of the mandate that people buy insurance or face a penalty, and congressional expansion of state Medicaid coverage for poorer patients.

On the first point, conservative Supreme Court justices decided that Congress lacked the power under the Constitution’s commerce clause to enact the mandate. Although conservative justices normally look to the “original intent” of the founders, the five conservatives ignored the fact that in 1790 and 1798, George Washington and John Adams each signed laws requiring the purchase of health insurance by ship owners and sailors.

Still, Chief Justice Roberts saved  . . .

Continue reading. There’s much more.

Written by LeisureGuy

10 November 2020 at 2:37 pm

Why do Republicans hate people who need healthcare?

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Note the names listed in the video. These are the people who want to take healthcare away from millions of Americans, and who have worked hard to do that.

Written by LeisureGuy

24 October 2020 at 4:53 pm

Superspreader-in-Chief: The timeline of Trump’s deadly coronavirus denial

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This timeline by Dave Gilson, Laura Thompson, Clara Jeffrey, Nina Liss-Schultz, Kiera Butler, and Will Peischel in Mother Jones is well worth reading and pondering. It begins:

On January 22, two days after the first confirmed case of COVID-19 in the United States, President Donald Trump breezily declared, “We have it totally under control.” Since then, we have witnessed the devastating consequences of his attempt to spin, bluster, and blame his way out of a national emergency that will go down as the greatest scandal of a scandal-plagued presidency. On the eve of the most important election of our lifetimes, more than 200,000 Americans have died, more than 7 million have been infected, and the numbers in many states are still getting worse. And now, an outbreak centered around Trump and his White House has further exposed just how careless and callous his response to the virus has been. This timeline details how we got here.

Read from the top, filter the entries, or jump to the past two weeks. Check back for regular updates. . .

Continue reading to see the timeline. It begins January 20, 2020, with this entry:

The Centers for Disease Control confirms the first COVID-19 case in the United States, a Washington man who returned from Wuhan, China, five days earlier. • Two days earlier, President Donald Trump received his first major briefing on the virus from Health and Human Services Secretary Alex Azar. According to the Washington Post, the president asked Azar when a ban on flavored vaping products would be lifted.

Written by LeisureGuy

9 October 2020 at 11:56 am

An editorial from the New England Journal of Medicine: Dying in a Leadership Vacuum

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The editors of the New England Journal of Medicine write:

Covid-19 has created a crisis throughout the world. This crisis has produced a test of leadership. With no good options to combat a novel pathogen, countries were forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy.

The magnitude of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering,1 the United States leads the world in Covid-19 cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000. Covid-19 is an overwhelming challenge, and many factors contribute to its severity. But the one we can control is how we behave. And in the United States we have consistently behaved poorly.

We know that we could have done better. China, faced with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, as compared with more than 500 per million in the United States. Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks. And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a prepandemic level. In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude.

Why has the United States handled this pandemic so badly? We have failed at almost every step. We had ample warning, but when the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be way behind the curve in testing. While the absolute numbers of tests have increased substantially, the more useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have.2 Moreover, a lack of emphasis on developing capacity has meant that U.S. test results are often long delayed, rendering the results useless for disease control.

Although we tend to focus on technology, most of the interventions that have large effects are not complicated. The United States instituted quarantine and isolation measures late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. Our rules on social distancing have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had been achieved. And in much of the country, people simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective infection control measures. The government has appropriately invested heavily in vaccine development, but its rhetoric has politicized the development process and led to growing public distrust.

The United States came into this crisis with enormous advantages. Along with tremendous manufacturing capacity, we have a biomedical research system that is the envy of the world. We have enormous expertise in public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much of that national expertise resides in government institutions. Yet our leaders have largely chosen to ignore and even denigrate experts.

The response of our nation’s leaders has been consistently inadequate. The federal government has largely abandoned disease control to the states. Governors have varied in their responses, not so much by party as by competence. But whatever their competence, governors do not have the tools that Washington controls. Instead of using those tools, the federal government has undermined them. The Centers for Disease Control and Prevention, which was the world’s leading disease response organization, has been eviscerated and has suffered dramatic testing and policy failures. The National Institutes of Health have played a key role in vaccine development but have been excluded from much crucial government decision making. And the Food and Drug Administration has been shamefully politicized,3 appearing to respond to pressure from the administration rather than scientific evidence. Our current leaders have undercut trust in science and in government,4 causing damage that will certainly outlast them. Instead of relying on expertise, the administration has turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.

