HealthCommentary

Exploring Human Potential

The Planetary Patient

Posted on | February 12, 2019 | No Comments

CNN Source

Mike Magee

In 2005, I published a book called Healthy Waters in an attempt to raise environmental health and the deteriorating “planetary patient” as a pressing health care issue. My efforts were only modestly successful.

Chapter 8 in the book was titled “Natural Water Disasters” and summarized the costs in human life and fortune as a result of global warming and environmental degradation.

At the time, no natural disaster had generated more powerful and destructive images than did the tsunami that struck Asia and Africa in December of 2004. That single event, in dramatic fashion, illustrated both the power of water and the vulnerability of coastal and river basin populations.

Source: Washington Post

At the time , CO2 levels were 380 parts per million. Now 13 years later, they have risen to 410 ppm. In the age of Trump, manufacturers global carbon emissions have risen from  27 billion tons of CO2 a decade ago to 37 billion tons of CO2 in 2018.

A recent article in the Washington Post on the topic is simply headlined, “We are in trouble.” The Paris Accord had us heading in the right direction with global emissions flat between 2014 and 2016. But in 2017, global emissions rose 1.6% and in 2018 grew 2.7%. In that year, US emissions grew 2.5% while EU emissions declined -1%

Outlining the damage caused by global warming already to our planet would take more room than we have here. In fact, the federal government delivered a 1,700 page congressionally mandated climate impact update to Trump on Thanksgiving, 2018, which left little room for thanks. This came one month after the President’s appearance on 60-minutes where he said, “I don’t know that it’s man-made” (and that the warming trend) “could very well go back.”

Of note in the report: The continental U.S. is 1.8 degrees F. warmer  and our seas 9 inches higher than they were 100 years ago.

You don’t have to convince Miami’s Chief Resilience Officer, Susanne Torriente, that there’s a problem. She said, “We don’t debate who caused it. You go outside, the streets are flooded. What are you going to do about it? It’s our reality nowadays. We need to use this best available data so we can start making decisions to start investing in our future. … It shouldn’t be that complicated or that partisan.”

A decade ago, New York Times columnist, Tom Friedman, launched the term “Green New Deal” covering a range of activities he thought might treat the planetary patient’s environmental illness.

The term has now been picked up by Rep. Alexandria Ocasio-Cortez (D-NY) to encompass a range of progressive goals including climate related initiatives. Some claim it will be a litmus test for Democrats, while others predict it will be their demise.

But as the victims of the recent California fires could easily attest, the risk is growing. Back in 2006, I wrote, “Absent preparedness, the losses are complex and considerable, measured in human life and the loss of social, economic and environmental capital.  Such disasters are increasingly magnified through human error, can occur out of nowhere, and generate highly uncoordinated responses.  Poor and marginalized populations are most often the victims with secondary down cycling of health status a predictable end effect.”

It was true then, and even more so now.

“blank”…. FOR ALL.

Posted on | February 11, 2019 | No Comments

Mike Magee

In a Washington Post interview this week, Rep. Donna Shalala, former head of HHS and now a member of Congress from Florida, suggested that democratic reformers focus on universal coverage by whatever means possible. In her view, this includes opening up voluntary access to Medicare (50+), Medicaid (more liberal entry standards), employer based insurance (for employees kids up to age 30),  ACA exchanges (with increased subsidies to enhance affordability), and reinforced CHIP.

Without saying it, Shalala and others believe that you don’t have to strong arm people or restrict choice of coverage to make progress. You just need to offer them better options. Her major point, forged by the pragmatism of someone who has been in the battle for a long, long time, is that mandated universal coverage or the “blank…FOR ALL” is what matters – through whatever means possible.

She cites as one example the natural expansion of ACA funded Medicaid which has now been adopted by 37 states (including D.C.), leaving only 14 (out of 33) Republican governor hold out’s.

Despite Trump’s attempts (echoed vigorously on FOX News) to brand efforts to establish “Medicare-for-all” the way Medicare was attacked a half century ago as big government “socialized medicine”, the majority of governors has tacitly acknowledged what Warren Buffett was right when he described the health care status quo as “the tapeworm of American economic competitiveness”.

The decline of state economies reinforced by the burden of weak social service systems, challenged and undermined by a raging opioid epidemic, had caused Republican governors like John Kasich to declare independence when it came to health policy.

