HealthCommentary

Exploring Human Potential

Should U.S. Presidential Candidates be Drug Tested?

Posted on | January 14, 2019 | No Comments

Mike Magee

During a nationally televised speech last week on border security, the airwaves lit up. But the discussion was not limited to fact seekers by now well accustomed to counter-checking the President’s deliberate misrepresentations. Joining in were health professionals and addiction experts who literally counted the number of Trump sniffs that became prominent half way through the brief 9 minute teleprompter address.

Sixty (60) was the calculation – enough to revitalize a earlier Newsweek story citing a former NBC staffer’s claim that the president is addicted to snorting crushed Adderall.  Arm chair analysts quickly made their own assessments noting that such speculation was consistent with the President’s seeming inability to tell the truth, sometimes erratic behavior, bizarre sleep schedule, and hasty governance by tweet.

Establishing that the President is on a mind-altering amphetamine might at this point be too little too late.  Historically presidential succession has been treated as a political rather than a medical process.

Surprisingly, presidential succession was something of an after-thought for the Framers of our Constitution. It was first addressed in 1787 by James Madison with these words, “In case of his [the President’s] removal as aforesaid, death, resignation or inability to discharge the powers or duties of his office, the Vice President shall exercise those powers and duties until another President be chosen, or until the inability of the President be removed.”

It was up to fellow Conventioner, John Dickinson of Delaware, to voice the common concern of the day: “What is the extent of the term ‘inability’ and who is to be the judge of it?” The vagueness of the term “inability” was felt by most future scholars to have been left intentionally vague, as was the role of medical professionals in certifying “inability.”

The nation’s current predicament was voiced by The New Yorker journalist, Evan Osnos,  in a 2017 article titled “How Trump Could Get Fired.” He wrote, “unless the President were unconscious, the public could see the use of the amendment as a constitutional coup. Measuring deterioration over time would be difficult in Trump’s case, given that his ‘judgment’ and ‘ability to communicate clearly’ were, in the view of many Americans, impaired before he took office.”

The amendment he refers to is the 25th Amendment to the Constitution, penned by Birch Bayh (D-IN) and ratified on  February 10, 1967, following the death of John F. Kennedy. It resolved the issue of Vice Presidential succession to the Presidency and the power of the new President to nominate a new Vice President, pending Congressional approval. It gave the power to declare “inability” to the Vice President and a majority of Cabinet members, with rights of challenge to the President being ousted, who – if he were to challenge – could appeal to Congress to resolve the issue.

What the 25th Amendment did not resolve however was the definition of “inability” and the role and responsibility (if any) of the White House physician or an “expert medical panel.” Bayh for one was opposed to empowering medical leaders in any way other than “consultation as required.” He emphasized that inability was essentially “a political question” and a “professional judgment of the political circumstances existing at the time.”

Essentially, on behalf of his fellow legislators, he was saying, “Not to worry – Congress has this.” But do they under Trump?

Conservative New York Times columnist Ross Douthat set off a firestorm in May, 2017, when he weighed in on Trump inability stating “one needs some basic attributes: a reasonable level of intellectual curiosity, a certain seriousness of purpose, a basic level of managerial competence, a decent attention span, a functional moral compass, a measure of restraint and self-control…Trump is seemingly deficient in them all.”

But other commentators were considerably more restrained, suggesting that impeachment, not the 25th Amendment, is the proper remedy for political malpractice.

Why has the 25th Amendment never been used in a case of active “inability”? The New Yorker’s Osnos says it best. The reason it “has never been used to remove a sitting president is that the inquiry requires assessments of presidential incapacity and mental illness that mental health experts generally want no part of, and politicians are reluctant to engage in.”

Essentially, by the time a President is elected, there is little recourse. As one Princeton professor noted, Mitt Romney in his run for the Presidency “supported legislation mandating drug testing for recipients of federal aid, such as: the unemployed, families in assistance programs — in general, citizens down on their luck or in trouble. Interestingly, none of these politicians has suggested drug tests for executives whose banks benefit from billions in federal aid and bailouts.”

And, he might have added, for any past or present candidate for the Presidency itself. What if mandatory drug testing had been required of all candidates in the 2016 Presidential election? It is quite possible we would have averted our current crisis.