Let’s be clear about the cost of not taking even simple measures. An outbreak that has . . .

Continue reading. The costs they cite are real — and were to a great extent avoidable.

Written by LeisureGuy

7 October 2020 at 5:32 pm

The Positive Share of COVID-19 Tests Has Passed 5 Percent in the United States

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The chart above is from a post by Kevin Drum that’s definitely worth reading.

Written by LeisureGuy

6 October 2020 at 4:48 pm

Health Care: The Best and the Rest

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In the NY Review of Books David Oshensky reviews a book that takes a look at the healthcare systems of various countries.

Which Country Has the World’s Best Health Care?

by Ezekiel J. Emanuel
PublicAffairs, 453 pp., $30.00

“Bow your heads, folks, conservatism has hit America,” The New Republic lamented following the 1946 elections. “All the rest of the world is moving Left, America is moving Right.” Having dominated both houses of Congress throughout President Franklin Roosevelt’s three-plus terms in office (1933–1945), Democrats lost their majorities in a blowout. Some blamed it on the death of FDR, others on the emerging Soviet threat or the bumpy return to civilian life following World War II. The incoming Republican “Class of ’46” would leave a deep mark on history; its members, including California’s Richard Nixon and Wisconsin’s Joseph McCarthy, were determined to root out Reds in government and rein in the social programs of the New Deal.

One issue in particular became fodder for the Republican assault. In 1945 President Harry Truman had delivered a special message to Congress laying out a plan for national health insurance—an idea the pragmatic and immensely popular FDR had carefully skirted. As an artillery officer in World War I, Truman had been troubled by the poor health of his recruits, and as chairman of a select Senate committee to investigate the defense program during World War II, his worries had grown. More than five million draftees had been rejected as “unfit for military service,” not counting the 1.5 million discharged for medical reasons following their induction. For Truman, these numbers went beyond military preparedness; they spoke to the glaring inequities of American life. “People with low or moderate incomes do not get the same medical attention as those with high incomes,” he said. “The poor have more sickness, but they get less medical care.”

Truman proposed federal grants for hospital construction and medical research. He insisted, controversially, not only that the nation had too few doctors, but that the ones it did have were clustered in the wrong places. And he addressed the “principal reason” that forced so many Americans to forgo vital medical care: “They cannot afford to pay for it.”

The facts seemed to bear him out. Close to half the counties in the United States lacked a general hospital. Government estimates showed that about $11 million was spent annually on “new treatments and cures for disease,” as opposed to $275 million for “industrial research.” Though the nation claimed to have approximately one physician per 1,500 people, the ratio in poor and rural counties regularly dipped below one per 3,000, the so-called danger line. On average, studies showed, two thirds of the population lacked the means to meet a sustained health crisis.

The concept of government health insurance was not entirely new. A few states had toyed with instituting it, but their intent was to replace wages lost to illness or injury, not to pay the cost of medical care. Truman’s plan called for universal health insurance—unlike the Social Security Act of 1935, which excluded more than 40 percent of the nation’s labor force, mostly agricultural and domestic workers. Funded by a federal payroll tax, the plan offered full medical and dental coverage—office visits, hospitalization, tests, procedures, drugs—to all wage and salary earners and their dependents. (“Needy persons and other groups” were promised equal coverage “paid for them by public agencies.”)

People would be free to choose their own doctors, who in turn could participate fully, partly, or not at all in the plan. Private health insurance programs would continue to operate, with policyholders required to contribute to the federal system as well—a stipulation the president compared to a taxpayer choosing to send a child to private school. “What I am recommending is not socialized medicine,” Truman insisted. “Socialized medicine means that all doctors work as employees of government. The American people want no such system. No such system is here proposed.”

It did him no good. At the first Senate hearing on the proposal, Ohio’s Robert A. Taft, a perennial presidential candidate known to his admirers as “Mr. Republican,” denounced it as “the most socialistic measure that this Congress has ever had before it.” A shouting match ensued, with one Democrat warning Taft to “shut your mouth up and get out of here.” Taft retreated, but not before vowing to kill any part of the plan that reached the Senate floor.

