HealthCommentary

Exploring Human Potential

All the way or Incremental on M4A?

Posted on | December 5, 2019 | No Comments

Source: blog.rendia.com

Mike Magee

At a Code Blue presentation locally last week, questions centered on next steps in health reform – all the way, or incremental. Increasingly, I split the difference. A complete flip I believe is difficult to pull off because what we are asking Americans to do is to change their historic culture (one built on self-interest, hyper-competitiveness, the absence of traditions of solidarity and belief in good government, and a celebrity obsession).

Health care as fundamental to building a nation and its culture from scrap was what drove the military’s decision in the re-build of Germany and Japan to start with a health plan – in part because they recognized that all other social determinants would be enhanced in the process leading to a tradition that could support a stable Democracy.

This is essentially the same challenge we as a country (having wandered so far off course as to elect Trump) are faced with today. Changing culture, as health professionals know, is a tall order and requires voluntary movement and evolution of support. So in this context, I believe central oversight combined with a voluntary public option for all comers is the way to go.

If we choose to go this route however, I think its essential that it be open to all, that insurance be a requirement and mandated as such, that Medicaid expansion (or combination with the new public offering) be required in all states without exception, and that a complete benefit package as delineated in the ACA be required (no skimpy substitutes). In others, the public offering must be muscular, nationwide, and accessible to all comers.

Kamala Gone, But “Medicare-for-All” Not Forgotten.

Posted on | December 5, 2019 | 2 Comments

MIKE MAGEE MD

As the number of Democratic contenders for the Presidency begins to dwindle, the “Medicare-for-all” debate continues to simmer. It was only ten months ago that former candidate Kamala Harris’s vocal support drew fire from not one, but two billionaire political rivals. Michael Bloomberg, looking for support in New Hampshire declared, “I think we could never afford that. We are talking about trillions of dollars… [that] would bankrupt us for a long time.” Fellow billionaire candidate Howard Schultz added, “That’s not correct. That’s not American.”

Remarkably, neither man made the connection between large-scale health reform’s potential savings (pegged to save 15% of our $4 trillion annual spend according to health economists) and the thoughtful application of these newly captured resources to all U.S. citizens without discrimination. Bloomberg’s own 2017 Health System Efficiency Ratings listed the U.S. 50th out of 55, trailed only by Jordan, Columbia, Azerbaijan, Brazil, Russia. Yet he seemed unable to connect addressing waste with future affordability.

Schultz was similarly short sighted. While acknowledging that the manmade opioid epidemic, mental health crises, and income inequality are “systemic problems” and at levels “the likes of which we have not had in a long time”, he failed to connect the cause (a remarkable dysfunctional and inequitable health care system) with these effects.

As I outline in “Code Blue: Inside the Medical Industrial Complex” (Grove Atlantic/2019), today’s greatest risk to continued progress and movement toward universal coverage and rational health planning is sloppy nomenclature.  To avoid talking past each other, we need to define the terms of this debate while agreeing on common end points.

“Universal health care” is an end point goal that reinforces the principle that health is a human right rather than a privilege for the most entitled. It is an expression of national solidarity and reflects a shift in our culture.

“Single payer” is one strategy or tactic often associated with the Canadian health care system. However, the Canadian system is not technically a “single payer” system, in that provision of insurance (set to national standards) and the delivery of the care are the responsibilities of individual provinces, not the national government. A more accurate label for their system would be “Single Oversight/Multi Plan”.

Canada has choice and also maintains an active private health insurance market that provides supplemental health care plans purchased by 70% of citizens to cover roughly 30% of health costs including optical, dental and drugs which are not covered by government plans. Private insurers in the U.S. in the future might play a similar role.

The Canadian government’s role is focused on formalized government health planning as well as insurance standards and oversight. It also outlaws DTC drug advertising and sets prices annually for all essential drugs. The national government is the guardian of universality and (often overlooked) simplicity. Providers provide. Provincial government pays. Patients concentrate on health and wellness, and are not plagued by insurance gamesmanship and endless bill bickering on the local level.

