Health as a foundation for society
Editorial - The Lancet - January 4, 2021
As the New C.D.C. Chief, I’ll Tell You the Truth
Even when the news is bleak.
Dr. Walensky has been nominated by President-elect Biden to be the director of the Centers for Disease Control and Prevention.
Last Wednesday, the same day our nation’s Capitol was in the grips of an insurrection, the United States recorded 3,964 deaths from Covid-19, a record high. That day, Covid-19 claimed a life every 22 seconds. The Centers for Disease Control and Prevention predicts that this month the country will surpass more than 400,000 deaths from Covid.
The challenge ahead is enormous.
On Jan. 20, I will begin leading the C.D.C., which was founded in 1946 to meet precisely the kinds of challenges posed by this pandemic. I agreed to serve as C.D.C. director because I believe in the agency’s mission and commitment to knowledge, statistics and guidance. I will do so by leading with facts, science and integrity — and being accountable for them, as the C.D.C. has done since its founding 75 years ago.
I acknowledge that our team of scientists will have to work very hard to restore public trust in the C.D.C., at home and abroad, because it has been undermined over the last year. In that time, numerous reports stated that White House officials interfered with official guidance issued by the C.D.C.
As chief of the infectious diseases division at Massachusetts General Hospital, I and many others found these reports to be extremely disturbing. The C.D.C.’s science — the gold standard for the nation’s public health — has been tarnished. Hospitals, doctors, state health officials and others rely on the guidance of the C.D.C., not just for Covid-19 policies around quarantine, isolation, testing and vaccination, but also for staying healthy while traveling, strategies to prevent obesity, information on food safety and more.
As C.D.C. director, it will be my responsibility to make sure that the public trusts the agency’s guidance and that its staff feels supported. On my first day, I will ask Anne Schuchat, the principal deputy director, with 32 years of experience at the C.D.C., to begin a comprehensive review to ensure that all existing guidance related to Covid-19 is evidence-based and free of politics.
Restoring the public’s trust in the C.D.C. is crucial. Hospitals and health care providers are beyond tired, beyond stretched. I know because I have stood among them, on the front lines of the Covid-19 response in Massachusetts. We also face the need for the largest public health operation in a century, vaccinating the population — twice — to protect ourselves and each other from a surging pandemic. Because the impact of Covid-19 does not fall equally on everyone, we must redouble our efforts to reach every corner of the U.S. population.
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The research and guidance provided by the civil servants at the C.D.C. should continue regardless of what political party is in power. Novel scientific breakthroughs do not follow four-year terms. As I start my new duties, I will tell the president, Congress and the public what we know when we know it, and I will do so even when the news is bleak, or when the information may not be what those in the administration want to hear.
Never before has the C.D.C.’s partnership with Congress been so important. Last year demonstrated how a frail, poorly tended public health infrastructure can bring a great country to its knees. Public health has been diminished and underfunded for years. The relief package that Congress passed in December is a good start, but more funds will surely be needed to increase the pace of the vaccine rollout; to strengthen data reporting, management and analytics; and to conduct proper surveillance not just of this virus but also of future pathogenic threats.
Our successful recovery from this virus requires us to make sure that those who have suffered disproportionately are no longer left behind. As the C.D.C. director, I will work to address inequities that have left African-Americans, Latinos and Native Americans hospitalized and dying at disproportionately higher rates from Covid-19, by focusing on the health conditions that are prevalent in communities of color.
Our nation faces untold collateral damage from this pandemic. Life expectancy rates among middle-age adults had already decreased in recent years. Data will likely show that in the past year we have lost more hard-earned ground on immunizing children, helping people control their blood pressure and reducing rates of preventable chronic conditions. Rates of substance-use, opioid overdoses, depression and suicide have soared. We are in the middle of a behavioral health crisis that demands intervention.
I promise to work with my colleagues at the C.D.C. to harness the power of American science and confront these challenges.
Rochelle P. Walensky (@rwalensky) chief of the division of infectious diseases at Massachusetts General Hospital and a professor at Harvard Medical School, has been nominated by President-elect Biden to be the director of the Centers for Disease Control and Prevention.
