HealthCommentary

Exploring Human Potential

How to gin up the Base: “Repeal and Replace” – again?

Posted on | May 21, 2018 | No Comments

Mike Magee

It’s been 11 months since Sen. John McCain (R-AZ) gave the thumbs down to repealing Obamacare. But get ready for another push at “Repeal and Replace!” That’s what’s circulating within the halls of Congress right now. This has little to do with over-riding the wishes of the majority of Americans, and more to do with riling up Trump’s base for the 2018 mid-terms.

Still the fire drill will once again require a mandatory push back. If there is any silver lining, it may be that accompanying polls will likely reveal that Americans are inching ever closer to a universal approach with “single payer/multi plan” efficiencies.

During the last attack on the popularly supported ACA, veteran Health Policy expert, James A. Morone, Ph.D., made an interesting argument for single payer health care in the NEJM. In proposing a sweeping change that would directly address “the American patchwork”, assert “the norms of communal decency”, promote planning and efficiency, and empower “a righteous band of reformers, deeply committed to a cause, pushing against all odds”, he did not sidestep higher taxes on the rich.

Rather he sold into them, presenting high taxes on the rich in return for universal health coverage as “on a short list of available policies designed to push back on inequality.”

His argument boiled down to the fact that a central element to the populist anger that helped to elect Trump was our remarkable income inequality. In roughly a half-century, our separation between rich and poor that used to mirror France and Japan, now aligns with Mexico and Brazil.

Our top 1% controls roughly 40% of all wealth, while the bottom 90% manages a paltry 23%. If you’re a white family in America, you were born lucky. On average, your family is about 10 times as wealthy as your black family counterpart.

But what about taxes, and distrust of “Big Government?” Morone reminded us that major policy changes can, and have, flipped on a dime in the past. As he wrote, “Disruptive populism ended past American gilded ages, and it shows signs of challenging the current one.” With better health delivery, and more equality and social justice, we might also redirect the course of American politics and American politicians.

What Trump and his Congressional enablers are doing is fairly transparent – they are intentionally undermining the two critical pillars of American society, truth and trust. The rehashing of “repeal and replace” force one more look in the mirror for all Americans trapped within an epic American struggle over how to topple the health care status-quo, a Medical-Industrial Complex controlled and directed by members of the 1%.

The outcome hangs on whether we – the citizens – are able to discern fact from fiction.

The key question for health reform and for the future of America: Do we trust our own government to assure each of its citizens have the right to “life, liberty, and the pursuit of happiness.”

So if we must, let each of us repeat once again the principles that define why universality through a simplified, single payer methodology makes common sense for Americans today:

Universality: Health coverage is a right of citizenship.

Public Administration: Administration of basic health coverage is organized in the most cost-efficient manner possible with central oversight by the government.

Local Control of Delivery: The actual delivery of services is provided by health professionals and hospitals at the local and state levels.

Health Planning a Priority: Creating healthy populations is a high priority on the federal and state levels.

Transparency: Providers submit bills. Government ensures payment of bills. Patients focus on wellness or recovery.

Juul – Fun Facts!

Posted on | May 14, 2018 | 3 Comments

Mike Magee

Most everyone by now has heard about Juul, the leading brand name for e-cigarettes. But, for most of us, that’s where our knowledge begins and ends – except for a growing awareness that there’s a controversy brewing about risk, teenage use, school policy, and profiteering by Big Tobacco which is getting a piece of the action.

So here are the facts:

Juul is a thin high tech vaporizer about half the width and half the weight of a Bic lighter – which means it’s easy to hide and conceal in your hand. It costs $34.99. The habit forming experience is called “vaping.” Juul is the market leader with 60% of all e-cigarette sales.

A juul is the energy required to produce one watt of power for one second. So there’s that, but also the name evokes the preciousness of a rare jewel as well.

It’s flavored nicotine package, called a pod, is the size of a thumbnail and comes in eight flavors (mango and mint are the best sellers). The pods each contain the amount of nicotine in a pack of cigarettes. The nicotine makes up 5% of a pod’s weight. A pack of 4 pods caosts $15.99.

40 million Americans continue to smoke cigarettes. Cigarettes remain the #1 cause of preventable death in the U.S., killing about 500,000 Americans a year.