The U.S. has no such government-directed, national health planning apparatus. Service levels and reimbursement vary widely across an endless array of private and public offerings that have devolved into a “free-for-all.” Our profit-driven, scientific research community regularly diverts resources from health planning and patient care, and our insurance system harbors an enormous number of health system middlemen to support “non-real” work (16 positions for every one physician – half with no clinical role).

What we do have are $4 trillion already committed (albeit badly misallocated), a remarkable array of educational institutions, a dedicated network of public health schools and practitioners, under-utilized nurses and pharmacists, and a testing ground of 50 different states.

The true impact of spiraling health care costs and their secondary effects—including stagnant wages, income inequality, a lack of job mobility, high rates of medical bankruptcy, the closure of rural hospitals, an inability to invest in infrastructure repairs, and our growing national debt – is staggering. We are the only developed nation in the world that spends more on health care than all other social services combined.

Warren Buffett, a man who knows something about sustainable growth, said recently: “The health care problem is the number-one problem of America and of American business. . . . Medical costs are the tapeworm of American economic competitiveness.”

For far too long, our leaders have focused on how to make American corporations wealthy. But let us be clear – there is another way. We could have the courage and the will to reapply our more than ample health care assets and reject the status quo. We could vote in change on a large scale.  We could elect leaders willing to honestly address a simple, long overdue question that is at the very center of Code Blue: “How do we make Americans healthy?”

Good News on Childhood Obesity – and “Good Government.”

Posted on | December 3, 2019 | No Comments

Mike Magee

As the debate over health reform wages on, it is increasingly apparent that the real underlying issue we are grappling with is the role of “good government.” Without it, as one philosopher suggested nearly four centuries ago, life is “solitary, poor, nasty, brutish, and short.”

Canada had relatively smooth sailing from the time the province of Saskatchewan first raised the question, “How can we make Canada and Canadians healthy?” in 1947, to when the country fully embraced national health care in 1966. Why? In part because of their century old national motto (and practice), adopted in the Constitution Act of 1867 which reads “Peace, Order, and Good Government.”

Yet it’s never too late to learn from our neighbors to the north, as appears to be evident in a November 22, 2019 release by the CDC, that good government does in fact make a difference, especially when it comes to health care.

At issue, obesity rates in children. What we know? “Among children aged 2-4 years enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), obesity prevalence decreased from 15.9% in 2010 to 13.9% in 2016.”

What is also known is that childhood obesity is associated with type 2 diabetes, asthma, liver disease, bullying, and poor mental health. Emphasis on nutrition, breastfeeding, and physical activity (all part of WIC) decrease the likelihood of obesity.

During the most recent 6 years studied (2010-2016), significant decreases in childhood obesity prevalence occurred in 41 of 56 WIC states or territories. The largest improvements (>3%) were in Guam, New Jersey, New Mexico, Northern Mariana Islands, Puerto Rico, Utah, and Virginia. Only three states showed significant increases. They were Alabama (0.5 percentage points), North Carolina (0.6 percentage points ), and West Virginia (2.2 percentage points).

Progress according to the CDC reflects a “good government” practice of continuous improvement in the WIC dietary offerings. According to the agency, “The revised food packages include a broader range of healthy food options; promote fruit, vegetable, and whole wheat product purchases; support breastfeeding; and give WIC state and territory agencies more flexibility to accommodate cultural food preferences.” 

Political attitudes toward government do affect the lives and health of citizens. This is glaringly obvious in these United States, where state leadership often defines federal health program availability and access. Consider the stubborn intransigence of 14 Republican governors to the adoption of ACA funded expansions of Medicaid and/or draconian work requirements that actively limit enrollment.

These and other activities that undermine “good government” contribute to the high variability of state-by-state health performance. In the 2019 Commonwealth Fund Scorecard on State Health System Performance, the top 5 performers were Hawaii, Massachusetts, Minnesota, Washington, and Connecticut. The lowest five were Mississippi, Oklahoma, Texas, Nevada, and Arkansas.