Jeff Bezos, Jamie Dimon and Warren Buffett tried to solve health care. 3 years later, their company has shut down
New Study Reveals Flawed Predictions of Runaway Costs and Usage Under Medicare for All
Analysts who've confidently projected a tsunami of healthcare use and costs after Medicare for All are ignoring history."
by Kenny Stancil - Common Dreams - January 5, 2021
With the Covid-19 pandemic raging and recognition of the inadequacy and injustice of America's for-profit healthcare system at a possible zenith, a new study released Tuesday reveals that projections of large and costly usage increases under a single-payer program have been overstated, bolstering the case that Medicare for All would save both lives and money.
In a paper published Tuesday in Health Affairs, Drs. Adam Gaffney, David Himmelstein, and Steffie Woolhander of Cambridge Health Alliance/Harvard Medical School and James Kahn of the University of California San Francisco—all associated with Physicians for a National Health Program, which advocates for Medicare for All—analyze the relationship between universal healthcare and the use of medical services.
"Nearly all predictions of utilization surges stemming from universal coverage expansions are overestimates."
—Gaffney et al., Health Affairs
What the researchers find is that most estimates of the effect of universal coverage expansion on healthcare utilization are overblown, adding to a growing consensus that Medicare for All is less costly than previously thought due to lower administrative costs and usage rates that increase only slightly or not at all.
The authors anticipate that "debate over public coverage expansion and its costs" is likely to grow as a result of the pandemic's exposure of the problems with employment-based insurance and the return of a Democratic administration to the White House.
In contrast to most models of the relationship between coverage expansions and utilization changes, the authors' findings, based on examining the history of past coverage expansions in the U.S. and 10 other affluent countries, are more modest.
While demand for medical services is elastic, meaning that "people use more healthcare when the price they pay is lower and less care when prices rise," the authors contend that prior research documenting the effect of coverage expansions on healthcare use and costs have underestimated the impact of "supply-side constraints."
Although the number of physicians and hospital beds is malleable in the long-run, current limitations on supply can provoke a reduction in the provision of low-value services and yield a more egalitarian prioritization of care, the authors say.
As Dr. Gaffney explained in a statement Tuesday, "Our findings clash with the traditional economic teaching: that giving people free access to care would cause demand and utilization to soar."
"That traditional thinking ignores the 'supply' side of the health care equation: doctors' and nurses' time and hospital beds are limited, and mostly already fully occupied," Gaffney added. "When doctors get busier, they prioritize care according to need, and provide less unnecessary care to those with minimal needs to make way for patients with real needs."
Between 1973 and 2020, various models have projected utilization increases ranging from 2% to at least 21%, but according to the authors, "nearly all predictions of utilization surges stemming from universal coverage expansions are overestimates."
There are a handful of studies that have sought to quantify how extending coverage to individuals affects healthcare consumption, but "the effect of universal coverage on society-wide utilization may differ from the effects of providing coverage for individuals," the authors write.
"Past society-wide coverage expansions haven't caused surges in healthcare use, so analysts who've confidently projected a tsunami of healthcare use and costs after Medicare for All are ignoring history," said Dr. Woolhandler.
According to the authors' review of the historical record, "universal coverage expansion would increase ambulatory visits by 7-10% and hospital use by 0-3%," while "modest administrative savings could offset the costs of such increases."
Notwithstanding discrepancies about the extent to which usage rates change in relation to coverage expansions, one finding shared by all analyses, the authors emphasize, is that "utilization-related cost increases would be partially or fully offset by savings on drug prices or reductions in provider fees, waste, and administrative costs."
As Common Dreams reported last month, the Congressional Budget Office (CBO) has estimated that implementing a single-payer health insurance program in the U.S. would reduce overall healthcare spending nationwide by about $650 billion per year.
"When doctors get busier, they prioritize care according to need, and
provide less unnecessary care to those with minimal needs to make way
for patients with real needs."
—Dr. Adam Gaffney, Harvard Medical School
Between the CBO's finding that Medicare for All's administrative cost savings have been underestimated and Gaffney et al.'s finding that the effects of universal coverage reforms on healthcare utilization and costs have been overestimated, it is becoming increasingly clear that in addition to saving lives, Medicare for All would be less expensive than previously acknowledged.
"In projecting the impacts of coverage expansions, analysts who fail to accurately account for supply-side factors will overestimate the costs of reform," the authors write. "Such errors may cause policymakers to mistakenly conclude that reforms that would cover millions of Americans are unaffordable."
