American babies are 76 percent more likely to die in their first year than babies in other rich countries
by Christopher Ingraham - The Washington Post - January 9, 2018
American babies are 76 percent more likely to die before they turn a year old than babies in other rich countries, and American children who survive infancy are 57 percent more likely to die before adulthood, according to a sobering new study published in the journal Health Affairs.
Comparing the United States to 19 other wealthy democracies in the Organization for Economic Co-operation and Development (OECD), the study found if the United States had simply kept pace with average childhood mortality rates in those countries, 600,000 young lives could have been saved since 1961. That amounts to roughly 20,000 dead children and teens each year.
As the charts above show, in the 1960s the United States had significantly lower child mortality rates than the other rich countries included in the study. But starting in the 1970s, that changed.
Among infants, that shift was driven primarily by changes in our premature birthrate (babies born before full gestational age), which is the highest in the developed world. Our rate of “extreme” prematurity — babies born before 25 weeks — is three times higher than the OECD average.
Among older children, the United Stands stands out on our rate of deaths by injury. In particular, Americans teens age 15 to 19 are 82 times more likely than teens in other rich countries to die of a gun homicide. Among black American adolescents, gun homicides are the leading cause of death in the United States.
The root cause of all these problems is well understood: “Persistently high poverty rates, poor educational outcomes, and a relatively weak social safety net have made the U.S. the most dangerous of wealthy nations for a child to be born into,” the study, led by Ashish Thakrar, an internal medicine resident at the Johns Hopkins Hospital, concludes.
Starting in the 1980s, the U.S. childhood poverty rate exploded relative to other wealthy nations. Roughly 21 percent of American children live in poverty, one of the highest rates in the developed world.
American children are also falling behind on education relative to their peers. “Both poverty and education have repeatedly been shown to track along a gradient of health in children, with lower incomes and lower education correlated with worse health outcomes,” according to the report.
These two factors are compounded by a weak American social safety net. “During the period we analyzed, the U.S. spent significantly less of its gross domestic product per capita on child health and welfare programs, compared to other wealthy nations,” the authors write.
Those 600,000 deaths, in other words, are largely the result of deliberate policy choices made by American voters and their elected representatives.
A 2010 study found governing decisions about welfare policies explained up to 47 percent of the observed differences in life expectancy between countries. An earlier study found about 20 percent of country-level differences in infant mortality rates could be explained by a nation's governing style.
“The care of children is a basic moral responsibility of our society,” the report's authors write. “All U.S. policymakers, pediatric health professionals, child health advocates, and families should be troubled by these findings.”
Opioid abuse is so bad it is lowering our life expectancy. Why hasn’t the epidemic hit other countries?
by Amanda Ericsson - The Washington Post - December 29, 2017
For the second year in a row, life expectancy in the United States has dropped.
It is not hard to understand why: In 2016, there was a 21 percent rise in the number of deaths caused by drug overdoses, with opioids causing two-thirds of them. Last year, the opioid epidemic killed 42,000 people, more than the deaths from AIDS in any year at the height of the crisis.
“We should take it very seriously,” Bob Anderson, chief of the Mortality Statistics Branch at the National Center for Health Statistics, told my colleagues Lenny Bernstein and Christopher Ingraham. “If you look at the other developed countries in the world, they’re not seeing this kind of thing. Life expectancy is going up.”
In other words: In no other developed country are people taking and dying from opioids at the rates they are in the United States. We have about 4 percent of the world’s population but about 27 percent of the world’s drug-overdose deaths.
What explains the discrepancy?
The U.S. medical system.
Americans are prescribed opioids significantly more often than their counterparts in other countries. In the United States, 50,000 opioid doses are taken daily per every million residents. That is nearly 40 percent higher than the rate in Germany and Canada, and double the rate in Austria and Denmark. It is four times higher than in Britain, and six times higher than in France and Portugal. As the BBC put it, “American doctors prescribe — a lot.”
That is in large part a result of our health insurance structure. Unlike countries that provide universal health care funded by state taxes, the United States has a mostly privatized system of care. And experts say insurers are much more likely to pay for a pill than physical therapy or repeat treatments.
“Most insurance, especially for poor people, won’t pay for anything but a pill,” Judith Feinberg of the West Virginia University School of Medicine told the BBC. “Say you have a patient that’s 45 years old. They have lower back pain, you examine them, they have a muscle spasm. Really the best thing is physical therapy, but no one will pay for that. So doctors get very ready to pull out the prescription pad. Even if the insurance covers physical therapy, you probably need prior authorization which is a lot of time and paperwork.”
As a result, Americans were being prescribed opioids. Often, they were given several more pills than they could be expected to use, to avoid repeat visits. “Other countries deal with pain in much healthier ways,” said Feinberg, a professor in the Department of Behavioral Medicine and Psychiatry at the West Virginia University School of Medicine.
The U.S. health care system is different from other countries’ in other ways, too. There is pressure to address pain, and a pervasive attitude that everything is fixable. As a result, doctors in the United States are much more likely to provide painkillers than are doctors in other countries. One comparative study found that Japanese doctors treated acute pain with opioids about half the time. In the United States, the number was 97 percent of the time.
“I’m 51,” professor Keith Humphreys of Stanford University told the BBC. “If I go to an American doctor and say, ‘Hey, I ran the marathon I used to run when I was 30, now I’m all sore, fix me,’ my doctor will probably try to fix me. If you do that in France the doctor would say, ‘It’s life, have a glass of wine, what do you want from me?’”