As we continue at lightening speed toward the 2020 election day of reckoning, and debates on health reform remain front and center, it’s important to remind ourselves what is really at stake. Do the majority of Americans believe in “good government” or not?

We must be “Declaration of Independence Walking.”

Posted on | November 24, 2019 | 3 Comments

Source

Mike Magee

In the shadow of last week’s Presidential Impeachment hearings, I have been searching for a silver lining. I tell myself it is helpful our Democracy is being stress tested and our Constitutional weaknesses revealed so that we might take corrective actions in the future. I recognize that this is not Trump’s fault alone but our’s as well, having supported a culture rich in celebrity idolatry, and one tolerant of unsustainable levels of inequity. And I acknowledge we live in a land of unbridled capitalism where solidarity and good government are diminished in equal measure.

So I was heartened to see our public servants, several of whom were first generation immigrants, display their competence, professionalism and courage in support of these United States. I want to believe that they, rather than their inquisitors, represent us. I want to believe that any fair-minded viewers could see our taxpayer money well invested in these remarkable women and men, and that we now better understand the art of diplomacy when contrasted with the bare knuckle hooliganism of Guiliani and his band of thugs.

My search for goodness led me back to 2010 and the Annual ADAP Convention at the Georgetown Westin Hotel. ADAP is a non-profit committed to making HIV/AIDS drugs affordable and accessible to all in need. I was honored and pleased to receive the invitation to deliver their keynote address that year from Executive Director, Brandon Macsata, who had been responsible for my original invite nine years earlier. That invite, in turn, was the result of Brandon hearing me address John Kemp’s Disability group the prior year. “Goodness spreads, you see.”, I told myself.

Brandon asked that I reflect on the role of “advanced professionalism” and “enlightened leadership”. To prepare, I relied heavily on a book my son, Michael, had published with the University of Alabama Press in 2004, titled, “Emancipating Pragmatism: emerson, jazz, and experimental writing”. The book derived from his PhD dissertation at the University of Pennsylvania, and extensively delved into the writings of both Ralph Waldo Ellison, author of “The Invisible Man”, and his namesake, Ralph Waldo Emerson.

So what did my son Michael say in his book that was so compelling that I turned to it that day, and return to it today, in the shadow of Trump-led Republican denials?

Page 3: Quoting Emerson, “To interpret Christ, it needs a Christ…to make good the cause of freedom against slavery you must be…Declaration of Independence walking.”

Page 7: On Fake News”, “Ultimately, Emerson came to believe that ‘America’ itself was a kind of text being read, its meaning a matter of collective decision. It followed that one’s linguistic theory, one’s view of how words generate meanings, had potentially large-scale social ramifications. In suggesting that words were ‘million-faced’, Emerson came to realize, he was suggesting that social possibility was remakeable.”

Page 18: On Change and Diversity, “Emerson writes…’the philosophy we want is one of fluxions and mobility’”.

Page 19: On the American Culture and Diversity, “‘Out of the democratic principles set down on paper in the Constitution and the Bill of Rights’, Ellison says, Americans ‘were improvising themselves into a nation, scraping together a conscious culture out of various dialects, idioms, lingos, and methodologies of America’s diverse peoples and regions’”.

Page 24: On the Emerson View of the Evolution of American Language and Culture, “We forget, conveniently sometimes, that the language we speak is not English, although it is based on English. We forget that our language is such a flexible instrument because it has had so many dissonances thrown into it ….from Africa, from Mexico, from Spain, from God knows, everywhere.”

Page 25 and 28: On Creating Our History, “The jazz musician—who, Ellison says, always plays both ‘within and against the group’ — constantly reflects and redefines the ensemble in which he plays. Likewise the ensemble reflects and redefines the larger community to which it belongs….that ‘anticipatory arena where actuality and possibility, past and present, are allowed to collaborate on a history of the future.’”