Taft was not without allies. A predictable coalition soon emerged, backed by pharmaceutical and insurance companies but directed by the American Medical Association, which levied a $25 political assessment on its members to finance the effort. At its crudest, the campaign pushed a kind of medical McCarthyism by accusing the White House of inventing ways to turn a brave, risk-taking people into a bunch of “dainty, steam-heated, rubber-tired, beauty-rested, effeminized, pampered sissies”—easy pickings for the nation’s godless cold war foe. “UNAMERICAN SYSTEM BLUEPRINTED IN THE KREMLIN HEADQUARTERS OF THE COMMUNIST INTERNATIONALE,” read one AMA missive describing the origins of Truman’s plan.

Precious freedoms were at stake, Americans were told: when the president claimed that medical choices would remain in private hands, he was lying; federal health insurance meant government control; decisions once made by doctors and patients would become the province of faceless bureaucrats; quality would suffer and privacy would vanish. Skeptics were reminded of Lenin’s alleged remark—likely invented by an opponent of Truman’s heath plan—that socialized medicine represented “the keystone to the arch of the socialized state.”

The economist Milton Friedman once described the AMA as “perhaps the strongest trade union in the United States.” It influenced medical school curriculums, limited the number of graduates, and policed the rules for certification and practice. For the AMA, Truman’s proposal not only challenged the profession’s autonomy, it also made doctors look as if they could not be trusted to place the country’s needs above their own. As a result, the AMA ran a simultaneous campaign congratulating its members for making Americans the healthiest people in the world. The existing system worked, it claimed, because so many physicians followed the golden rule, charging patients on a sliding scale that turned almost no one away. If the patient was wealthy, the fee went up; others paid less, or nothing at all. What was better in a free society: the intrusive reach of the state or the big-hearted efforts of the medical community?

Given the stakes, the smearing of national health insurance was not unexpected. What did come as a surprise, however, was the palpable lack of support for the idea. For many Americans, the return to prosperity following World War II made Truman’s proposal seem less urgent than the sweeping initiatives that had ended the bread lines and joblessness of the Great Depression. Even the Democratic Party’s prime constituency—organized labor—showed limited interest. During the war, to compensate workers for the income lost to wage controls, Congress had passed a law that exempted health care benefits from federal taxation. Designed as a temporary measure, it proved so popular that it became a permanent part of the tax code.

Unions loved the idea of companies providing health insurance in lieu of taxable wages. It appeared to offer the average American the sort of write-off reserved for the privileged classes, and indeed it did. Current studies show that union members are far more likely to have health insurance and paid sick leave than nonunion workers in the same industry. Employer-sponsored health insurance now amounts to the nation’s largest single tax exemption, costing the government more than $250 billion annually in lost revenue.

At about the same time, popular insurance plans like Blue Cross emerged to offer cheap, prepaid hospital care, followed by Blue Shield for doctors’ visits. In 1939 fewer than six million people carried such insurance; by 1950, that number had increased fivefold. In the years after Truman’s plan died in Congress, the government filled some of the egregious gaps in the private insurance system with expensive programs for the poor, the elderly, and others in high-risk categories, thereby cementing America’s outlier status as the world’s only advanced industrial nation without universal health care.

What the United States does have in common with several of these nations, says Ezekiel Emanuel in his valuable Which Country Has the World’s Best Health Care?, is that its health care struggles have not been unlike theirs, despite the markedly different outcomes. The United Kingdom, for example, decided in favor of national health care at the very moment that Truman’s plan was being shredded. And the main adversary turned out to be the British Medical Association, which used the hated specter of Nazism (as opposed to Bolshevism) to demonize the proposed National Health Service as a Hitlerian menace run by a “medical fuhrer.”

The NHS succeeded because . . .

Continue reading. There’s more.

Later in the column:

The UK and the US are the bookends of the eleven health care systems that Emanuel has studied—not so much to determine which one is “best” or “worst,” as which one most closely resembles a socialized system. (The others are Australia, Canada, China, France, Germany, the Netherlands, Norway, Switzerland, and Taiwan.) The UK excels in universal coverage, simplicity of payment, and protection of low-income groups. While the NHS remains quite popular, it also is seriously underfunded: the UK ranks dead last in both health care spending per capita ($3,900) and health care spending as a percentage of gross domestic product (9.6) among the six European nations under examination. The most common complaints, not surprisingly, concern staff shortages and wait times for primary care appointments, elective surgeries, and even cancer treatments, which can stretch for months. “The public does not want to replace the system with an alternative,” writes Emanuel. “All the public wants is a fully operational NHS.”