American Health Care’s New Year’s Resolution: Confront The Lie.

Posted on | December 31, 2018 | No Comments

Mike Magee

On the last day of a rather disastrous 2018, the Washington Post ran the headline, “Our agents did everything they could.”

The article captured the performance of Kevin McAleenan, head of the U.S. Customs and Border Protection defending his agencies oversight of the death of a second migrant child in the week after Christmas. 

On ABC News’s “This Week” his justification read somewhere between ineffectual and reactive. The words: “our agents did everything they could as soon as these children manifested symptoms of illness to save their lives.”

As wicked and depressing as this performance, the words cut deeper still as an indictment of the U.S. Health Care system at large. 

In the immediate post WWII period, we never asked the question, “How do we make America and all Americans healthy and productive?” We believed that we could “defeat disease” as we had “defeated the Nazis” – through high-tech, profit-driven, cross-sector collaboration. And that in defeating disease, health would be left in its wake.

Over the half century that followed, practitioners in government, industry and academic medicine discovered each other, and manners of collusion that assured career advancement and steady streams of revenue. In this increasingly organized medical-industrial complex, everyone who cooperated was dealt in – except the patient.

Nearly seven decades into this experiment, this remarkable miscalculation, members of the medical-scientific elite feel more than comfortable suggesting that America’s unhealthy culture is not their problem, and ignore the fact that our’s is the only developed nation that spends more on health care than all other social services (themselves determinants of health) combined.

In 2019, we need to confront the lie that “we did all that we could.” We have not. It is time to return to the original question we ignored, “How do we make America and all Americans healthy?” If we acknowledge the learnings of all other developed nations, we will embrace:

1. Universality: Health coverage and quality accessible health services are a right of citizenship in the United States.

2. Public Administration: Administration of basic health coverage is organized in the most cost-efficient manner possible with central oversight by the government. Incremental steps allowing the option of public sponsored plans to those already insured should be encouraged. 

3. Local Control of Delivery: The actual delivery of services to ensure quality and cost effectiveness is provided by health professionals and hospitals at the local and state levels.

4. Health Planning is a Priority:  Creating healthy populations is a high priority forour national and state leaders. Working to establish health budgets and priorities, leaders must integrate health services with other social services, advance prevention planning and manage vulnerable populations.

5. Transparency: Providers submit bills. Government ensures payment of bills. Patients focus on wellness or recovery. All essential services (those defined under the ACA)  are covered.

Wishing you a happy and healthy New Year!

What Leads To 20,000+ Deaths per Year in American Kids? Autos + Guns = 35%

Posted on | December 20, 2018 | No Comments

Source: https://www.nejm.org/doi/full/10.1056/NEJMsr1804754?query=featured_home

Commonwealth Report on U.S. Maternal Health Just Released.

Posted on | December 19, 2018 | No Comments

https://www.commonwealthfund.org/publications/issue-briefs/2018/dec/womens-health-us-compared-ten-other-countries?omnicid=EALERT1531955&mid=drmikemagee@gmail.com

The Decoupling of Health from Health Care

Posted on | December 18, 2018 | No Comments

Mike Magee

“Our health care system’s focus, at every phase of its development, but especially since its expansion and increasing sophistication since World War II, has been on maximizing opportunities for profit and/or career advancement for the players within it.” Code Blue: Inside the Medical Industrial Complex (Grove Atlantic Press, coming in Spring, 2019)

In this week’s Wall Street Journal, Stanford University Hoover Institution fellow, Dr. Scott W. Atlas, reveals, without intention, American health care’s “original sin.”

Atlas is a neuroradiologist and deeply entrenched in the Medical-Industrial Complex, collecting consulting fees for “advising entrepreneurs and companies in the life sciences, medical technology, and health information technology sectors.” His world view is more than adequately reinforced by the Hoover Institution  which “seeks to improve the human condition by advancing ideas that promote economic opportunity and prosperity.”

The WSJ piece claims that U.S. health care’s dismal rankings on a global scale are “grossly flawed calculations.” Through Dr. Atlas’s lens, America’s ranking of 32nd of 35 nations in infant mortality is because we over-report compared to comparator nations; and because our mothers indulge in more harmful behaviors; and because America possesses higher rates of “racial and ethnic minorities.”