This has been a momentous week. We have made progress. We are not static, not trapped, not powerless or fixed in place. But there is much left to be done. This should neither surprise nor discourage. On the final page of Michael’s book, he writes, “An emancipated pragmatism happens whenever and wherever a creative mind or community of creative minds engages in democratic symbolic action.”

Democratic – Symbolic – Action. These are more than words. They are a culture of values. Our future is being written now. VOTE.

CODE BLUE: Sequel to The Social Transformation of American Medicine

Posted on | November 22, 2019 | No Comments

Background: www.codeblue.online

“Code Blue should be in every college Public Health and Health Policy syllabus in 2020!”

In the preface to his 1984 Pulitzer Prize winning book, “The Social Transformation of Medicine”, Princeton sociology professor Paul Starr states, “History does not provide any answers about what should be done… My hope is that this historical analysis may help to illuminate our present predicament even for people of diverse sympathies. I have sought to trace not only the origins of the institutions and policies that are with us today but also the fate of those that failed or were defeated or stunted in their development. I would not be sorry if these analyses of roads not taking serve as a reminder that the past had other possibilities and so do we today.”

Thirty-five years later, medical historian and health economist Mike Magee retraces the same path carrying it into the present and providing an invaluable sequel to Starr’s landmark text. In his acclaimed and comprehensive book, “Code Blue: Inside the Medical Industrial Complex”, Magee not only brings us up-to-date, but also takes us inside a conspiratorial and collusive network of health related corporations and associations committed to profitability over care. As the Kirkus starred review noted, he also  “suggests multiple sensible reforms in the realms of medical education, clinical research, publication of medical trials, marketing by pharmaceutical companies, and politically driven interactions within the Medical Industrial Complex.”

Paul Starr’s book changed the way students and professors looked at American health care, questioning whether it was “the best health care in the world.” Mike Magee not only picks up the trail and carries it into the present, but also explains and illustrates how we created the least efficient and effective health care system in the world, and (most importantly) what we should do about it now. Code Blue deserves a prominent location in the modern interdisciplinary college curriculum, and Mike Magee deserves a prominent position on the college speakers’ circuit.

Doctors or Entrepreneurs? The Triple Mission Problem.

Posted on | November 22, 2019 | 2 Comments

source: Science

Mike Magee

This week’s blockbuster investigative article in Science doesn’t pull punches. Its’ headline: “Investigation reveals widespread double dipping in NIH program to pay off school debt.” The article cites incontrovertible evidence of taxpayer dollar support for student debt loan forgiveness being granted to many clinical investigators (more than half MD’s) who are on for-profit industry payrolls. More than this, rules designed by the NIH itself to curtail double dipping and blatant conflict of interest rules were found to have been broken by the NIH and sponsoring academic institutions in 1/3 of the 182 cases studied.

The history of research fraud and abuse is covered in exquisite detail in “Code Blue: Inside the Medical Industrial Complex.” Spanning eight decades since WWII, academic medical leaders have been able to “have their cake and eat it too” by embracing the concept of a “triple mission” – as clinicians, educators, and researchers all in one. Fraudsters like Arthur Sackler knew well the value of wrapping themselves in academic garment – creating institutes, fraudulent journals, and bogus publications – to create professional CVs and public biographies that defined them as saints when in fact they were sinners.

This mingling of roles is somewhat unique to the Medical Industrial Complex (MIC). Even the Military Industrial Complex recognizes that Boeing is in the job of generating profit; that their paid research promoters are required to register as lobbyists, and that transparency and checks and balances are necessary to challenge outright greed and avarice.

The MIC supply chain, which now controls 1 in every 5 dollars in America, casts a wide net, and includes medical journals (dependent on income from advertising and reprint sales), continuing medical education, voluntary accreditation services, patient advocacy non-profits, and contract research organizations (CROs).