By contrast, the US health care system—if one can call it that—excludes more people, provides thinner coverage, and is far less affordable. It combines socialized medicine practiced by the Department of Veterans Affairs, four-part federal Medicare (A, B, C, D) for the elderly and disabled, state-by-state Medicaid for the poor, health coverage provided by employers, and policies bought privately through an insurance agent or an Affordable Care Act exchange—all of which still leave 10 percent of the population unprotected. Among the biggest problems, says Emanuel, is that Americans are baffled by their health care: uncertain of the benefits they’re entitled to, the providers that will accept their insurance, the amount of their deductibles and copays, and the accuracy of the bills they receive. It is a system, moreover, in which people are regularly switching insurers out of choice or necessity—a process known as churning. “The United States basically has every type of health financing ever invented,” Ezekiel adds. “This is preposterous.”

And extremely expensive. America dwarfs other nations in both health care spending per capita ($10,700) and health care spending as a percentage of GDP (17.9). Hospital stays, doctor services, prescription drugs, medical devices, laboratory testing—the excesses are legion. Childbirth costs on average about $4,000 in Western Europe, where midwives are used extensively and charges are bundled together, but close to $30,000 in the US, where the patient is billed separately by specialists—radiologists, pathologists, anesthesiologists—whom she likely never meets, and where charges pile up item by item in what one recent study called a “wasteful overuse of drugs and technologies.” There is no evidence that such extravagance makes for better health care outcomes. The rates of maternal and infant death in the US are higher than in other industrialized nations, partly because the poor, minorities, and children are disproportionately uninsured.

For head-spinning price disparities, however, nothing compares to . . .

Written by LeisureGuy

5 October 2020 at 1:56 pm

The dark side of capitalism (aka greed): Investors Extracted $400 Million From a Hospital Chain That Sometimes Couldn’t Pay for Medical Supplies or Gas for Ambulances

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Peter Elkind with Doris Burke report in ProPublica:

In the decade since Leonard Green & Partners, a private equity firm based in Los Angeles, bought control of a hospital company named Prospect Medical Holdings for $205 million, the owners have done handsomely.

Leonard Green extracted $400 million in dividends and fees for itself and investors in its fund — not from profits, but by loading up the company with debt. Prospect CEO Sam Lee, who owns about 20% of the chain, made $128 million while expanding the company from five hospitals in California to 17 across the country. A second executive with an ownership stake took home $94 million.

The deal hasn’t worked out quite as well for Prospect’s patients, many of whom have low incomes. (The company says it receives 80% of its revenues from Medicare and Medicaid reimbursements.) At the company’s flagship Los Angeles hospital, persistent elevator breakdowns sometimes require emergency room nurses to wheel patients on gurneys across a public street as a security guard attempts to halt traffic. Paramedics for Prospect’s hospital near Philadelphia told ProPublica that they’ve repeatedly gone to fuel up their ambulances only to come away empty at the pump: Their hospital-supplied gas cards were rejected because Prospect hadn’t paid its bill. A similar penury afflicts medical supplies. “Say we need 4×4 sponges, dressing for a patient, IV fluids,” said Leslie Heygood, a veteran registered nurse at one of Prospect’s Pennsylvania hospitals, “we might not have it on the shelf because it’s on ‘credit hold’ because they haven’t paid their creditors.”

In March, Prospect’s New Jersey hospital made national headlines as the chief workplace of the first U.S. emergency room doctor to die of COVID-19. Before his death, the physician told a friend he’d become sick after being forced to reuse a single mask for four days. At a Prospect hospital in Rhode Island, a locked ward for elderly psychiatric patients had to be evacuated and sanitized after poor infection control spread COVID-19 to 19 of its 21 residents; six of them died. The virus sickened a half-dozen members of the hospital’s housekeeping staff, which had been given limited personal protective equipment. The head of the department died.

The litany goes on. Various Prospect facilities in California have had bedbugs in patient rooms, rampant water leaks from the ceilings and what one hospital manager acknowledged to a state inspector “looks like feces” on the wall. A company consultant in one of its Rhode Island hospitals discovered dirty, corroded and cracked surgical instruments in the operating room.