As for America’s plunging life expectancy rates (ranked 26th for men, and 29th for women), he, without irony, adopts a “Don’t blame us!” posture, pointing instead to “unhealthy lifestyle choices, violence, urbanization, marriage and economic inequality.”

As for treating the diseases that he blames on others, he celebrates America’s “superior results”, and our remarkable access to surgeries, screenings, diagnostics and drugs, without mentioning our remarkable over-consumption, our permissive risk/benefit calculus, our raging opioid epidemic, or our near half-million avoidable deaths a year in unsafe hospitals.

The reader is left with the feeling that we all live in an alternative universe, where health is decoupled from health care, where cause can not be linked to effect, and where a privileged world view comfortably co-exists with remarkable and growing levels of unconscionable inequity.

Dr. Atlas’s essay does little to advance his cause. Rather, it reveals a stubborn committment to the status-quo and adherence to American health care’s “original sin.” In the immediate post WWII period, we never asked the question, “How do we make America and all Americans healthy and productive?” We believed that we could “defeat disease” as we had “defeated the Nazis” – through high-tech, profit-driven, cross-sector collaboration. And that in defeating disease, health would be left in its wake.

Nearly seven decades later, this remarkable miscalculation is so well entrenched that members of the medical-scientific elite feel more than comfortable suggesting that America’s unhealthy culture is not their problem, and ignore the fact that our’s is the only developed nation that spends more on health care that all other social services (themselves determinants of health) combined. 

AMA Tells Trump “No Way” on ACA

Posted on | December 15, 2018 | 2 Comments

MEMORANDUM TO: Reporters, Editors, Producers and Interested Parties FROM: American Medical Association

DATE: December 15, 2018

SUBJECT: Texas v. Azar Decision ______________________________________________________________________________ Judge Reed O’Connor’s decision is a stunning display of judicial activism. Judicial power does not extend to settling policy disputes or exercising general supervision over the other branches of the federal government. Congress declined to repeal the ACA on more than 70 occasions. Yet, this judge has stepped in and single-handedly done has what Congress chose not to do – with a weak, unprecedented interpretation of “standing,” a failure to grapple with binding legal precedent, and an indefensible understanding of the interplay between the ACA, the Supreme Court’s decision in NFIB, and the TCJA. This decision violates multiple precepts that guide and limit the exercise of the judicial power – and it sets a dangerous precedent that invites politicians to resort to the unelected, life-tenured judiciary when they cannot achieve their political goals through the democratic process. Elected and accountable officials at the federal and state level continue to debate how best to ensure the provision of quality health care to the American people. 

1. The Decision Will Wreak Havoc on American Health Care If It Were Left to Stand Current Law Should Remain in Place Pending Resolution of All Appeals

If upheld, the consequences of Judge O’Connor’s decision will be staggering. The ACA expanded access to affordable, quality health insurance, and millions of Americans have gained coverage under the statute. The decision will strip health care from tens of millions of Americans who depend on the ACA; result in higher insurance costs; and sow chaos in the nation’s health care system. 

The decision reverses the historic gains in health insurance coverage that have been achieved since the implementation of the ACA, which have benefited millions of patients and the American health system. 

Empirical research demonstrates that the lack of insurance contributes to premature deaths, worse health outcomes and preventable patient suffering. 

2. Plaintiffs Lack Standing 

The decision disregards the fundamental doctrine of “standing,” which is intended to ensure that courts confine themselves to their properly limited role, and avoids embroiling courts in political disputes that our Constitution assigns to the democratically accountable branches of government.

As the judge recognized, the American Medical Association (AMA) explained why the plaintiffs in this case did not have standing to bring their case. The plaintiffs do not have standing because they have not suffered any real, concrete injury. They do not have to pay a penny in tax if they choose not to obtain health insurance. That unavoidable fact makes clear that the plaintiffs simply seek to change the federal government’s health care policy through the courts, rather than through the legislature. 

In rejecting those common-sense arguments, Judge O’Connor offered an unprecedented theory of standing—that parties may bring suit to free themselves from what they subjectively view as “arbitrary governance.” No court has ever recognized such a radical theory. 