Attempts to bring rule-breakers to heel have repeatedly failed due to “triple mission” comingling. For example, to combat fraud by increasing transparency, in 1997 Congress passed the FDA Modernization Act, requiring that studies for life-saving drugs be registered on a new website, ClinicalTrials.gov, when the studies were initiated. The FDA broadened its criteria for which studies needed to be registered. After four years of experience, it was clear that companies were not rushing to the land of transparency. So, in 2004, the International Committee of Medical Journal Editors, which included editors from JAMA and the New England Journal of Medicine, elected to use their own power to force early disclosure of all studies. Their lever was a declaration that they would no longer publish research papers based on studies that had not first been formally registered on ClinicalTrials.gov.

When the $700 billion pharmaceutical industry threatened to cut off millions of dollars of advertising revenue, the standards-defending editors folded like paper tigers. They knew all too well that drug money, paying not just for ads but for bulk reprints of individual favorable articles, which their reps distributed to doctors, kept these journals alive. Debate and critique played out in critical articles in the journals themselves. For example, a JAMA article in 2009 criticized editors for purposefully vague directives such as “We encourage the registration of all interventional trials.” Authors also shared their analysis of the results of 323 clinical drug trials in the 10 top medical journals in 2008 and found that 176, or 55 percent, were inadequately registered.

In 2007, Congress ramped up oversight with an FDA Amendment Act requiring that all pharmaceutical trials, at any stage in the development process, be registered. It further required that all results, positive or negative, be posted on the site within one year of completion. Five years later, only one in five studies had met their obligations. A review of 8,907 studies that underwent mandatory registration on the government site over a three-year period (2009–2012) found that less than half had reported any results of those trials at all on the site. Five years later, a 2018 investigation revealed that barely three-quarters of the ongoing clinical trial studies had been registered to the site, and journals have not fully embraced the role of policemen for the government’s trial transparency efforts.

In some cases, academic researchers need only lend their name and credibility. For example, a 2011 study that analyzed 630 publications in JAMA, Lancet, the New England Journal of Medicine, Annals of Internal Medicine, Nature Medicine, and PLoS Medicine determined that, based on the voluntary admissions from the 70 percent of authors contacted who agreed to participate in the confidential survey, industry-hired consultants (ghostwriters) were involved in manuscript preparation in 12 percent of the research articles, 6 percent of the review articles, and 5 percent of the editorials—and that is without considering the 30 percent of authors who chose not to participate in the survey.

The numbers on first glance may appear to be small, but they are more than enough to undermine the credibility of these premier medical journals and undermine public trust in the medical evidence presented in these publications.

Any new health care system the nation develops should dismantle artificial protections for academic medicine’s “triple mission”. With 20% of the GDP in tow, medical research, like military research, can more than stand on its own two feet without shielding its behavior behind direct patient care activities. Entrepreneurial medical researchers deserve to be rewarded for their discoveries, but should not be confused with patient care physicians whose stock in trade is compassion, understanding, and partnership, and not dreams of fame and fortune.

“Socialized Medicine” – Can It Work One More Time?

Posted on | November 12, 2019 | 1 Comment

With excerpts from CODE BLUE: Inside the Medical Industrial Complex.

Mike Magee

In an interview that aired this week on Democracy at Work, Professor Richard Wolff asked me about the term “socialized medicine.” My response: Once our nation makes it through the Impeachment hearings, expect the Republican party to pull out the “golden oldies” when it comes to the health care debate.

Just this week, Trump (pro-Russian but not above using Red Scare tactics when necessary) found time to tweet, “These Democratic policy proposals … may go by different names, whether it’s single-payer or the so-called public option, but they’re all based on the totally same terrible idea: They want to raid Medicare to fund a thing called socialism.” At the same time, he continues to work diligently behind the scenes to destroy the Affordable Care Act including authorization of exploitative 364 day plans as “short term” and Medicaid work requirements designed primarily to destroy Medicaid outreach to our most vulnerable citizens.

