HealthCommentary

Exploring Human Potential

How Long Will You Live? Check Your Zip Code.

Posted on | March 6, 2018 | No Comments

RWJF has created this interactive tool which looks at life expectancy by Zip Code. Check it out HERE.

The Simplification Movement in American Healthcare

Posted on | March 5, 2018 | No Comments

CDC Obesity Map

Mike Magee

As the debate over health care in America rages on, the great lie oft repeated but never defended is that our system is exceptional and too complex to wrestle to the ground. That is the breech, reinforced over half a century that has left our citizens and now our entire economy at risk. The truth is, the solution is rather clear, the resources available, and the liability of continued inaction of mounting concern.

How do we make America healthy? Before we address this critical baseline question, let’s first tackle another, “Why should we make America healthy?” The answer to this question could go on for pages but the short-hand response is that healthy citizens maximize human productivity and societal stability. If the idea is to make America as great as it can be, then healthy citizens are the starting point.

So, how do we make America (and Americans) healthy? Whatever we decide to create and provide in pursuit of this fundamental goal, it must be universally and simply available to all citizens. This is because we are an inter-dependent species. We are only as well, or as productive, effective and mutually supportive as the weakest link in our chain. Insecurity breeds insecurity. Fear and dislocation breeds fear and dislocation. Despair undermines our collective futures. So whatever we offer to promote and assure a healthy America must be available at the outset, and with certainty and simplicity, to each and every one of our citizens.

Logic dictates that the execution and management of this offering should be designed to consume as few resources as is humanly possible. The more we consume in the offering and financial management of universal basic health coverage the less will remain for actual services. This simple reality is why most nations have centralized the primary back room functionings of coverage and financial administration. Where most industrial nations (and our own Medicare) consume 5% to 10% of total health resources on this first step, our complex free-enterprise and employer dependent approach to the offering consumes as much as  25% of total resources while failing to ensure universal coverage.

If all must be covered, and the administration of the offering must be a public and centralized responsibility to assure accountability, uniformity, and cost-effectiveness, that leaves the definition of services and the actual delivery of services. These need not, and some would argue should not, be centralized. A basic package of services should be required of all, and not all services are affordable or even desirable. For example, Canadians universal health plan covers on average 70% of the total cost of health care for Canadians. The plan does not cover pharmaceuticals, optical needs or dentistry. Citizens who wish to can purchase private supplemental plans to cover these costs. Furthermore, plans total offerings vary from province to province, as defined by budgets and priorities set by provincial governments year to year. Hospitals are funded by the provinces, and doctors (who on average make more than American doctors) are largely reimbursed fee-for-service. Ample leeway, state to state, as we see with Medicaid, could be offered to allow a reasonable amount of experimentation and choice.

This combination of central control and management of insurance coverage and local responsibility for budgeting, prioritization, and quality assurance has consistently outperformed America’s purposefully complex free-enterprise health sector free-for-all for over a half century. Our complex approach under performs by almost every health measure, costs nearly twice as much, and has patient satisfaction ratings of only 25% in the latest polls. We have paid dearly for our complexity in funding an astonishing array of “non-real work”. We support nearly a half million individuals selling and managing health insurance in the US, and and equal number of hospital and physician office coders and billers on the other side working diligently to get payments from the mostly for-profit insurance companies.

But our fundamental error or conceit dates backs to 1947, as we exited WWII and considered how best to manage an enormous chronic burden of disease. Lead by Vannevar Bush, whose military approach to scientific collaboration had provided new blood products, penicillin, and the atomic bomb, our leaders concluded that a similar unencumbered collaborative free-enterprise approach could defeat disease as it had defeated the Nazis. By omission, their definition of health was the absense of disease. Defeat disease and health would be left in its wake. Fund the effort on the backs of employers and unions as a benefit, and ignite collaboration and a collusive integrated career pathways with federal dollars and enabling patent legislation and victory was assured.

In contrast, Canada took the time to earnestly ask “How do we make Canada (and all Canadians) healthy?” In response, they created universal coversal and continuously refined their answer to this basic question. By 2010, prevention, not intervention, surfaced as mission central. In their words: “Health promotion is everyone’s business. While it is clear that health services are a determinant of health, they are just one among many. Others include: environmental, social and economic conditions; access to education; the quality of the places where people live, learn, work and play; and community resilience and capacity.”

It really matters little whether Republicans prevail in their regressive efforts to reinforce over a half century of failed health care policy. The die has been cast. As Warren Buffett recently stated,  “Medical costs are the tapeworm of American economic competitiveness.” The cost and inefficiencies have been well documented including:  High administrative costs with 850 health insurance companies selling to millions of employers; high costs passed on to employees in rising contributions and lost wages with the burden weighing more heavily on low income employees; employees of small firms and the unemployed/underemployed left out of coverage; employment based insurance the major contributor to bankruptcies and poor labor relations; and finally a coverage system that discourages worker mobility and advancement. Together, these fatal flaws in a single sector of our society are bringing us to our economic knees.