"Conversely," they continue, "policies that increase the supply of medical resources are likely to increase utilization, even without coverage expansions... Supply expansions that are not tailored to need could have the unintended consequences of boosting the provision of low-value care and costs."
The authors insist that like other countries, the U.S. can constrain "utilization and cost growth without resorting to cost barriers while achieving universal coverage and a more equitable distribution of care."
As Matt Bruenig of the People's Policy Project wrote last month, "The barriers to the policy are not technical deficiencies or costs, but rather political opposition from Republicans and conservative Democrats who would rather spend more money to provide less healthcare."
With New Majority, Here’s What Democrats Can (and Can’t) Do on Health Care
Senate control opens up new possibilities, but the party will still need to contend with arcane rules and the challenges of a narrow majority.
by Sarah Kliff and Margot Sanger-Katz - January
The Democrats’ new congressional majority puts a variety of health policy ideas suddenly into reach, even if big structural changes remain unlikely.
A series of tweaks bolstering the Affordable Care Act stands the best chance of passage. Legislators could make insurance subsidies more generous, get coverage to low-income Americans in states that haven’t expanded Medicaid, and render moot a pending Supreme Court lawsuit that aims to overturn the entire law.
But structural overhauls like “Medicare for all,” which would move all Americans to a government-run health plan, face a much tougher road. So would elements of Joe Biden’s health agenda, such as a public option, which would give Americans a choice between a new public plan and private insurance.
Most legislation in Congress effectively requires 60 votes in the Senate because of procedural rules. But a budget maneuver called reconciliation can allow legislators to pass certain bills with a bare majority of votes. With Raphael Warnock and Jon Ossoff in the Senate, Democrats will have just enough votes to control the chamber.
However, reconciliation bills must follow a set of complicated requirements known as the “Byrd Rule.” The simplest way of thinking about them is that legislative provisions have to be budgetary to be allowed. That means that the process isn’t ideal for writing large-scale health reform, experts say, but it may be the best tool Democrats have to pass laws with their slim majority.
“The Democrats have to deal with Robert Byrd and his nattering little rule that hasn’t gone away,” said Rodney Whitlock, a vice president at McDermott+Consulting and a former health aide to Senator Chuck Grassley who worked on reconciliation bills during his Senate tenure.
Legislators have often turned to reconciliation to pass health policy when their majority is slim. Democrats used it in 2010 to pass final tweaks to the Affordable Care Act after losing their supermajority. Republicans used it in a failed effort to repeal the health law in 2017 and in a successful attempt later the same year to make changes to the tax code.
There are six areas of health policy where congressional aides and health policy experts could see Democrats focusing their efforts this year. Smaller policy reforms are expected to be easier, both legally and politically, while more ambitious policies may not easily slot into reconciliation’s strict rules — or the political preferences of enough Democratic lawmakers.
Affordable Care Act expansions
Congress is most likely to act on a set of changes meant to expand the Affordable Care Act and to make health coverage less expensive for those who buy their own plans. One priority is raising the income ceiling for those who receives subsidies, expanding the number of people who qualify for help. Another is rewriting formulas to peg the size of the subsidy to a more generous health insurance plan, a way to increase the amount of assistance.
Democrats in the House passed such policies last year, which the Republican-controlled Senate did not take up.
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Because these changes are largely budgetary — focused on the size of certain tax credits — most experts agree they would be an easy target for reconciliation, and may need only a simple majority to become law.
Democratic legislators may also be eager to protect the A.C.A. another way, passing legislation that would neuter Texas v. California, the pending Supreme Court challenge that argues the entire A.C.A. is unconstitutional.
That lawsuit came about because of legislation that a Republican-controlled Congress passed in 2017, lowering the penalty for not carrying health insurance to zero dollars. Democrats could use reconciliation to reverse those changes, although they’d be likely to reinstate only a nominal fee for going uninsured.
Closing the Medicaid gap
In the 12 states that do not participate in the health law’s Medicaid expansion, millions of low-income Americans are left without affordable coverage options. Many Democrats are eager to change this but have so far been stymied by states’ decisions to decline the program.
In his campaign plan, President-elect Biden proposed fixing this problem by allowing these patients to enroll in a new public health plan. That type of policy may be too complex to move through reconciliation, but simpler policy options could also do the trick. One option that has been floated is to extend the Affordable Care Act’s tax credits to this population — they wouldn’t get to enroll in Medicaid, but they would have access to a highly subsidized private plan on the health law’s marketplace.