Teen smoking of cigarettes continues to decline, but new school “vaping” in on the steep incline. Sales are up 25% over last year at $5 1/2 billion (still small compared to $120 billion in U.S. cigarette sales).

E-cigarettes were invented by Chinese pharmacist Hon Lik who patented the heating device that vaporized liquid nicotine in 2003. Juul’s high tech vaporizer comes from China. It’s liquid nicotine is stored in five-gallon containers and is made in the U.S. but no one knows where – big secret!

A cigarette has over 600 ingredients. Juul has five – glycerol, propylene glcol, nicotine, benzoic acid, flavoring.

Juul employs 400 workers. The 54 year old CEO, Kevin Burns, came from Chobani in 2017. He’s their positioner, saying that Juul is the “cigarette killing company.” The company has its own PAC now and is trying to fight off FDA regulation.

High school administrators are going nuts trying to keep Juuls out of the classroom. Use under age 21 is technically illegal. But you can get it on the Internet and there’s a brisk drug trade inside school walls by enterprising students. Kevin Burns has a new wave answer – Jule’s new “mindfulness curriculum” – and a new Android app to track your nicotine intake.

Jonathan Winickoff, former chair of the American Academy of Pediatrics Tobacco Consortium, isn’t too impressed. He says: “Juul is already a massive public health disaster.” The Heart Association and Lung Association also oppose exposure to this “lethal and addictive” substance.

But David Abrams, former director of the Office of Behavioral and Social Sciences Research at the NIH, isn’t too worried about kids vaping their brains off. It’s only nicotine, adding reassuringly, “It changes your heart rate a little bit…” As for the pediatricians, he adds: “The AAP is doing its job. And we should be protective of kids. But there are adult lives at stake, too.” Abrams believes that over 6 million lives a year would be saved if 10% of American smokers switched to Juuls.

Guys like Abrams like to quote anti-smoking guru Michael Russell who said in 1976, “People smoke for the nicotine, but they die from the tar.”

The kids love the Juul in part because it’s distinctly their’s with its sleek design, ability to be personalized, armed with its own circuit board, and upsetting to school officials and parents alike. It’s deliberately “not their parents cigarette” – no tip glow, no rounded tube – and yet it still “peps you up while calming you down.”

And that’s why 50% more middle-schoolers and high schoolers in America now vape than smoke.

Cutting Safety Net Sends Health Status Lower in U.S.

Posted on | May 8, 2018 | No Comments

Mike Magee

A Commonwealth Fund study in 2015 compared 13 nations on cost and quality. As most know by now, the U.S. finished near the bottom in quality measures and at the very top, by far, in cost. But the chart that drew my attention was the one above showing health expenditures vs. total spending on all other social services combined.

As you can see, the U.S. is the only nation that spends more on health care (by a margin of 2 to 1) than all of our other social spending combined. What are the consequences of such short-sightedness? Let me share just two from the news this week.

1. Nutrition:

In the U.S. we invest remarkably little taxpayer money on nutritional education. Instead we relegate that space to food and beverage companies in the name of free enterprise, and have convinced ourselves that their advertising has an educational component. So we should not be surprised that that latest obesity numbers are the worst ever.

Our overall obesity incidence in 2016 sits at 40%, up from 34% a decade ago. Extreme obesity has risen from 5.7% to 7.7% during the same time frame. The five worst states now have obesity rates greater than 35%

Obesity accounts for 18% of deaths and is the leading cause of death in the U.S. It is a contributor in 40,000 cancer deaths a year, and obese people are 2.5 times more likely to die of heart disease.

Other nations address obesity through national social services programs that emphasize nutrition education, local access to healthy foods, aggressive taxing of unhealthy foods, school programs focused on nutrition and exercise, and general public health campaigns.

2. Poverty:

The majority of Americans will now experience poverty some time in their lifetime. For those age 25 to 60, 62% will experience at least 1 year in the lowest 20% by income, and 42% will spend 1 year in the lowest 10% by income. Your chances of poverty increase if you are young, nonwhite, female, not married, have a high school education or less, or have a work disability.

Childhood poverty cost the nation $1.03 trillion or 5.4% of its GDP in 2015 by undercutting productivity, engaging in crime, or suffering poor health. For each $1 spent to ameliorate poverty, our nation would save $7 in the economic costs of poverty.