Whether now or in the future, we will be forced to ask that simple question, “How do we make America (and Americans) healthy?” In responding, we will not be limited by resources. More than ample resources, currently misapplied, have already been dedicated to these services. We need only to recognize that health is not the absense of disease, and mirror Canada’s simple 2005 proclamation:  “As a nation, we aspire to a Canada in which every person is as healthy as they can be—physically, mentally, emotionally and spiritually.”

Parkland Teens Teach “Positive Leadership”!

Posted on | February 28, 2018 | No Comments

nbcnewyork.com

Mike Magee

At this time of year my wife and I always try to see the movies nominated for an Academy Award. Recently  we saw Darkest Hour, up for Best Picture as well as a Best Actor nod to Gary Oldman in his role as Winston Churchill. The film begins with Dunkirk and the historic private flotilla evacuation which Churchill directed as his advisers were defining the move as a hopeless cause and insisting that Britain’s only option was to surrender to the overwhelming German forces.

 

 

 

 

 

 

As I viewed those opening scenes, I couldn’t help but be reminded of a the maritime evacuation of Manhattan Island on 9/11 – 300,000 evacuated by mostly private vessels responding to a Coast Guard call for “All Available Boats” – documented in a book by the same name. But it was not only the vessels and rescues that drew the comparison but Oldman’s performance itself which reminded me that in times of crisis, such as the recent Parkland shootings, leaders must emerge who are unafraid and determined to guide us through to safer shores.

We are currently being challenged by destructive change and negative predatory leadership. Change is one of the few human conditions that can simultaneously support two diametrically opposed human emotions, fear and exploration.  Change is the critical lever in leadership.  Pull it one way and you create a positive leader.  Pull it the other and you create a negative leader. 

Negative leaders are short-term thinkers who use fear as a currency to herd people together and move them in whatever direction suits their needs.  It is a short term, successful strategy, but suffers from a critical weakness, and that is that heightening fear causes people to retrench, reinforcing old beliefs and behaviors, naturally segregating segments of society, reinforcing silos and resisting change.  In the short and medium term, fear can hold a population in place, even as the world around them continues to change.  But the inability to evolve, to stay in step with or ahead of a changing world, insures that negative leaders will eventually fail.

In contrast, positive leaders like the Parkland high school students view change as exploration, and lead with vision rather than fear.  Their view is longer term and they reach out across the divide.  Rather than segregate, they congregate.  Rather than build walls and silos they build islands of common stewardship.

As the Parkland shooting and its aftermath well illustrated this week, Americans currently live in fear. Why should this level of fear concern us?  Well first, fear is the currency of negative leaders, and they are more likely to emerge and succeed in a fearful environment.  Second, fear undermines trust, and trust is the fabric of a civic society.  Third, fear clearly has short and long term mental health implications.  Fourth, fear accumulates, especially in those who are already fearful.  Post 9/11 studies showed clearly that fear biased women and minorities.  Finally, fear obstructs vision, actively discouraging imagination, innovation and hopefulness.  In compromising our wonder and inventiveness, fear fundamentally alters our collective future.

The Parkland teens, with their family’s support, and the coalescent of high schoolers across the nation this week have taught us all a thing or two about how to manage fear.  First, they have identified, nurtured, and advanced individuals with the values and temperament to become tomorrow’s positive leaders.  Second, they have incorporated fear management into their academic curriculum.  Third, they reinforced the value that human beings should never remain silent in the face of evil.  Forth, they have honored the ties between individual, family, community, and society; and in the process personalized and individualized their efforts in a manner that honors diversity and respects cultures.  Fifth, in confronting the NRA, they have embodied the belief that judgment is at least as important as decisiveness, and that militarizing America is a poor judgment which ensures faulty decisions under stress.

People are basically good, but they are not perfect.  People are basically kind, but when afraid they may act unpredictably.  People are basically loving, but when misled respond with hatred and contempt.  People are people.  That is why we must continue to devote as much time and energy to the preparation for peace as you do for the preparation for war.  For our homeland will never be secure if fear has so weakened the fabric of our society that we lose the capacity to be human and humane toward each.

#2018 Election.

Health Reform – Is This a 1960s Moment?

Posted on | February 12, 2018 | 1 Comment

Mike Magee

Quietly rising out of the ashes of the Republican led campaign to “repeal and replace” the Affordable Care Act, are pragmatic efforts, not focused on “if”, but focused on “how” and “when” the U.S. will join all other developed nations and provide all of her citizens with affordable, high-quality care.