Congress could also pursue policies that would encourage more states to expand Medicaid. The recent House bill offered to pay the entire bill for the three initial years of Medicaid expansion if states choose it.
Reducing drug prices
The Democratic House’s other big recent health bill was an effort to lower the prices of certain expensive prescription drugs. Lowering drug prices has been a Democratic policy priority for many years, and one that Mr. Biden endorses, at least in general. President Trump has championed legislation on drug prices as well, as has Mr. Grassley, but many Republican lawmakers dislike the proposals, and the current Senate majority leader, Mitch McConnell, has never allowed such a bill on the floor.
Experts thought that certain drug pricing controls might be possible with reconciliation, since they have clear budgetary effects. But the politics of passage could be difficult with narrow majorities in both the House and Senate and such strong opposition from the drug industry.
A public option
President-elect Biden included a public health insurance option, available to all Americans, in his 2020 campaign platform. The slim majority in the Senate, however, may make it hard to move this type of plan forward.
Even if there were unanimous support among Democratic senators, the public option isn’t a policy that fits neatly into reconciliation’s rigid rules. Congressional procedure experts say it would need to include nonbudgetary policies, such as defining a package of benefits, that would require a more conventional legislative process.
And unanimity among 50 Democratic senators may be a big political challenge in any case. When Congress last debated the public option in 2010, it split the Democratic caucus and couldn’t garner enough support to pass.
“The way the public option saves money is by paying providers less,” said Cynthia Cox, a vice president at the Kaiser Family Foundation. “Right now, providers are a pretty sympathetic group with the pandemic. I think there would be a lot of opposition from hospitals and doctors.”
Medicare for all
A Medicare for all health plan, long championed by Senator Bernie Sanders, would end private health insurance and move all Americans into a generous government-run insurance plan. Democratic primary contenders split on this policy, with President-elect Biden opposing such an approach.
There are versions of Medicare for all that might work within the confines of the reconciliation process, such as a simple expansion of the current Medicare program to cover Americans younger than 65. But the more detailed policy Mr. Sanders and his co-sponsors envision might be harder to defend as budgetary.
The larger obstacle to such a plan is more likely political than procedural. Currently, a majority of House Democrats back Medicare for all, but that would not be nearly enough votes to pass such a bill. An even smaller share of senators back the plan.“It’s certainly a steep, uphill, rocky path that they probably can’t climb, and that’s assuming 50 Democrats even want to put on their hiking boots,” said Sarah Binder, a professor of political science at George Washington University.
Editor's Note -
Here is another powerful argument for Universal Health Care:
When Biden Takes Office, Undoing Trump's Health Policies Won't Be Easy
by Kaiser Health News - NPR - January 9, 2021
Even with Democrats technically in the majority in Congress, the party split is so slim that passing major health care legislation will be extremely difficult.
So speculation about President-elect Joe Biden's health agenda has focused on the things he can accomplish using executive authority. Although there is a long list of things he could do, even longer is the list of things he is being urged to undo — actions taken by President Trump.
While Trump was not able to make good on his highest-profile health-related promises from his 2016 campaign — including repealing the Affordable Care Act and broadly lowering prescription drug prices — his administration did make substantial changes to the nation's health care system using executive branch authority. And many of those changes are anathema to Democrats, particularly those aimed at hobbling the ACA.
For example, the Trump administration made it easier for those who buy their own insurance to purchase cheaper plans that don't cover all the ACA benefits and may not cover pre-existing conditions. It also eliminated protections from discrimination in health care to people who are transgender.
Trump's use of tools like regulations, guidance and executive orders to modify health programs "was like an attack by a thousand paper cuts," said Maura Calsyn, managing director of health policy at the Center for American Progress, a liberal-leaning think tank. Approaching the November election, she said, "the administration was in the process of doing irreparable harm to the nation's health care system."
Reversing many of those changes will be a big part of Biden's health agenda, in many cases coming even before trying to act on his own campaign pledges, such as creating a government-sponsored health plan as part of the ACA.
Chris Jennings, a health aide to former Presidents Barack Obama and Bill Clinton, said he refers to those Trump health policies as "bird droppings. As in you have to clean up the bird droppings before you have a clean slate." Republicans, when they take over from a Democratic administration, think of their predecessors' policies the same way.