This week President Trump vowed to further compromise social spending levels approved by Congress in their 2018 budget agreement. As with all things Trump, members of his own party in Congress have remained mute.

They should take heed of Mark Rank’s recent New York Times editorial. He’s a professor of social welfare at Washington University, and wrote: “Instead of slashing an already weakened safety net, we should be following the example of most leading countries, which have built effective support systems that prevent poverty. By doing so, we would give our children a much better chance of reaching their full potential, which benefits us all.”

Where will reform come next, and who will lead the way?

Posted on | April 16, 2018 | No Comments

Mike Magee

“On résiste à l’invasion des armées; on ne résiste pas à l’invasion des idées.”  – Victor Hugo.

It’s useful for all health professionals  to reflect on the words of this 19th century French writer. The translation: “Greater than the tread of mighty armies is an idea whose time has come.”

As the AEI chart above illustrates, there is growing collective awareness that our health care system is breaking the bank as it fails to deliver a healthy America while robbing resources from other critical societal needs that contribute to our health and wellbeing.

Hospital cost inflation over the past two decades tops the inflation list above at over 200% with general medical care weighing in at 125%. One in every five dollars consumed by health care today goes to our medical-industrial complex.

Warren Buffett’s assessment that “Medical costs are the tapeworm of American economic competitiveness”  is right on. His critique has focused on data, cost, and level of engagement. We are challenged by the virtual absence of national health planning and a massively inefficient delivery system.

One of the pillars of resistance to addressing the status-quo, the medical establishment, is eroding as we speak. More than half of all physicians are now corporate employees. Teams with “physician extenders”, known by their patients as health professionals, are the standard, not they exception. Physicians sloppy prescribing has ignited the opioid epidemic and exposed them as easy marks for health product marketers. And it’s not just opioids. Witness anti-depressant addiction especially in women over 55 or poly-pharmacy in seniors nationwide.

Quality issues beg for health delivery disruption. Add to this that there is more than enough money in the system were it to be redirected. The centralized standardization of basic benefit packages and billing systems alone would deliver a 15% savings on our $4 trillion plus annual spend right off the block. Centralization is not socialization. Delivery solutions in all developed nations involve public/private solutions executed on a local level.

In our own country,  we are witnessing the emergence of “disruptors.” The current favorite for speculators in the health sector is CVS who has a $69 billion offer to purchase Aetna on the table. In this week’s JAMA, the new Panning Dean of the new Kaiser Permanente School of Medicine, geriatrician and medical ethicist Christine Cassel offered her analysis.

She notes that CVS has 9700 stores nationwide and 1100 attached retail clinics thus far. Leaders of the corporation envision providing “10,000 front doors” to patients of the future.

CVS’s growth in direct care thus far has been based on access and convenience – and sometimes physician choice. For example, when I was due for a shingles vaccine recently, my internest ( who is employed by a corporate health system)  elected to send me to the pharmacist next door rather than spend time (and money) himself.

Another CVS standard is pharmaceutical continuity and delegation of care to non-physicians. Offerings at first were limited, but they are rapidly approaching the offerings of most primary care offices, quite a feat since CVS has made a minimal investment as yet in adequate brick and mortar to house the services. Cost-effectiveness is also a goal with almost all services coming in under $100, and insurers welcome.

CVS has also been making a run at the status-quo with data (They now own a dominant PBM and will soon add a major insurance database). All that’s left is engagement. Specifically, they need to connect to existing health care systems. With Aetna, they may have a running start since the insurer has been active in the Medicare Advantage plans and in Medicaid risk bearing health delivery, both proposed as vehicles for a public march toward universality.

But they needn’t wait for Aetna – and as it turns out, they haven’t. Four years ago, the Advisor Board reported that CVS already had formal relationships with 350 hospitals in addition to clinics and physician groups. In the D.C. area at the time they were integrating their electronic medical records with MedStar Health’s 10 hospitals and 4000 doctors, and promising the system’s patients the future ability to access their medical records at any of the CVS stores nationwide. And it wasn’t just MedStar. At the time CVS had 41 similar health-system agreements formalized. That was four years ago.

But has “the time come” as Victor Hugo professed?