Expanded Medicaid celebrated a new approach (within the corridors of defined eligibility) of universality, access, health planning, portability, and integration with other social service programming. Participating governors liked the fact that the program was well funded, that the benefit package was broad (not a sham skimp HSA product), and that they preserved the flexibility within bounds to set the priorities on spending and were allowed to define how best to advance the overall health of their state populations.

The governors learned that centralized administration of a universally available health insurance offering carried distinct cost savings. Specifically, governor guided single payer health delivery under Medicaid came in 22% less costly than privately insured comparators.

Participating governors well understand that the U.S. is the only civilized nation in the world where more is spent on the mechanics of disease fighting than on all social services combined – the very combination of services and supports that help keep a population well.

Given the power and flexibility under Medicaid, they can redeploy essential human health resources. For example, as wildly expensive nursing home use declines, those employees, now mobile are a potentially useful and experienced mobile home services health corps. Given room for experimentation, as they have been under the ACA, governors have applied both innovation and structural remodeling to expand safety, security, and health across multi-generational families.

Despite Trump and McConnell opposition, The Medicaid single payer authority experiment has gone large scale. Under the direction of autonomous state leaders, nearly 80 million have received care of late with extraordinary high satisfaction levels. 34 million of these citizens are children. 2 million new citizens will be ushered into the human race this year through Medicaid prenatal and obstetric coverage. 9 million blind and disabled citizens sleep easier each night thanks to the governors. Nearly a third of the states structure offerings through a managed care approach. All integrate physical and mental health, including addiction services.

Trump and his followers may be intent on creating chaos, promoting regressive legislation, and reimagining reality, but governors in most states are laser focused on solutions – and the more they experience single payer authority and efficiency, and benefit from integrated health planning, the more they and their citizens like it.

So it’s well to remember that it’s not whether you are for or against “Medicare-for-all” that matters. What really matters is that there be central oversight, uniform high standards, careful public health planning, integrated care, and  – above all – that comprehensive health insurance be mandatory all-for-one and one “… FOR ALL” .

Dr. Ralph Northam and the Culture of Forgiveness

Posted on | February 6, 2019 | 1 Comment

Mike Magee

Within 24 hours of the airing of Governor Ralph Northam’s 1984 Yearbook page last week, commentators were discussing the implications of his history of racial bias on his performance as a physician.

Second year psychiatry resident Jennifer Adaeze Okwerekwu asked in STAT this week,  “Why are we less forgiving of Ralph Northam as a politician than as a doctor?”  In the article she says, “To be a healer is to recognize that medicine is a fundamentally human enterprise — we are all flawed and make mistakes, and sometimes these mistakes can cost people their lives.”

 As a medical historian and social scientist, I spent more than a few years describing the patient-physician relationship and its important role in a civil society. My bottom line was that doctors are neither saints nor sinners. They are simply human beings like you and I. Their behaviors are impacted by the circumstances and events occurring around them, and by leaders who help shape those realities.

As medical educators, we strive to accept into medical school individuals with the values and qualities required for caring for others without prejudice. Compassion, understanding, tolerance, empathy, and a sense of humanity are but a few. Landmark studies in Philadelphia in 1999, published in Academic Medicine, revealed that we at times fall short of the ideal.

In a 2006 speech at the AMA President’s Forum, I shared the view that, “if all patient-physician relationships were to disappear, stable civil societies would immediately notice the difference. Our populations would be more fearful, less trusting, less tolerant, less connected, less compassionate, less productive, and less committed to the future.”

In the same address, I cautioned the physician leaders assembled that we functioned as part of a society, and were not immune to negative influences. Specifically I said that “negative leaders, who view change with fear and leverage that fear as a currency to control a population in order to reinforce existing and past power silos, who attempt to segregate us one from another to maintain the status quo, deserve our contempt. They not only draw down the reservoir of good will locally and globally, but ensure our medium and long term failure.”

Dr. Adaeze Okwerekwu wisely recognized that, “Health disparities persist when no one corrects mistakes and there’s no opportunity to listen, apologize, or learn. We must face bias head on, or risk repeating our preventable mistakes”

At the same time she states, “I’m thankful medicine is a forgiving profession…My wish was for each doctor or doctor-in-training to listen to feedback, apologize for their mistakes, and learn from their lapses in judgment.”