Though changing policies made by the executive branch seems easy, that's not always the case.
"These are issue-by-issue determinations that must be made, and they require process evaluation, legal evaluation, resource consideration and timeliness," said Jennings. In other words, some policies will take more time and personnel resources than others. And health policies will have to compete for White House attention with policies the new administration will want to change on anything from the environment to immigration to education.
Even within health care, issues as diverse as the operations of the ACA marketplaces to women's reproductive health to stem cell research will vie to be high on the list.
Why the changes are hard to reverse
Some types of actions are easier to reverse than others.
Executive orders issued by the president, for example, can be summarily overturned by a new executive order. Agency "guidance" can similarly be written over, although the Trump administration has worked to make that more onerous.
Since the 1980s, for example, every time the presidency has changed parties, one of the incoming president's first actions has been to issue an executive order to either reimpose or eliminate the "Mexico City Policy" that governs funding for international family planning organizations that "perform or promote" abortion. Why do new administrations address abortion so quickly? Because the anniversary of the landmark Supreme Court abortion decision Roe v. Wade is two days after Inauguration Day, so the action is always politically timely.
Harder to change are formal regulations, such as one effectively banning Planned Parenthood from the federal family planning program, Title X. They are governed by a law, the Administrative Procedure Act, that lays out a very specific — and often time-consuming — process. "You have to cross your i's and dot your legal t's," said Nicholas Bagley, who teaches administrative law at the University of Michigan Law School.
And if you don't? Then regulations can be challenged in court — as those of the Trump administration were dozens of times. That's something Biden officials will take pains to avoid, said Calsyn. "I would expect to see very deliberate notice and comment rule-making, considering the reshaped judiciary" with so many Trump-appointed judges, she said.
What comes first?
Undoing a previous administration's actions in a new administration is an exercise in trying to push many things through a very narrow tube in a short time. Department regulations have to go not just through the leadership in each department, but also through the Office of Management and Budget "for a technical review, cost-benefit analysis and legal authority," said Bagley. "That can take time."
Complicating matters, many health regulations emanate not just from the Department of Health and Human Services, but jointly from HHS and other departments, including Labor and Treasury, which likely means more time to negotiate decisions among multiple departments.
Finally, said Bagley, "for really high-profile things, you've got to get the president's attention, and he's got limited time, too." Anything pandemic-related is likely to come first, he said.
Some items get pushed to the front of the line due to calendar considerations, as with the abortion executive orders. Others need more immediate attention because they are part of active court cases.
"You have all these court schedules and briefing schedules that will dictate the timeline where they make all these decisions," said Katie Keith, a health policy researcher and law professor at Georgetown University.
A high-profile example in that category is the Trump administration's efforts to allow states to set work requirements for many low-income adults who gained Medicaid coverage under the Affordable Care Act's expansion of the program. The Supreme Court has agreed to hear a case challenging HHS approval of work requirements for Arkansas and New Hampshire in the next few months. Some Democrats are concerned about how the high court with its new conservative majority might rule, and the Biden administration will have to move fast if officials decide they want to head off that case.
But court actions also might help the Biden administration short-circuit the onerous regulatory process. If a regulation the new administration wants to rewrite or repeal has already been blocked by a court, Biden officials can simply choose not to appeal that ruling. That's what Trump did in ending insurance company subsidies for enrollees with low incomes in 2017.
Allowing a lower-court ruling to stand, however, is not a foolproof strategy. "That raises the possibility of having someone [else] intervene," said Keith. For example, Democratic attorneys general stepped in to defend the ACA in a case now pending at the Supreme Court when the Trump administration chose not to. "So, you have to be pretty strategic about not appealing," she said.
One other big decision for the incoming administration is whether it wants to use the opportunity to tweak or add to Trump policies rather than eliminate them. "Is it undoing and full stop?" asked Keith. "Or undoing and adding on?"
She said there is "a full slate of ideologically neutral" policies Trump put out, including ones on price transparency and prescription drugs. If Biden officials don't want to keep those as they are, they can rewrite them and advance other policies at the same time, saving a round of regulatory effort.
But none of it is easy — or fast.
One big problem is just having enough bodies available to do the work. "There was so much that undermined and hollowed out the federal workforce; there's a lot of rebuilding that needs to done," said Calsyn of the Center for American Progress. And Trump officials ran so roughshod over the regulatory process in many cases, she said, "even putting those processes back in place is going to be hard."