Consider the politics in addition to the financials. For the past two years we have witnessed our worst tribal instincts on full display. In general, America’s goodness has so far survived and appears to be  growing in strength and organization whether it be teens rising up against gun violence, media on hyper-alert as they face off  “fake news” or the independence of our Justice System reinforcing through action that “no one is above the law.”

The 2018 election could create the momentum for a push toward solidarity and a refocus on positive values. If so, at least based on the chart above, health care reform and educational reform will likely lead the way.

“On résiste à l’invasion des armées; on ne résiste pas à l’invasion des idées.”

You Are Your DNA – or Are You???

Posted on | April 10, 2018 | No Comments

Source:
U. of Utah Epigenetics

Mike Magee

Early in my career, embryology and physiology competed for my affection.

What they had in common was functionality – one developmental with time dependent triggers and the other driven by feedback loops with humoral packets of information traveling through blood channels or along neurons.

I viewed both processes as eloquent, intricate, and genomically dependent. But what appeared so concrete to me then, is being challenged by modern science in the name of epigenetics.

The epigenome is nuclear information and is inheritable, but it’s also plastic. It contributes to cellular development and differentiation during embryogenesis, but its’ messaging can be modified by random chance changes or by environmental exposures.

All cells of the body have the same DNA, but they evolve during development assuming specialized functions. How is that possible? The answer is in part that the cells add epigenetic genomic information to their own genes.

The University of Utah’s Epigenetic training site says “The genome is just the A,G,T,C bases that encode proteins and other mRNAmolecules.  The “epi”genome are various modifications to the DNA – such as methylation (at C residues) – and acetylation of histone proteins.   These changes help the DNA form various secondary and tertiary structures that can facilitate or block the interaction of DNA with the transcriptional machinery.”

Conrad Waddington first described the “epigenetic landscape” in 1950 as the evolving specialized development of pluripotential stem cells. The instigators were presumed to be imbedded somehow in the DNA. But a more modern construct suggests that there are modifications and/or additions to the DNA, some driven by environmental factors, and that these modifiers are maintained in future cell divisions.

This not only modifies our view of embryology, but also of the aging process, the dietary impact on health, and the pathogensis of cancer and its metastatic spread.

For example, nicotine instigates epigentic changes in smokers and in cord blood and the placenta.

Almost all tumors have documented gains and losses in their cellular DNA. Where in the past cancer was viewed as many diseases, scientists are now beginning to believe they have more in common than previously thought, and that the essential common feature is a “disrupted and unstable epigenome.”

With wholesale availability of genetic testing, citizens are putting down their money to identify their genetic predisposition to disease. The problem is that this picks up only a very small fraction of ones vulnerability, failing to capture the role of the environment which scientists are now saying may account for 80% of ones disease risk.
Inflammation, diet, toxins and more deliver their destructive punch through an interaction between genes and the environment, and epigenetics – whose chemistry is now being structurally defined – likely mediates these destructive changes, as well as potential new therapies.

U.Utah Epigenetics

Finally the issue of epigentics and inheritabilty. The Utah experts suggest, “The sketch … tries to explain why epigenetic effects can, in practice, be difficult to disentangle from true (changes in the A,G,T,C sequence) genetic effects.  This is because – for one reason – a mother’s experience (extreme stress, malnutrition, chemical toxins) can – based on some evidence – exert an effect on the methylation of her child’s genome… if the daughter’s behavior or physiology were to be influenced by such methylation, then she could, in theory, when reaching reproductive age, expose her developing child to an environment that leads to altered methylation (shown here of the grandaughter’s genome).  Thus, an epigenetic change would look much like there is a genetic variant being passed from one generation to the next, but such a genetic variant need not exist – as it is an epigenetic phenomenon.”

So, are you really your DNA, or something more? Stay tuned!

DACA and the Health Benefits of a “Shot at Upward Mobility”.

Posted on | April 6, 2018 | No Comments

Mike Magee

A recent paper from the National Bureau of Economic Research, reported out in The Atlantic, began with the health outcomes in DACA children but ended with thoughts on why a teenage girl in Mississippi is 15 times more likely to give birth than her counterpart in Switzerland.

DACA is a favorite topic of President Trump along with claims of immigrant hordes and the scourges of NAFTA. Deferred Action for Childhood Arrivals (DACA) is an Obama initiative that shielded 1.3 million children who arrived initially with their illegal immigrant parents, and who then stayed and worked legally in the U.S. The legislation allowed registration and subsequent protection from deportation for renewable 2-year periods.

