Science Loses to Ideology – And So Do Kids

August 9, 2019

In 2010, the Healthy, Hunger-Free Kids Act was passed, calling for the government to establish improved nutritional standards for school lunches.  These standards, enacted in 2012, set limits on sodium, added-sugar, and calorie content of lunches, and required more whole grains and fruits and vegetables.  The goal, of course, was to address the growing problem of obesity.

Some of you will recall the pundits on cable news decrying the efforts of the “nanny state” to tell us how to feed our kids.  These investigative reporters discovered mountains of inedible food piling up in the trash cans of school cafeterias after the disgustingly nutritious meals were soundly rejected by students across the nation, who instead were demanding that ketchup once again be considered a vegetable.  Remember that?  It turns out it was untrue.

A recent study of the effect of the new lunch standards found the following:

  • The nutritional value of school meals increased substantially, from an average score of 57.9 out of 100 prior to the standards, to 81.5
  • Sodium, refined sugar, and calorie content of meals decreased, while adequacy of whole grains and vegetables increased
  • Participants in the lunch program ate healthier meals (average score 80.5) than their matched peers who did not participate, presumably bringing lunch from home (average score 65.1).
  • The amount of food tossed away was significant; it was higher among elementary than among high school students, and higher when lunch was served earlier, but was similar to the amount tossed away before the standards were set
  • School varied in their compliance with the standards, but among those with the most nutritious lunches, the participation rate of students buying those lunches was higher
  • Also among schools, there was no association between the mean cost of preparing lunch and the nutritional value of the lunches served

In other words, the lunches were healthier, students seemed to like them as much, and they were no more expensive to prepare.  Sounds like what most of us would consider a smashing success.  So of course, in 2017, the US Department of Agriculture announced that it was revising the standards to weaken the requirements.  This might make sense if the source of this data were a potentially biased advocacy organization of some kind, with a hidden nanny state agenda.

The study was actually done and published by – wait for it – the US Department of Agriculture itself.

Yes, the USDA is going against the findings of its own data to reverse what would appear to be a major public health accomplishment.  Secretary of Agriculture Sonny Perdue, in announcing the rollback, said “I wouldn’t be as big as I am today with chocolate milk.”  No doubt.

Earlier this year, a lawsuit was filed by several states (including Minnesota, I am happy to say) to overturn the revised, more lax standards, saying the changes were capricious and not supported by evidence.  Let’s hope that this time science and reason can prevail.  Our kids could do with a little less ideology – and a little less chocolate milk.


Racism and Health

July 31, 2019

If you have any interest in the health of children, the new policy from the American Academy of Pediatrics entitled The Impact of Racism on Child and Adolescent Health is worth reading.  The statement reviews evidence for the effect of racism on children’s health and on health disparities, and makes recommendations on how health professionals can address and ameliorate the adverse health impacts of racism.

One “aha” for me is the notion that racism is, in fact, a social determinant of health.  While I had always considered that disparities in health can arise from disparities in housing, education, etc., and that many of these are mediated by racism, I hadn’t made the connection that racism itself is a social determinant. Not only does racism drive the kind of disparities in these other social determinants, but the internalized experience of racism creates a toxic stress response with adverse health effects as well.

As noted in the AAP Policy Statement, racism is a “system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call ‘race’) that unfairly disadvantages some individuals and communities, [and] unfairly advantages other individuals and communities.”  It further goes on to state that racism can operate through different mechanisms: institutionalized (or structural), and personally mediated.  The latter includes not only the kind of overt, willful, and ugly race hatred of the Bull Connor variety that involves violent threats and racial epithets, but also the subtler, unconscious forms of implicit bias we all carry.  As the National Association of Educators of Young Children puts it, “racism is a system of oppression that results from a combination of prejudice and power.”

Now, the topic of racism has been much in the news recently.  The term itself is seen as partisan and divisive.  Part of the problem is that the term “racism” refers to a concept that is multidimensional and complex, hardly amenable to Twitter-based discourse.  And this, I think, is where much of the rancor comes from.  For many people, “racism” connotes solely the personally-mediated variety, and more specifically, the willful, angry variety.  For them it is only about the prejudice, and not about the power.  Thus they feel that calling out racism equates to questioning their integrity and character, and that of the majority of the population.  Moreover, the fact is that there is fortunately less of that kind of viciously-expressed race hatred than there once was (if still a disturbing amount).  It is thus tempting to think of racism as a thing of the past, rather than an ongoing legacy of centuries.