These aren’t mere anecdotes or anomalies. All but one of Prospect’s hospitals rank below average in the federal government’s annual quality-of-care assessments, with just one or two stars out of five, placing them in the bottom 17% of all U.S. hospitals. The concerns are dire enough that on 14 occasions since 2010, Prospect facilities have been deemed by government inspectors to pose “immediate jeopardy” to their patients, a situation the U.S. Department of Health and Human Services defines as having caused, or is likely to cause, “serious injury, harm, impairment or death.”

Prospect has a long history of breaking its word: It has closed hospitals it promised to preserve, failed to keep contractual commitments to invest millions in its facilities and paid its owners nine-figure dividends after saying it wouldn’t. Three lawsuits assert that Prospect committed Medicare fraud at one of its facilities. And ProPublica has learned of a multiyear scheme at a key Prospect operation that resulted in millions of dollars in improper claims being submitted to the government.

Leonard Green and Prospect, which have operated hand-in-glove throughout this period, both declined requests for interviews. (Near the end of the reporting for this article, Prospect’s CEO, Lee, spoke to ProPublica on the condition that he not be quoted.) Leonard Green and Prospect responded to ProPublica’s questions in . . .

Continue reading. There’s much more, including a photo of mold breaking through a hospital wall.

Written by LeisureGuy

30 September 2020 at 11:15 am

“That’s Their Problem”: How Jared Kushner Let the Markets Decide America’s COVID-19 Fate

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Katherine Eban reports in Vanity Fair:

On the evening of Saturday, March 21, a small group of Silicon Valley entrepreneurs, business executives, and venture capitalists gathered in the White House Situation Room to offer their help to the Trump administration as it confronted a harrowing shortage of lifesaving supplies to battle COVID-19.

More than seven weeks after the federal government first learned that a new and lethal coronavirus was barreling toward U.S. shores, hospitals were pleading for masks, gloves, and other personal protective equipment to safeguard their medical staff. Intensive care nurses had been photographed wearing garbage bags instead of gowns. More than 19,600 Americans had been diagnosed with the disease, and at least 260 had died.

The meeting’s attendees—some present, some dialing in—were a bipartisan collection of heavy hitters. The ad hoc group had spent weeks canvassing America’s private sector to map the shortages and draft a plan to solve them. Briefly using a hotel ballroom in Washington, D.C., as a makeshift headquarters, they sought answers to some urgent questions: What capacity did America’s companies have to manufacture protective equipment and medical supplies? What supplies could be ordered now? Were there hidden reserves?

They had secured commitments from dozens of major corporations, including General Motors, to manufacture ventilators, map supply needs, create a system for contact tracing, and much more.

On Friday, March 20, they met with a large group of officials at the Federal Emergency Management Agency—people one attendee described as “the doers”—to strategize how best to replenish the nation’s depleted reserves of PPE. The attendees had gotten a significant pledge from, among many others, Mary Barra, the CEO of General Motors. Her company could reconfigure a production line to make ventilators, so long as the federal government would commit to purchasing them. To accomplish that, the private sector attendees and the FEMA officials discussed the need for President Donald Trump to invoke a federal law called the Defense Production Act, which would unleash the government’s procurement powers.

As one attendee recounted, certain government officials there had “implored” the group to return the next day to the White House for a follow-up with President Trump’s son-in-law and senior adviser, Jared Kushner, to make the case for the Defense Production Act. Earlier in the month Kushner had formed a coronavirus “shadow task force” running parallel to the official one helmed by Vice President Mike Pence.

The meeting on Saturday began at 6:30 p.m. Kushner is an observant Jew and normally wouldn’t work during Shabbat, which ended at 8:00 that evening, but a “rabbinic dispensation” allows him to make exceptions for matters of public importance, according to a senior administration official.

Those representing the private sector expected to learn about a sweeping government plan to procure supplies and direct them to the places they were needed most. New York, home to more than a third of the nation’s coronavirus cases, seemed like an obvious candidate. In turn they came armed with specific commitments of support, a memo on the merits of the Defense Production Act, a document outlining impediments to the private-sector response, and two key questions: How could they best help? And how could they best support the government’s strategy?

What actually transpired in the room stunned a number of those in attendance. Vanity Fair has reconstructed the details of the meeting for the first time, based on recollections, notes, and calendar entries from three people who attended the meeting. All quotations are based on the recollections of one or more individual attendees.