The success of the program was highly dependent on these vulnerable individuals trusting their government, and believing it would not subsequently turn on them once they came in from the shadows and exposed themselves thru registration. As is clear now, that is exactly what Trump attempted to do. Up till now court rulings have checked his predatory instincts.

The NBER paper makes the point that the elimination of DACA would not only be a remarkably callous and unethical move, but it would also have significant negative health consequences.

It turns out that DACA kids have been doing quite well since Obama set them free. High school graduation (a requirement of DACA) has increased 15%, college attendance is up 25%, and teen births have declined 45%.

What’s most interesting about these results is what they tell us about the relationship between optimism and health outcomes. These authors and others in the field believe that hope for the future ignites course corrections in teens. They see the future though different glasses. Their education, work/study jobs, drivers licenses, and lower stress, combined with the promise of higher wages in the future, lead to less high-risk behavior in the present.

Multiple prior studies have suggested that the option of pregnancy for a teen is often an active choice when other options for a promising future are removed. Teen pregnancies and births outside of marriage track with advancing income inequality.

Mississippi is Mississippi and not Switzerland when it comes to life expectancy for mothers and babies as much because of hopelessness as anything else. There is a price to be paid each day, for DACA kids and each and every American, for a culture absent universality and solidarity. Health breeds wider choices and better futures. #2018 elections.

 

What Uwe Reinhardt (or Angus Deaton) Would Say About HC Costs.

Posted on | March 19, 2018 | No Comments

Mike Magee

A March 13, 2018 article written by scholars from the London School of Economics and published in JAMA focused on an all too familiar subject – comparative health care costs in America. That article was accompanied by a number of editorial reaction pieces including the one written by Zeke Emanuel who generated the comparative pricing chart below.

In general, most all agree that the facts suggest that in four areas – drugs, high volume/high margin interventional procedures, radiologic imaging tests, and administrative costs – the U.S. is financially out of whack. Other commentators placed a spotlight on our encouragement of “monopolists” in pursuit of “innovation”, and our reckless spending priorities at the beginning and end of life.

In return we have the dubious distinction of generating 57% of new chemical entities, at least some of which add little extra and have been advanced through DTC ad-driven market expansion with the tacit support of remarkably gullible over-prescribing physicians. And of course those new “Right-to-Try” policy shifts advocated by Trump should just add to our “American exceptionalism” in health.

One editorial written by two JAMA editors was entitled “What Uwe Reinhardt Might Have Said.” The much revered Princeton health economist who recently died was known for not pulling punches. In one analysis of our private health insurers, he documented that 18 cents on every insurer’s dollar was spent on “operations” which included “marketing, determining eligibility, utilization controls (eg, prior authorization of particular procedures), claims processing, and negotiating fees with each and every physician, hospital, and other health care workers and facilities.” All of this, he charged, proceeds within a “shroud of secrecy.”

Were he to be alive, the JAMA editors predicted he might have commented on “the many self-interested parties, including professional societies, patient groups, hospitals, drug and device manufacturers, and insurance companies, that profit from high health care spending.” Noting that Reinhardt often would initiate a comment with the phrase, “You Americans”, the editors offered two probing questions he might have posed:

1. “How can the US health care system and health care spending be recalibrated to ensure basic care for all US residents, particularly the less fortunate?”

2. “How is it possible to overcome the shortchanging of many other important sectors of society, including education, infrastructure, and the environment, because of the high cost of health care?”

Such comments only gently scratch the surface of the Medical-Industrial Complex’s full culpability. Were Reinhardt still alive, he would have done well to illustrate his legitimate points with the case study first exposed by his Princeton colleague, Angus Deaton. The still raging opioid epidemic demonstrates how far astray a health care system can wander when based on profit and greed rather than on planning and prevention; and how the leaders of Medicine, including those who own JAMA, played a critical role in igniting this disaster which continues to divert precious resources as it claims more and more American lives.

To my knowledge, they have never acknowledged or apologized for their institutional role in legitimizing Purdue-Pharma funded specialty pain societies; provided an advertising vehicle for their product, Oxycontin; and willingly enabled Purdue Pharma’s soft target, data driven physician prescription profiling through sales of their physician masterfile database.

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