Last week, a new bipartisan coalition led by Obama-era health policy guru, Andy Slavitt, and former Republican senator, Bill Frist, called the “United States of Care”, was announced. A consensus building effort featuring early listening tours, policy papers from the University of Pennsylvania, and a commitment to long-lasting solutions, did lay out four “musts” including: 1) universal (”every American without exception”), 2) high quality, 3) efficient (which included affordable for all, and sustainable for the country financially), and 4) equitable (no exclusions of coverage).

Grounded in optimism and consensus building, the “United States of Care” believes they can “redefine the goal in human, not political terms.” They make sure to tip their hat to American exceptionalists at the center of the Medical-Industrial Complex by stating that, “America leads the world in so much of health care. We drive world class research and…scientific innovation…that the rest of the world benefits from.” And “we have a highly trained clinical workforce that is the envy of the world.”

Of course, whether those innovations and skills deliver full human potential for all Americans or simply profitability for the entitled remain richly debated. But to their credit, they say straight up that we have real problems – vulnerability, limits on access, and unaffordability – which translate into “living in fear.” Bill Frist writes, “Our patient is the United States health care system, and it is very sick.”

If there is good news, most agree it comes in two forms: 1) There is ample money on the table if only it can be efficiently redirected. 2) Individual states, unleashed by Obamacare inducements, are in an experimenting mood. It is at these states that Slavitt and Frist and cohorts are targeting their listening tour with a subheading “Galvanizing Public Opinion and Taking the Conversation to the States.”

Institutional partner, U Penn, has added granularity in a white paper of its own. Opening with the fact that 28 million of our citizens continue to lack insurance coverage, they emphasize that coverage = access to 5 critical realms; primary care, preventive care, chronic illness treatment, medications, and surgery. (Left unaddressed is whether too much of any of these things might make you sicker rather than healthier.)

The paper then analyzes five states that have had a go at universal coverage including MA, VT, CO, NV, CA. In general, they all were focused on closing the “coverage gap”. But they had multiple other objectives as well including: cost-control, stabilzation of state insurance markets, and more choice of plans.

The analysis demonstrates that there are multiple pathways that lead to universality, just as there are many ways to undermine solidarity including: 1) Lack of clarity on financing, 2) Lack of clarity on long term sustainability, 3) Private sector fears of price controls and job loss, 4) Unclear federal government support for state-based solutions, and 5) Proposals that suggest drastic tax increases.

There is a certain amount of déjà vu to the “Can’t we all just get along?” model of health reform.  After all, the AMA and allies used “Red Scare” tactics, fighting tooth and nail in the late ‘50’s and early ‘60’s to block progress in health coverage. Their main strategy (coordinated with other members of the Medical-Industrial Complex) was to feign cooperation and offer voluntary policy pablum, while at the same time hiring GE’s Ronald Reagan to mobilize letter-writing doctors wives and rent the Madison Square Garden for a rebuttal speech to JFK’s appeal for expansion of health care.

At the end of the day, it was LBJ pulling Wilbur Mills strings, that carried the day and rammed Medicare and Medicaid through. Once there, American seniors couldn’t quite figure out how they ever managed to live without it.

Now those very same Americans, and their children and grandchildren, hold the strings to our futures – with the 2018 election just 10 months away.

 

Health Coverage “Black Eye” Needs a #MeToo Wake-Up Call.

Posted on | February 10, 2018 | 2 Comments

Mike Magee

It came as no surprise to #MeToo’ers across the nation that Gen. John Kelly expressed “shock” about Rob Porter’s eye-blackening abuse of his first wife, of which he was informed months before; any more than they were taken aback that Mike Pence fell back on his now well-worn defense, “This is the first I’ve heard of it.”

Their complicity is obvious to them and each of us. In Porter’s second wife,  Jennie Willoughby’s haunting post describing her experience, she well describes her hostage status with these words, “Everyone loved him. People commented all the time how lucky I was. Strangers complimented him to me every time we went out. But in my home, the abuse was insidious. The threats were personal. The terror was real. And yet I stayed.

Arguably, wives Colbie Holderness and Jennie Willoughby thought they had done enough when they warned FBI agents who were completing an investigation for Porter’s security clearance. But we likely must thank the #MeToo movement for providing them enough courage to speak up when the system failed, knowing that now their stories will be believed.

But Willoughby’s “Why I Stayed” post points to a larger problem – an institutional problem – which remains for #MeToo and all of us to address. Porter like Pence and Kelly and others lied convincingly and selectively, leaving Willoughby on the institutional out’s. In her words, “Friends and clergy didn’t believe me. And so I stayed.” A portion of our most autocratic leaders in and out of the government have been nurtured by a culture whose institutions are more than comfortable with gender abuse on a grand larger scale.

Consider the American health care system. Over the past three decades, death during pregnancy in America has increased from 7 per 100,000 live births to 18 per 100,000 live births. In the 2015 global rankings, the U.S. ranked 9th in economic status, 16th in education, 61st in maternal health, 42nd in childhood wellbeing, and 89th in female political status.