Incoming officials will also have other time-sensitive work to do. Writing regulations for the newly passed ban on "surprise" medical bills will almost certainly be a giant political fight between insurers and health care providers, who will try to re-litigate the legislation as it is implemented. Rules for insurers who sell policies under the ACA will need to be written almost immediately after Biden takes office.
Anyone waiting for a particular Trump policy to be wiped from the books will likely have to pack their patience. But law professor Bagley said he's optimistic it will all get done.
"One of the things we've grown unaccustomed to is a competent administration," he said. "When people are competent, they can do a lot of things pretty quickly."
An 11th-Hour Approval for Major Changes to Medicaid in Tennessee
The Trump administration’s move, which Biden could eventually reverse, would loosen program rules and cap the state’s funding as part of a block grant.
by Margot Sanger Katz - NYT - January 8, 2021
With 12 days to go, the Trump administration on Friday approved a long-held conservative goal: to issue a state’s Medicaid funding as a spending-capped block grant.
The structural experiment in Tennessee, which would become effective once approved by the state legislature, would last for 10 years. Block grants for Medicaid have been a priority for Seema Verma, the administrator for the Centers for Medicare and Medicaid Services and a former consultant who helped states write waiver requests.
“What we tried to do was take some of what we thought were some of the wins, some of the positive things about block grants people have talked about for years,” Ms. Verma said. “And we tried to go through and address some of the criticisms.”
Patient advocates in Tennessee, who fear the new structure would cause poor people to lose access to health care, say they plan a court challenge, and the Biden administration will almost certainly seek to reverse it when it takes over the Department of Health and Human Services.
But in the last week, the Trump administration has tried to slow the reversal of its Medicaid experiments. Traditionally, such waivers are agreements between H.H.S. and states that can be severed with minimal fuss. But Ms. Verma has sent letters to state Medicaid directors, asking them to sign, “as soon as possible,” new contracts that detail more elaborate processes for terminating waivers. Under the contract terms, the federal agency pledges not to end a waiver with less than nine months of notice.
“It’s so blatant,” said Joan Alker, the executive director at the Georgetown Center for Children and Families. “She’s trying to handcuff the Biden administration.”
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Ms. Verma said the contracts were a way of ensuring that waivers were revoked only if they were harmful. “We want to make sure that people don’t come into office and on a political whim terminate waivers,” she said.
The waiver allows Tennessee, one of a dozen states that haven’t adopted Medicaid expansion under Obamacare, to abandon the normal structure of the Medicaid program. In that structure, the federal government establishes detailed rules for who must be covered and what benefits they are offered in exchange for an open-ended commitment to pay a share of Medicaid patients’ bills. Tennessee would be given new freedom to alter what services its program covers, but its funding each year would be capped according to a formula.
If Tennessee spends less than the block grant amount, it will be allowed to keep 55 percent of the savings to spend on a broad array of services related to “health.” If it spends more, the difference will need to be made up with state funds. The waiver establishes some limitations on the aspects of the program that can be changed and would allow the spending cap to grow if more people enrolled in Medicaid, as typically happens in an economic downturn.
A key area of flexibility in the waiver relates to prescription drugs. In general, Medicaid must cover a wide variety of medications but is guaranteed to pay the lowest price of any purchaser in the United States. Tennessee will be allowed to renegotiate prices with drugmakers and can decline to cover drugs if it deems the prices too high. Massachusetts had submitted a waiver asking for a similar authority without a broader block grant, and it was denied.
In Tennessee, doctors and hospital groups, among others, have criticized the proposal. “The vast majority of comments C.M.S. received opposed Tennessee’s proposed demonstration,” the approval document noted.
Gov. Bill Lee, a Republican, described the program as a “legacy achievement.”
“We have shown that a partnership is a better model than dependence,” he told reporters.
Waivers have been a centerpiece of Ms. Verma’s tenure at the Medicaid agency. In addition to the Tennessee block grant waiver, she has approved Medicaid work requirements for certain adults in 12 states. Federal courts have repeatedly overturned those waivers, and few of them are in effect.