So how do we get past the sticking point we seem to be at, where the urgency seems clear to some, and the problem seems non-existent to others?  It won’t happen via Twitter, where the complexity of a seemingly simple 6 letter word cannot be explored.  Antiracists must understand that the opposite of antiracism isn’t necessarily pro-racism.  We need to recognize that many people have a narrower view of the same word, and when they hear an attack on racism they hear an attack on them personally.  We need to educate ourselves and each other on the many forms of racism – both prejudice and power – and how racism “saps the strength of the whole society through the waste of human resources.”  Especially our children.


What’s in a Slogan – “Medicare For All.”  Part 3: What Do We Do?

June 3, 2019

As I shared in part 2, “Medicare for All” is really a slogan that encompasses several different approaches to increasing the role of government in the financing of health care, and would represent steps toward universal coverage.  Lots of people, including nearly all folks running for the 2020 Democratic presidential nomination, claim to support MFA, though they differ on which version (and some have endorsed more than one).

A few thoughts all this:

  1. All versions would dramatically increase the government’s role in funding health care. The first option would likely increase the government share of health spending higher even than in Canada or the UK.  But keep in mind that government spending is already more than half of all health spending in the US.  None of the current recipients of this spending (seniors, veterans, etc.) are clamoring to do away with it, it has broad public support, and even those politicians who claim to want to move toward a more market-based system are only tinkering around the edges.  The genie of government role in health care is not going back in the bottle.

Moreover, none of these plans, even the most far-reaching, would mandate any significant change in the US provider system, which is and would remain primarily private.  Like most of the countries who have achieved universal coverage, this is not actually a socialized system like the National Health Service in the UK or the VA and Department of Defense here in the US.  Medicare for All is not the first mile on the road to becoming Venezuela.

  1. The success of any of these needs to recognize that Medicare (and even more so Medicaid) currently fails to cover the cost of providing care. We have managed this for years by shifting costs to the private sector.  The less private insurance there is, the less opportunity for shifting, and the more the government will need to adjust their payment rates in any of these MFA variations.  Any calculations of the cost of any MFA plan that does not account for this and assumes we can simply extend current Medicare or Medicaid rates is underestimating the total cost by at least 10-15%.

I fear that part of the popularity of these plans is the belief that we can achieve universal coverage without any hard choices.  We underfund schools, roads, and other government services and then complain about the quality.  By and large, you get what you pay for.  There is some waste in the current system – overutilization driven by financial incentives and (to a much lesser extent) defensive medicine, high overhead due to the complexity on the payment side, excessive marketing and profit – and some fraud and abuse (though far less than many think).  But the overall cost of achieving high-quality, universal health care will be high, no matter how we go about it.

  1. Every single one of these variations will have entrenched opposition. No matter how popular with the public, the battle to enact any expansion of government-sponsored coverage will make passing the Affordable Care Act look like a walk in the park.  And while the ACA did not solve all our problems, it was a good start.  My advice to those who want to improve health care is don’t let the perfect get in the way of the possible.  And don’t use Medicare for All as a purity test or weapon in partisan warfare.  The 2020 presidential candidates generally support some variation on a path to the goal of fairer, more affordable, more accessible health care.  Look at specifics, test assertions and assumptions, ask if a plan represents progress.  A journey of a thousand miles begins with one step, and the road to universal health care is a long one.  Slogans aren’t policy, and no nation’s health system fits easily on a bumper sticker.

What’s in a Slogan – “Medicare For All.”  Part 2: What Does It Mean For The Future?

May 31, 2019

In part 1, we explored the current US healthcare “system” in all its Byzantine complexity and unsustainability.  “Medicare For All” has become the standard by which nearly all potential 2020 presidential candidates (at least the Democrats) are being judged.  But what exactly does it mean?

Recall that Medicare is the current federal insurance program primarily for the elderly.  All Americans over 65 are eligible, and costs are paid primarily from Medicare payroll taxes and premiums paid by enrollees.  Payments for hospital services, doctor fees, and prescription drugs are made according to a set fee schedule (with adjustments for local factors), with some cost sharing to enrollees.  It is, essentially, a single-payer system for older Americans.  However, private insurance has a role.  First of all, enrollees can choose either traditional Medicare, where payments are made directly by the government, or Medicare Advantage, in which private insurance companies are contracted by the government to provide the benefit.  (In this arrangement, the private insurer can offer additional benefits, typically by negotiating lower payments to providers in exchange for narrowing the provider choice for enrollees.)  Also, traditional Medicare beneficiaries can purchase supplemental private insurance known as Medigap to pay for services not covered by Medicaid, or to offset some of the cost sharing.