3. The Minimum Essential Coverage Provision Remains a Constitutional Exercise of Congress’s Taxing Power

 Judge O’Connor concluded that, in light of the TCJA, the Individual Mandate in the ACA is no longer fairly readable as an exercise of Congress’s Tax Power and, thus, the ACA is unconstitutional. His logic is fatally flawed.

 A law need not raise “some revenue” to qualify as a tax under Congress’s taxing power. All that is required is that the authority to tax be preserved, even if no revenue is actually raised. That is precisely what Congress did when it amended § 5000A. By keeping the minimum coverage requirement and its provisions imposing a tax, but only reducing the amount of that tax to $0, Congress preserved the statutory power to tax. 

Judge O’Connor ignores a critical Fifth Circuit case on this point (United States v. Ardoin, 19 F.3d 177 (5th Cir. 1994)), which is a sign he has no answer for it. The AMA cited that decision again and again in its amicus brief, but the judge did not bother to address those arguments—or the binding decision of the court of appeals that he is required to follow. The NFIB case cited by the judge did not displace judicial precedent (i.e. Ardoin ) that a law is constitutional where taxing authority still exists, but is merely not exercised. 

4. The Minimum Coverage Provision Is Severable from the Remainder of the ACA

 The severability inquiry turns on congressional intent. The actions of the 2017 Congress leave no doubt about its intent: Congress reduced to zero the tax liability for failing to have minimum essential coverage, but it left the ACA otherwise unchanged. Congress thus already decided that the remainder of the law’s provisions—the protections for people with pre-existing conditions, the Medicaid expansion, and the rest of the law—should continue to be enforced as they were before the Tax Cut and Jobs Act of 2017 was enacted.

“A” Rating from NRA – The New Scarlet Letter

Posted on | December 13, 2018 | 2 Comments

The New Scarlet Letter

Mike Magee

“The NRA’s A-rating used to be a badge of honor. On Election Day, it was a scarlet letter.”  Those were the words of Shannon Watts, founder of Moms Demand Action for Gun Sense. And she had facts to back it up. More than 1000 candidates in the 2018 Mid-Term elections ran and won on gun safety. 

Gun safety advocates signed up more than 100,000 new voters. In 43 races that featured a head-to-head challenge with an NRA “A” rater, only 10 candidates with the now dreaded scarlet “A” letter prevailed.

If three strikes mean you are out, the NRA is remarkably close to being retired. Strike 1: They challenged physicians for the loyalty of patients, admonishing doctors who support gun safety to “stay in their lane.” Strike 2: The NRA, with this weeks guilty plea by Russian spy, Maria Butina, stands convicted of laundering Russian money into the hands of Trump and Republican candidates across the land in the 2016 elections. Strike 3: In the wake of childhood massacres from Sandy Hook to Parkland, parents across America and their kids have struck an electoral blow into the heart of the NRA “A” rating.

Facts don’t lie according to the American Academy of Pediatrics. At their annual conference in Orlando this month, they reviewed the tight link between childhood gun deaths and NRA dominated state legislatures.

Using 2017 statistics, authors correlated a state’s Brady score (a numeric reflection of the strictness of gun control laws) with CDC reports of avoidable gun deaths in children.

2,715 children died of gun shots in 2017 – 62% were homicides and 31% were suicides.

After adjusting for other factors like poverty, employment, and addiction, they isolated lax gun laws as a determining factor in the deaths.

States with the weakest protections had 5 child deaths per 100,000, compared to the best states who had half as many deaths.

In the 27 states that have laws forcing parents to secure access to firearms in their homes, there were only .63 deaths per 100,000 compared to the states without these laws that had 2.57 per 100,000.

In the 12 states with universal background checks for sale of guns, 3.8 children per 100,000 were killed, versus 5.7 per 100,000 in states without such protections. When background checks were extended in 5 states to the sale of ammunition, the death rates dropped further to 2.3 children per 100,000.

Doctors, nurses and health professionals across the land increasingly recognize that a largely armed American culture with a penchant toward violence is fundamentally unhealthy. They also are leaning toward universal health coverage and robust health planning (including the varied social determinants of health) as an expression of solidarity and the assurance of “life, liberty, and the pursuit of happiness” for all Americans.

Women across America are today’s political story, and they’ll tell you straight-up, the NRA is “so yesterday.”

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