Back in 1998, when Viagra was released, and without a great deal of effort secured insurance reimbursement far and wide, the American College of Obstetrics and Gynecology went to the mat on gender bias, noting that 1 in 3 pregnancies was unintended, and demonstrating that reimbursement for contraception was still largely absent across America. Within a month, 2.4 million federal employees received contraceptive coverage.

With the passage of the Affordable Care Act, women thought the issue of contraceptive coverage had been finally resolved. The law mandated that all insurers provide contraceptives as part of their plans. The provision enjoyed the support of 77% of women and 64% of men. But the Catholic Bishops Association sent a small group of elderly chaste women, the Little Sisters of the Poor, to the bar to argue that the two page escape clause, designed by the Obama administration to skirt the issue, and allow Catholic institutions to house such coverage with a independent third party, was too onerous, stating that the signing would be morally tantamount to condoning contraception.

In 2017, a tenured department chair at Mount St. Mary’s college in Maryland prepared to leave her teaching post after more than a decade. Part of what led to her decision was the action taken in 2014 by college president, Tom Powell, in the service of his most influential Board member, Archbishop William Lori. At the time, Powell informed college employees that the coverage of contraception, which existed in the current agnostic employee health plan, would happily disappear if the Little Sisters prevailed.

In words and tone as seemingly benign as if they came out of Mike Pence’s own mouth, Powell said, “The whole issue about providing health care to society…that’s great. Health care is a good thing. It’s a funny thing for us to be fighting about health care. Nobody wants to be people’s life police.” With appropriate legal remedies, he said, “Then we’re not actually buying it….and let them use their own judgement.”

As #MeToo has revealed, the assault on women in America is real and pervasive. Believe it! The personal demons of Rob Porter reached deeply into the sacred space of the Oval Office. But he was not alone but in the company of Donald Trump, Mike Pence, John Kelly….and by extension, Tom Powell, William Lori, and countless other well entrenched mostly male leaders determined to maintain an edifice of gender bias and abuse.

Jennie Willoughby’s final sentence in her post reads, “In the end, who is the real victim of his choices?” I would answer, “America and her institutions.”

#MeToo2018.

Hiding In America’s “Deep Poverty Problem” is Health Care.

Posted on | February 8, 2018 | No Comments

Mike Magee

Angus Deaton, the Princeton professor and Nobel Laureate who documented the tie between America’s raging prescription opioid epidemic and the first multi-year decline in U.S. life expectancy in our history, has done it again.

This time it’s America’s poor in a New York Times Op-ed title “The U.S. Can No Longer Hide From Its Deep Poverty Problem.” In the piece he reviews the findings of the U.N.’s Professor Philip Alston’s extensive December, 2017 report on poverty and human rights in the U.S. What he discovered is that over 40 million people (12.7% of the population) live in poverty in the U.S., and the number is growing in part because of our inequitable health care system.

As he says, “Americans can expect to live shorter and sicker lives, compared to people living in any other rich democracy.” Some of the bulleted finds are so crazy as to be unbelievable like:

* U.S. infant mortality rates in 2013 were the highest in the developed world.

*12 million Americans live with a neglected parasitic infection.

* The U.S. has the highest prevalence of obesity in the developed world.

*In access to clean water and safe sanitation, we rank 36th in the world.

* We have the highest incarceration rate in the world – that includes Cuba, Russia, and everyone else. 11 million are admitted to local jails each year. In total, 3/4 of a million are currently incarcerated with 2/3rds awaiting trial.

* Our youth poverty rate is a startling 25%, compared to 14% for OECD nations. Child poverty is greatest in three southern states – 30% in Mississippi and New Mexico, and 29% in Louisiana.

* We have the highest income inequality rate of all Western nations.

* Only 56% of our citizens voted in our last Presidential election. 64% of our voting age adults were registered to vote compared to 91% in Canada and the UK, 96% in Sweden, and 99% in Japan.

* 8 million more whites are poor in America than are African Americans living in poverty. 31% of poor children are White, 24% and Black, and 36% are Hispanic.

* In 1980, the top 1% in Europe controlled 10% of the wealth. They now control 12%. In the U.S., during the same period, the top 1% went from controlling 10% of the wealth to 20%.

* Between 2010 and 2014, as a result of medical outlays, an additional 1.5% of total income has been transferred from poor to rich.

* 7 million Americans making more than 150% of the poverty line ($31,000 for a family of three) dropped below the poverty line after paying medical costs between 2010 and 2014. Over half of them ended up below 50% of the poverty level.

How can America walk back poverty? The quickest and most effective way is by now obvious to most:  institute nationwide universal health coverage.

Majority Favor ACA by 8%.

Posted on | January 26, 2018 | No Comments

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