Michele Johnson, executive director of the Tennessee Justice Center, a legal aid group that helps poor Tennesseans, said she was trying to encourage legislators to reject the waiver. A block grant, which she has always opposed, is a particularly poor match for a public health crisis, she said, in which health spending could accelerate in unusual ways. “The only way this makes sense is in the context of the Trump administration burning everything down on their way out the door,” she said.
She also noted a history of challenges the state has faced running its more traditional Medicaid program. “It’s hard to imagine a state that would be a worse fit for a block grant than ours,” she said.
Income-Related Inequality In Affordability And Access To Primary Care In Eleven High-Income Countries
Dr. Marcella Nunez-Smith Takes Aim at Racial Gaps in Health Care
Appointed head of the incoming administration’s task force on health equity, the Yale University scientist “is not sitting in her ivory tower.”
Growing up in the United States Virgin Islands, Dr. Marcella Nunez-Smith saw firsthand what can happen in a community with limited access to health care. Her father, Moleto “Bishop” Smith Sr., was only in his 40s when he suffered a debilitating stroke that left him partly paralyzed and with slurred speech.
The cause was high blood pressure, which could have been treated but had never been diagnosed. Without prompt access to advanced treatments, “the stroke was allowed to run its course,” Dr. Nunez-Smith, 45, recalled in a recent interview. Her father never fully recovered.
“He was a champion and a fighter,” she said. “But my memories are of a father who had to live life with this daily reminder of how we had failed in terms of our health care. I don’t want another little girl out there to have her father suffer a stroke that is debilitating and life-altering in that way.”
Now, tapped by President-elect Joseph R. Biden Jr. to lead a new federal task force, Dr. Nunez-Smith, an associate professor of internal medicine, public health and management at Yale University, will address a terrible reality of American medicine: persistent racial and ethnic disparities in access and care, the sort that contributed to her father’s disability.
Dr. Nunez-Smith has an expansive vision for the job, with plans to target medical resources and relief funds to vulnerable communities but also to tackle the underlying social and economic inequalities that put them at risk.
Her goals are ambitious, experts noted.
“For so long, we’ve been setting our sights on the more achievable goals and attempted to say, ‘We probably can’t have totally equitable care, so let’s at least make sure minority patients get insurance, or at least make sure there’s a health clinic in their community,’” said Dr. Utibe R. Essien, an assistant professor of medicine at the University of Pittsburgh School of Medicine who studies racial disparities in cardiovascular disease.
“This is a great opportunity to stretch and reach for what’s been imagined for decades, if not centuries,” he said.
Racial health disparities represent a vast, structural challenge in this country, made all the more stark by the raging pandemic. Black, Latino and Native Americans are infected with the coronavirus and hospitalized with Covid-19 at higher rates than white Americans, and they have died of the illness at nearly three times the rate, according to the Centers for Disease Control and Prevention.
“Making sure communities hardest hit by the pandemic have access to safe, effective vaccines remains a priority,” Dr. Nunez-Smith said. But “what’s needed to ensure equity in the recovery is not limited to health and health care. We have to have conversations about housing stability and food security and educational equity, and pathways to economic opportunities and promise.”
Many factors have contributed to higher rates of infection and severe disease in minority communities. Black, Latino and Native Americans are more likely to live in crowded households than white people, and less likely to be able to work from home. Minority Americans have higher rates of underlying health problems that increase their risk for severe Covid-19, and they often have limited access to medical care. Asian-Americans have been infected at a lower rate than white Americans, yet have had a slightly higher rate of both hospitalizations and deaths.While almost every American now knows someone who has been affected by Covid-19, in communities of color at least one third of people have lost someone close to them. “Think about the individual toll that takes,” Dr. Nunez-Smith said. “These are people’s parents, friends and love
Dr. Nunez-Smith currently serves as one of three co-chairs on an advisory board advising the Biden transition team on management of the pandemic. Colleagues describe her as a brilliant scientist with a gift for building consensus, a sharp contrast to the politically driven administration officials who guided the response during the Trump era.
“She is a national gem,” said Dr. Harlan Krumholz, a professor of medicine at Yale School of Medicine. “This is a person who spends her days thinking about how we can make health care more equitable, and what interventions can address these disparities.”
At Yale, Dr. Nunez-Smith wears many hats — practicing internist, scientist, teacher, mentor and the director of several research centers. She directs Yale’s Equity Research and Innovation Center, which she founded, as well as a research collaborative funded by the National Institutes of Health to study chronic disease in Puerto Rico, Trinidad and Tobago, Barbados, and the United States Virgin Islands.