Kushner, seated at the head of the conference table, in a chair taller than all the others, was quick to strike a confrontational tone. “The federal government is not going to lead this response,” he announced. “It’s up to the states to figure out what they want to do.”

One attendee explained to Kushner that due to the finite supply of PPE, Americans were bidding against each other and driving prices up. To solve that, businesses eager to help were looking to the federal government for leadership and direction.

“Free markets will solve this,” Kushner said dismissively. “That is not the role of government.”

The same attendee explained that although he believed in open markets, he feared that the system was breaking. As evidence, he pointed to a CNN report about New York governor Andrew Cuomo and his desperate call for supplies.

“That’s the CNN bullshit,” Kushner snapped. “They lie.”

According to another attendee, Kushner then began to rail against the governor: “Cuomo didn’t pound the phones hard enough to get PPE for his state…. His people are going to suffer and that’s their problem.”

“That’s when I was like, We’re screwed,” the shocked attendee told Vanity Fair.

The group argued for invoking the Defense Production Act. “We were all saying, ‘Mr. Kushner, if you want to fix this problem for PPE and ventilators, there’s a path to do it, but you have to make a policy change,’” one person who attended the meeting recounted.

In response Kushner got “very aggressive,” the attendee recalled. “He kept invoking the markets” and told the group they “only understood how entrepreneurship works, but didn’t understand how government worked.”

Though Kushner’s arguments “made no sense,” said the attendee, there seemed to be little hope of changing his mind. “It felt like Kushner was the president. He sat in the chair and he was clearly making the decisions.”

Kushner was accompanied by Navy Rear Admiral John Polowczyk, who had just been posted to FEMA to lead supply-chain efforts. He heaped flattery on Kushner, calling his ideas “brilliant,” and expressed skepticism concerning the motives of those in the room and on the phone. “Are you trying to hawk your wares on us?” he asked one participant.

Ultimately, there was little follow-up from the government on the group’s offers. President Trump invoked the Defense Production Act in name a week later, but he didn’t immediately use the act to formally order supplies, sparking confusion and delays. He also rage-tweeted at Barra, the CEO of GM: “Always a mess with Mary B.” The government waited until April 8 to announce its first order of ventilators from GM.

“We had so much potential to commandeer against this,” said one person who attended the meeting. “We had a real system for contact tracing, the world’s best mobile engineers on standby. There was a real opportunity to have a coordinated response.”

That attendee said he remains “angry” over the federal government’s intransigence in stockpiling supplies and feels certain that people died because of it. “At the time I just thought of it as blind capitalism and extreme libertarian ideals gone wrong,” he said. “In hindsight it’s not crazy to think it was some purposeful belief that it was okay if Cuomo had a tough go of it because [New York] was a blue state.”

According to another attendee, it seemed “very clear” Kushner was less interested in finding a solution because, at the time, the virus was primarily ravaging cities in blue states: “We were flabbergasted. I basically had an out-of-body experience: Where am I, and what happened to America?”

In response to a request for comment, a senior administration official told Vanity Fair that the meeting was not confrontational and said the attendees’ impressions were “not rooted in reality.” He said the federal government had sourced “over a billion items of PPE, enough ventilators so that no American was denied one, and we are the leading testing country in the world.” He added that the “vast majority of the federal response was aimed at helping blue states,” and pointed to public statements Governor Cuomo had made, in which he said Kushner had been “extraordinarily helpful.”

White House press secretary Kayleigh McEnany had this to say: “This story is another inaccurate and disgusting partisan hit job. President Trump has consistently put the health of all Americans first.”

At the end of July, writing for Vanity Fair, I revealed that Kushner had commissioned a robust federal COVID-19 testing plan, only to abandon it before it could be implemented. One public health expert in frequent contact with the White House’s official coronavirus task force said a national plan likely fell out of favor in part because of a disturbingly cynical calculation: “The political folks believed that because [the virus] was going to be relegated to Democratic states, that they could blame those governors, and that would be an effective political strategy.”

The story struck a nerve, partly because . . .

Continue reading. There’s much more, and it unfortunately is depressing albeit important.

And now it looks likely that Republicans will establish a strong conservative majority on the court and at least achieve their goal of ensuring that millions of Americans will lose access to healthcare by bringing down the Affordable Care Act.

Written by LeisureGuy

22 September 2020 at 9:05 am

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