Not exactly original. Way back in 1944, with Roosevelt elected to an unprecedented fourth term, supporters of a national health insurance program felt their moment had finally arrived. But then Roosevelt died suddenly, and Harry Truman was left to push for universal health insurance, a collective system of shared risk in which the high costs of the sick would be counterbalanced by the low costs of the healthy.

Studies at the time had confirmed and reconfirmed the weaknesses in the American health care system, in particular the fact that the poor and the aged, a rapidly increasing segment of the population, were especially vulnerable. Doctors and hospitals appeared to be inadequate, both in their numbers and in their distribution. Chronic disease was on the rise as soldiers arrived back home, and recent progress in new scientific treatments promoted by academicians of the day suggested that “disease could be eliminated” if only more research were funded.

Truman presented Congress with proposals for comprehensive national health reform. On November 19, 1945, he addressed Congress and had reason to believe his efforts would prevail. After all, weren’t taxpayers already funding the creation of national health plans for our vanquished enemies, Germany and Japan, through the Marshall Plan? Certainly they would support health care for our own citizens at home. But they met stiff resistance from the AMA, which labeled his call for national health insurance and the creation of a national medical board “socialized medicine.” To prevail, the organization teamed up with the Pharmaceuttical Manufacturers Association (now PhRMA) and enlisted the same PR agencies utilized by the tobacco industry to unleash a barrage of blistering warnings. The “Red Scare” worked like a charm leaving Truman to be satisfied with easily neutralized incremental changes.

As the decade wore on, a worsening chronic burden of disease in an increasingly aging American population kept the issue alive. The AMA responded by expanding its state and federal government relations budgets, and by organizing and launching the AMA Political Action Committee (AMPAC) in 1961. In this effort, they were not short on allies. Other provider organizations such as the American Hospital Association, the American Dental Association, and the American Nursing Home Association were equally nervous about allowing government to become their paymaster. Also lining up in opposition were the National Association of Manufacturers, the National Chamber of Commerce, the Pharmaceutical Manufacturers Association, and the Health Insurance Association of America.

To defeat legislation that would become Medicare, the AMA set out to generate thousands of “spontaneous” letters—notably from non-physicians—voicing opposition.  Their “trusted spokesperson” recruited in 1961 was a B-movie actor who had already made the transition to corporate spokesman, and who was also the son-in-law of an archconservative physician and Chicago-based AMA bigwig named Loyal Davis. The man in question, Ronald Reagan.

On the 78 LP record distributed by the AMA, in his most reassuring tones, Reagan fanned doctors’ families worst fears saying, “The doctor begins to lose freedom. . . . First you decide that the doctor can have so many patients. They are equally divided among the various doctors by the government. But then doctors aren’t equally divided geographically. So a doctor decides he wants to practice in one town, and the government has to say to him, you can’t live in that town. They already have enough doctors. You have to go someplace else. And from here it’s only a short step to dictating where he will go. . . . All of us can see what happens once you establish the precedent that the government can determine a man’s working place and his working methods, determine his employment. From here it’s a short step to all the rest of socialism, to determining his pay. And pretty soon your son won’t decide, when he’s in school, where he will go or what he will do for a living. He will wait for the government to tell him where he will go to work and what he will do.”

Of course, that was then and this is now. As we speak, strong majorities of American favor universal coverage, health care as a right, and protections for those with pre-existing conditions. In addition, Democratic presidential candidates all support expansion of a public insurance offering as at least an alternative to private health insurance.

Faced with the threat of a single payer, government run system, the AMA has come out in favor of strengthening the Affordable Care Act. They also have quietly resigned from the Medical Industry Complex (MIC) lobbying sham cabal, the Partnership for America’s Health Care Future, stating they were leaving “to devote more time to advocating for these policies that will address current coverage gaps and dysfunction in our healthcare system.”

In the end, we’re fast approaching the point where politicians and medical leaders will have to choose. Do you side with patients or with MIC profiteers?

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