But she also is involved in community organizations like the Community Foundation for Greater New Haven and Connecticut Voices for Children. “She’s not sitting in her ivory tower,” said Christina Ciociola, senior vice president for grant-making and strategy at the foundation.
“She is out on the front lines,” Ms. Ciociola said. “She sees patients, and she’s seen friends and colleagues suffer with this illness. She’s lost people to the pandemic.”
Dr. Nunez-Smith’s early interest in medicine was encouraged by her mother, a retired nursing professor, who instilled her commitment to community or, as she puts it, “the village.” Her grandmother played a pivotal role in her life, as did her godfather, a surgeon who still practices in St. Thomas.
Her mother filled the home with medical books. “She said I could read anything I could reach,” Dr. Nunez-Smith recalled. “I started early on learning medicine and nursing texts, and became fascinated with the human body and biology.”
Over time, she came to understand the importance of health policy and its repercussions in places like the U.S. territories, where lower federal payments for services affect access to care and high quality medical care is limited. (A recent study she co-wrote found that older women in the U.S. territories with breast cancer waited longer for surgery and radiation, and were less likely to get state-of-the-art care, than their counterparts in other regions of the United States.)
After graduating from high school at age 16, Dr. Nunez-Smith attended Swarthmore College in Pennsylvania, majoring in biological anthropology and psychology, and went on to earn a medical degree at Jefferson Medical College, now called the Sidney Kimmel Medical College.
She completed a residency and internship at Harvard’s Brigham and Women’s Hospital, and then a fellowship at the Robert Wood Johnson Foundation Clinical Scholars Program, where she also received a master’s degree in health sciences.
Some of her research has been informed by her own experiences as a Black female physician, she said. She still encounters hospital patients who assume she has come into the room to collect their meal tray or empty their trash, even though she introduces herself as a doctor and has a stethoscope hanging around her neck.
In studies of attitudes toward the health care system among Black patients, she has found that distrust is rampant. A survey of 604 Black Americans, carried out in May jointly by Dr. Nunez-Smith’s Equity and Research Innovation Center and the N.A.A.C.P., found that more than half believed Black people were less likely than white people to get access to coronavirus tests when testing was scarce, and that they were less likely to be admitted to the hospital when needed. More than half thought that hospitalized Black patients were less likely to “have everything done to save their lives.”
The survey also found that over one-third of Black respondents had lost a job or seen their hours reduced. Nearly one-third said they did not have enough money to buy groceries and had trouble paying rent. Economic pressures keep them going to work even when they fall ill, Dr. Nunez-Smith said.
“People are very worried about surprise bills for seeking care, and this is very different from other countries, where cost is not a consideration,” she said. “How do we make sure there are positive incentives for coming in and getting tested and getting care?”
All of these factors must shape the response to the pandemic, she said. Testing sites must be located in or near low-income communities, for example — they cannot be only drive-through sites used by people who have cars.
Hotel rooms should be provided to people who don’t have space at home to quarantine or isolate after an exposure or positive test. Workplaces must take the steps necessary to keep essential workers safe.“One size won’t fit everyone — you can’t just say, ‘Everybody stay home and stay safe,’” she said. “There are people whose jobs require them to leave their h
Those hesitant to take a Covid vaccine must be reassured that the vaccines are safe and effective — and that they won’t get a surprise bill later. They need to be told in advance about the predictable side effects.
Scientists who study health equity acknowledged the task force’s goals will be difficult to accomplish, but welcomed the incoming administration’s ambitious focus.
“Yes, it will be hard and we will need to take iterative steps,” said Dr. Clyde W. Yancy, chief of cardiology at Northwestern University Feinberg School of Medicine. “But begin is exactly what we should do, and considering the link between poor health, poor education, poor housing and poverty, a case can be made to target economic development in the most vulnerable communities as an important first step.”
Like many Americans, Dr. Nunez-Smith is juggling work and community responsibilities while raising school-aged children amid a pandemic. She knows the pressures are bound to increase as she takes up difficult new responsibilities.“Everyone needs a village,” she said. “I feel grateful to have a great supportive spouse, family members. I had a friend drop off several meals yesterday, and someone else is going shopping for us. It’s our village we’re trying to keep safe.