So, what is Medicare For All (MFA)?  There are at least five different basic variations on this theme, and people supporting any of these have claimed to be in favor of MFA.  Here is my (admittedly simplified) synopsis, along with my alternate name to help distinguish them:

  1. Medicare for All. This is the bill officially introduced by Bernie Sanders in the Senate and Pramila Jayapal in the House under the name “Medicare for All,” and truly represents, well, Medicare for all.  Literally.  It would in large part extend the current Medicare program to all US residents except veterans and Native Americans (see below).  It would be financed and administered at the federal level, paid completely by taxes.  It would not only replace Medicaid (the federal-state program for the poor and disabled), it would replace all employer-provided and ACA exchange private insurance.  While the government would be the sole payer, providers would be independent rather than government owned.  This makes it most similar to the Canadian system, as opposed to the British National Health Service where hospitals and physicians are government-run.  (These bills would, however, retain the Veterans Affairs and Indian Health Services, which are fully nationalized as it is.)  It actually goes quite a bit further than the current US Medicare system in that there would be no premiums, no cost sharing by individuals, and no role for private insurance or managed care organizations.
  2. Medicare for Many, Opt-Out version (officially, Medicare for America). In many respects similar to number one, but employers could continue to offer private insurance, and people receiving this could opt out of the Medicare system.  The version that has been introduced also retains the Medicare Advantage options, thus preserving a role for private insurance companies.
  3. Medicare for Many, Opt-In version (there are several similar competing bills, such as Choose Medicare). In these flavors of MFA, Medicare would be a federal public plan available to anyone on the healthcare marketplace (“the exchange”).  Anyone could purchase this instead of a private plan, with the same subsidies though the cost to purchase would presumably be lower than for commercial insurance and therefore this would attract many people, including a large number who currently receive insurance from their employer.
  4. Medicare for More (known officially as Medicare at 50). Keeps the system more or less as is, but lowers the eligibility age to 50.
  5. Medicaid for More. This is similar to #3 above, but uses the federal-state Medicaid program to provide a public option rather than the purely federal Medicare.

Got all that?  Good.  In my third and final installment, I’ll share some thoughts on where we might go with all this.


What’s in a Slogan – “Medicare For All.”  Part 1: The Current System

May 28, 2019

My son Evan, when he worked on political campaigns, liked to say “yard signs don’t vote.”  You need to actually convince voters to support your candidate and get them to cast a ballot.  In a similar, though less catchy, way, one might say “slogans don’t create policy.”  Access and affordability of health care remains one of the top issues on the minds of Americans, and it is likely to have a marquee role in the 2020 elections.  The phrase “Medicare For All” has attracted a lot of attention from candidates and media, but what exactly does it mean, and how would it play out as policy?

To explore this question, I want to start with an overview of our current “system.”  I put that word in quotes because in reality we don’t have a health care system, we have a health care hot dish, a patchwork of various private and public methods of payment and delivery.  Let’s start with payment.  The annual spend on health care in the US is about $3,500,000,000,000 ($3.5 trillion – but it looks more impressive with all those zeroes, doesn’t it.)  Although the largest individual slice of that is from private insurance, cumulatively, public spending is almost half.  In fact, surprisingly, as a percent of GDP, government spending on health care in the US is almost the same as in other industrialized countries; the difference is we also spend far, far more from private sources.  Here is the breakdown (numbers may not add to 100% due to rounding):

  1. Private insurance (35% of total spending). As I said, this is the largest single source.  Most of this is provided by employers, with the cost of the premiums split between the employer and the employee.  It also includes private insurance obtained by individuals on the so-called Affordable Care Act-created exchanges or marketplaces.  Of the 167 million Americans covered by private insurance, roughly half are in for-profit plans (e.g., United HealthCare, Aetna) and half in not-for-profit plans (Kaiser, many Blue Cross/Blue Shield).
  2. Government insurance (41%). While the total here is higher than for private, it actually includes multiple different programs:
  3. Medicare (20%). This is a government insurance plan for elderly and certain disabled individuals; essentially all people 65 and older are eligible for Medicare, which covers some 62 million people. It is akin to the Canadian single-payer system (which is also called Medicare): government pays for the care, but is not the provider.  Medicare is paid for and administered entirely by the federal government, which pays for medical services either directly to providers, or indirectly through various private insurance companies which act as a sort of middleman (via “Medicare Advantage” plans).  The government share of the funding comes from a dedicated Medicare payroll tax, and individuals also pay a monthly premium based on their income.  Payment rates to providers are established nationally.  Importantly, while the figures are different for hospitals and physicians, overall the total reimbursement from Medicare tends to be less than the actual cost of providing the care, by 8-10%.
  4. Medicaid (17%). Like Medicare, this is a government insurance plan, but with some key differences. Eligibility is determined by income, rather than age; this is a plan primarily to cover the poor and some others with disabilities, totaling approximately 68 million people.  More importantly, this is a joint federal-state program.  Funding comes from a combination of federal and state sources, and the program is administered by the states, so while there are common standards set by the federal government, states have a good deal of flexibility to set eligibility criteria, benefits, and reimbursement rates to providers.  On average, the gap between Medicaid payments and the actual cost of care is larger than for Medicare, about 12-15% less, though in some states like Minnesota it is as much as 30% less than the cost. (The tradeoff is that Minnesota covers more people; we have very few uninsured.)  As with Medicare, payments may be made directly to providers, or indirectly via insurance companies who contract with the state to provide Medicaid managed care.
  5. Veterans and military (4%). The Department of Veterans Affairs and Department of Defense run systems more like the British National Health Service where government is not only the payer but the provider for some 15 million people.
  6. Individuals (10%). This includes out-of-pocket cost sharing (copayments, deductibles, coinsurance) for those people with one or more of the forms of private or public insurance above, as well as the cost of care for the 27 million people who remain uninsured.
  7. Other (14%). This includes a host of things including public health programs, Indian Health Service, school health, worker’s compensation, liability insurance, etc.