Reflecting on her chosen profession, she says, “It’s a commitment that allows us room to exercise humility when we make mistakes and change our behavior when it both undermines the humanity of others and the promise to do no harm.”

In a society and a democracy being actively tested, and searching for ways to heal our nation, all Americans would do well to consider her final words:

“To be a healer is to recognize that medicine is a fundamentally human enterprise — we are all flawed and make mistakes, and sometimes these mistakes can cost people their lives. Doctors don’t get ‘canceled’ or forced to resign whenever we err. By being open about these mistakes, we can identify the root causes and work collaboratively to prevent them from causing harm again. When we know better, all of us are able to do better.”

Is Big Change Coming? Jake and Kamala (& Michael and Howard)

Posted on | January 31, 2019 | No Comments

CNN’s Jake Tapper and Sen. Kamala Harris

Mike Magee

The decade long battle by Republicans to “repeal and replace” Obamacare is fading slowly into the background. But as this week’s dust up, ignited by CNN’s Jake Tapper’s probing of Presidential candidate Kamala Harris’s views on Medicare expansion revealed, we still have a long ways to go.

By the next morning, two of Harris’s potential opponents were selling fear at wholesale rates. 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, suggesting Americans must instead accept the way health care is rather than having the courage to pursue how it should be.

Schultz is 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.

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.

“Single payer” is one strategy or tactic for efficiently delivering on the promise of universal coverage. It is 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 a vibrant private health insurance market which covers supplemental health care plans purchased by 90% 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.

Americans now in sizable majorities have embraced universal and mandated coverage, with choice. There is little need to force citizens with employer based coverage into public options like Medicare or extended Medicaid. Both employers and employees, given time and control, will support this migration on their own if allowed. 

The Canadian government’s role is focused on formalized government health planning as well as insurance standards and oversight. The national government 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.

On the most fundamental 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.” 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, an underutilized group of pharmacists anxious to contribute to their full potential, an expanding primary-care army bolstered by nurse practitioners and physician assistants, a testing ground of 50 different states offering the ability to customize various approaches to care within parameters set by the national government, a first-class and highly profitable scientific research and discovery community that could well stand on its own without diverting resources from health planning or patient care, and an enormous number of health system middlemen (16 positions for every one physician) currently involved in non-real work who need to be redirected toward strengthening services that would contribute positively to the social determinants of health—including improvements in nutrition, education, environment, housing, transportation, and safety.

Kamala Harris is right that simple justice demands universal health care for all of our citizens. But the winning argument at the end of the day for fundamentally revamping a broken system that consumes 1 in every 5 American dollars is economic.

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.

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 .”

Trump’s massive tax cut for the richest rich took us from bad to worse. On a percentage basis, the U.S. became the fifth highest debtor nation (as a percentage of GDP) in the world after Japan, Greece, Italy, and Portugal. Predictably, Paul Ryan then resurfaced the notion of cutting health services for the elderly, the poor, the marginalized and discriminated against – to “save Medicare” and address budget deficits that Trump and his allies had exacerbated through recent tax cuts for the wealthy.

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: “How do we make Americans healthy?”

Public Opinion on Health Reform is Moving left for both R’s and D’s.

Posted on | January 24, 2019 | No Comments

Mike Magee

If there is a face for a “compassionate capitalist”, many would drop in the wise visage of Warren Buffett who famously declared “Medical costs are the tapeworm of American economic competitiveness.”

Others have stated it differently while agreeing with results of the 2018 Bloomberg health efficiency index placing the U.S. dead last. The problem is systemic and nearly everyone knows it by now. Legendary Princeton health economist Uwe Reinhardt said as much declaring  “At international health care conferences, arguing that a certain proposed policy would drive some country’s system closer to the U.S. model usually is the kiss of death.”

If most experts are there, where is the rest of the American public when it comes to a fundamental reboot of our inequitable and wasteful system focused on cure over care and profit over just about everything else?

The quick answer is, “They’re moving left at a pretty fast clip.”  That’s the underlying message in a just released poll from the Kaiser Family Foundation. The report states that “Medicare-for-all starts with net favorability rating of +14 percentage points (56% who favor it, minus 42% who oppose it). This jumps to +45 percentage points when people hear the argument that this type of plan would guarantee health insurance as a right for all Americans.”