A few key observations (and I will want to get back to these in part 2 of this blog):

  1. The system is very complicated, even in this ridiculously oversimplified rendition. (I don’t even get into the issue of people who qualify for more than one, such as the elderly poor who may be on both Medicare and Medicaid, or kids with disabilities who may have both Medicaid and private insurance.)  And while most other countries have managed to figure out how to provide universal coverage at a lower cost than the US, their systems are also relatively complicated.  None of them is easily described by a simple slogan.
  2. It is incorrect to say we do not have a government health system in the US. As you can see, government spending is as high as private.  Moreover, when you account for tax deductions for employer-provided insurance and health savings accounts, subsidies for exchange-based plans, etc., the government’s indirect spending (tax expenditures) is another $280 billion on top of the direct spending of $1.1 trillion.
  3. On the other hand, while health spending in the US is predominantly by the government, providers are primarily private: roughly 54% of hospitals are private not-for-profit, 24% private for-profit, and 22% public.
  4. Government sources of insurance do not cover the cost of providing care; doctors and, to a greater extent, hospitals tend to lose money when treating patients under Medicare or Medicaid. This has worked thanks to cost shifting.  For decades, private insurance has paid higher reimbursement to make up for the difference.  This has been a sort of social compact, stabilizing the system.  As the shortfalls from government programs grow, and costs of private insurance outpace inflation, this social compact is unraveling.

 

I’ll let you digest that for a couple of days and then consider “Medicare For All.”  Spoiler alert – it’s not as simple as it sounds.


Nurses Week 2019 – Show Me Your Cards

May 6, 2019

You’ve all no doubt heard by now of the Washington state senator who claimed nurses sit and play cards all day. At first I was outraged like everyone else.  But then I thought about it.  Now, I don’t know about the sitting part, but nurses do play cards every day.  Each day they come in and are dealt a new hand, never knowing what it’s going to contain, and they do their absolute best with whatever cards they get.  Moreover, you can never tell whether they got dealt a straight flush or a nine-high – they keep the same steady, compassionate, determined, get-it-done look regardless.  It may just be a metaphor, but nurses are the best darn card players I know.

On a more serious note, in my 30+ years in pediatric health care, I have had the opportunity to work with thousands of nurses, and my respect and appreciation for them and what they do grows every year.  For those of you who are nurses, you have my utmost gratitude.  I hope you have a happy Nurses Week.


Never Forget – Christchurch, NZ, 15 March 2019

March 19, 2019

Mucad Ibrahim, age 3

Abdullahi Dirie, 4

Sayyad Milne, 14

Khaled Mustafa

Hamza Mustafa, 16

Naeem Rashid & son Talha, 21

Ansi Karippakulam Alibava, 25

Atta Elayyan, 33

Haroon Mahmood, 40

Husne Ara Parvin, 42

Mohammad Imran Kahn, 47

Linda Armstrong, 65

Haji-Daoud Nabi, 71

Lilik Abdul Hamid

Ashraf Ali

Vora Ramiz, 28

Farhaj Ahsan, 30

Mojammel Hoq, 30

Syed Jahandad Ali, 34

Hussain Al-Umari, 36

Osama Adnan, 37

Kamel Darwish, 39

Amjad Hamid, 57

Abdelfattah Qasem, 59

Ali Elmadani, 66

Sohail Shahid

Syed Jahandad Ali

Syed Areeb Ahmed

Mahboob Haroon

Ghulam Hussain

Karam Bibi

Zeeshan Raza

Osama Abu Kowik

Maheboob Khokhar

Ramiz Vora

Asif Vora

Ozair Kadir

Hafiz Musa Patel

Mounir Sulaiman

Ahmed Jamal Aldean Abdulghani

Ashraf al-Morsi

Ashraf al-Masri


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