And this includes growing Republican support. Look at these numbers:

  • 77 percent of the public, including most Republican (69%), favor allowing people between the ages of 50 to 64 to buy health insurance through Medicare;
  • 75 percent, including most Republicans (64%), favor allowing people who aren’t covered by their employer to buy insurance through their state’s Medicaid program;
  • 74 percent, including nearly half of Republicans (47%), favor a national government plan like Medicare that is open to anyone, but also would allow people to keep the coverage they have if they want to; and
  • 56 percent, including nearly a quarter of Republicans (23%), favor a national plan called Medicare-for-all in which all Americans would get their insurance through a single government plan.

What are the concerns.

First, cost in the form of higher taxes. Most want to be assured that there will be substantial front end savings with universal coverage. That means simplifying insurance billing so that we no longer have 16 people employed for every physician in America.

Second, efficiency. Americans need to be reassured that universal coverage will not fundamentally undermine basic access to essential services.

Third, lower drug costs. People have grown tired of their politicians protecting well-heeled donors. They want action.

What would break the log jam in currently drugged-up America?

First, outlaw direct-to-consumer advertising like every other developed nation in the world. The days of creating a drug market and then selling into it need to come to an end.

Second, reference pricing of pharmaceuticals like Canada and European nations do. Set our prices so they come in line with the rest of the world.

Third, don’t buy the innovation argument from a medical-industrial complex that has over-promised and under-delivered while padding executives pockets. Trust me – American innovation can stand on its own two feet without systematically breaking the financial backs of average American families.

Our Coast Guard Families Deserve Better.

Posted on | January 16, 2019 | No Comments

Mike Magee

On January 15, 2019, Admiral Karl Schulz informed 42,000 members of the Coast Guard and their families they would not be receiving their January paychecks because of President Trump’s wall-induced government shutdown. “I recognize the anxiety and uncertainty this situation places on you and your family, and we are working closely with service organizations on your behalf,” he wrote.  

This is a long way from February 17, 2005, when Commander Bill Kelly, Captain Jim Thomas, Captain Robert Dash, and Chief Warrant Officer Guy Cashman welcomed me to the Coast Guard Academy to address their executive team on leadership. Since 9/11, we had been working closely together after the release of the book “All Available Boats” which recounted the largest maritime evacuation since Dunkirk, under the direction of our Coast Guard.

The Coast Guard – lifesavers, guardians, warriors, and certainly the most underrated Armed Force in America – is a treasure and a uniquely trained humanitarian force, as prepared for peace as it is for war.

Fourteen years ago, in New London, CT, I emphasized that change was the critical lever defining leadership.  Pull it one way and you create a positive leader.  Pull it the other and you create a negative leader.  

Back then I said, “Negative leaders are short-term thinkers who use fear as a currency to herd people together and move them in whatever direction suites their needs.”

 As we have recently witnessed, in the short term, it is a 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 medium and long term, fear holds the population in place, even as the world around them continues to change. This inability to evolve, to stay in step, or to step ahead of a changing world, insures that negative leaders will eventually fail.

In contrast, positive leaders view change as exploration, and lead with vision rather than fear.  Their view is long-term and they reach out across the divide.  Rather than segregate, they congregate.  Rather than build walls, they build islands of common stewardship.  

The Coast Guard Academy is an island of common stewardship.

Why should our current 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.  

And, finally, fear obstructs vision, actively discouraging imagination, innovation and hopefulness.  In compromising our wonder and inventiveness, fear fundamentally alters our collective future.

The Coast Guard finds itself in a unique position in today’s world.  As a humanitarian force it is both proactive and reactive.  Grounded in history, tradition, values and service, it is known and respected by all.  At the intersection of two powerful metaphors, it exerts great influence and arouses great expectation from those it serves.

What are those two metaphors?  They are water and vessels.  

Water representing life, purity, and goodness and vessels with the capacity to transport us to a better place. Water signals revitalization and rebirth.  Vessels contain hope and kindness, safety and salvation, equity and justice. At this intersection of water and vessel you will find the future hopes and dreams of not only the Coast Guard and their families, but also the human race.  

With the Coast Guard’s help and guidance, we are more likely to find liberty, opportunity, security, civility and democracy on these and other shores.

On 9/11, the Coast Guard reminded us that 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 the Coast Guard continues to devote as much time and energy to the preparation for peace as they 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.

Trump’s political gamesmanship has now ensnared these 9/11 heroes and their families. The Coast Guard deserves better. We all deserve better.

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.

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