There are other culprits, too. The United States is one of only two countries that allow prescription drug companies to advertise on television. (The other is New Zealand.) The companies do advertise, a lot. In 2016, pharmaceutical companies spent $6.4 billion on advertising. Experts say, too, that U.S. medical schools have not done enough to educate students on pain management, addiction, and opioid use and abuse.
Drug companies also try to woo physicians with gifts. Some companies host fancy dinners, and others sponsor conferences and junkets. In 2016, for example, OxyContin maker Purdue Pharma spent $7 million on gifts to doctors and teaching hospitals. From 1996 to 2001, the company sponsored 40 national “pain management symposia” in attractive destinations. In the same period, the company doubled its sales force, distributing coupons so doctors could offer patients 30-day supplies of OxyContin and other highly addictive drugs. In those six years, prescriptions for OxyContin jumped from 670,000 to more than 6 million.
That alarmed at least one public health group, which ran a 2009 bulletin titled, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy.”
By then, it was too late.
You’re Sick. Whose Fault Is That?
by Dhruv Kullar - NYT - January 10. 2018
On my pediatrics rotation in medical school, several residents told me they worked with children in part because they sometimes found themselves judging adults: Did they do drugs? Were they fat? Why did they drink so much?
The idea that Americans should take personal responsibility for their health has recently received renewed attention. Vice President Mike Pence has argued for “bringing freedom and individual responsibility back to American health care.”
Mick Mulvaney, director of the Office of Management and Budget, expressed a more punitive view, saying, “That doesn’t mean we should take care of the person who sits at home, eats poorly, and gets diabetes.”
The call for personal responsibility is not new, nor just conservative. Barack Obama said, “We’ve got to have the American people doing something about their own care.”
Many Americans think it’s O.K. to ask people with unhealthy lifestyles to pay higher insurance premiums and deductibles. Efforts to inject more personal responsibility into health care, however, have not consistently been shown to lower costs, improve outcomes or save lives. Effectiveness — or lack of it — is often in the eye of the partisan beholder.
What does it actually mean to take personal responsibility for health?
The basic idea is that if we adopt healthful lifestyles, are compliant patients and save money for our own medical care, we’ll feel better, spend less and reduce our burden on others. The details of how this philosophy is applied, however, get complicated: Which programs work and which are counterproductive? Does “personal responsibility” save money or just shift costs from insurers to patients? Who should judge whether we’re living a healthy enough lifestyle: Doctors? Insurers? Government?
Medicaid reform is the policy context in which personal responsibility is most frequently discussed. The Trump administration has signaled a willingness to allow states to impose requirements for people to maintain Medicaid eligibility.
Seema Verma, administrator of the Centers for Medicare and Medicaid Services, previously helped shape Indiana’s Medicaid expansion. To get full benefits in Indiana, patients must contribute monthly to a “personal wellness and responsibility account.” If they fail to pay, they may have benefits cut or lose coverage entirely for six months. They must also make co-payments for certain services, and pay a fee if they use the emergency department unnecessarily. A preliminary report suggests the program has had mixed results. A final evaluation is expected later this year.
Other states are considering similar proposals, but a recent redesign of West Virginia’s Medicaid program offers reason for caution. In 2007, West Virginia asked Medicaid-eligible individuals to sign a personal responsibility agreement to qualify for enhanced benefits. The agreement required beneficiaries to keep medical appointments, take medications, avoid unnecessary emergency department visits, and participate in health screenings.
Those who didn’t sign it — or couldn’t hold up their end of the bargain — had their benefits cut, and were enrolled in a basic plan that restricted prescription drug coverage, limited access to mental health and substance-abuse services, and excluded weight management or nutrition education programs. Both children and adults were subject to the agreement, which raised a basic fairness question: Children might be at the mercy of unreliable parents or guardians to follow the rules.
Less than 15 percent of those eligible signed the agreement, and more than 90 percent of children with Medicaid had benefits restricted. A central motivation of the program was to reduce emergency department use, but over all, people were more likely to visit the emergency room. There was no clear improvement in health or healthy behavior. The experiment was scrapped in 2010.
That individuals bear some responsibility for their health is undeniable. Behavior contributes to nearly half of cancer deaths in the United States, and up to 40 percentof all deaths. But viewing personal responsibility as a central driver of longer lives and lower medical costs is problematic.
American life expectancy has increased markedly in the past century, and few would argue it’s because we now lead healthier lives by dint of willpower. It’s also not clear healthful behavior saves money: People who live longer use more medical care. Smoking cessation, for example, may actually increase long-term health care costs. And ensuring that people bear greater financial risk doesn’t seem to help them make better decisions: A RAND study found that making people pay more for care does reduce how much they use, but that they cut out both highly effective and marginally effective services.
Personal responsibility is not always demanded equally of people at every income level. Many lawmakers want more “skin in the game” for Medicaid recipients, but not as many clamor for higher deductibles for wealthy Americans — even though they’re more likely to have enough “skin” to meaningfully play “the game.”
Personal responsibility is, of course, not a binary construct. When we say unhealthy behavior — overeating, smoking, excessive alcohol use — is not your fault, we may rob people of the initiative to change it. When we say that same behavior is all your fault, we fail to recognize a more complex reality: Health is a product of genes, environment, work, education, family, medical care and many other factors.
Although it seems we should encourage personal responsibility, punishing the opposite may be heavy-handed and even counterproductive. Breaking down every factor that leads patients to develop cancer or heart disease or Alzheimer’s — and penalizing or rewarding them based on the share they could in theory control — seems a herculean and morally suspect task.
Personal responsibility is an attractive goal with deep roots in American culture. But if it’s too aggressively pursued, it may conflict with another worthy ideal: In a nation as wealthy as the United States, sick humans deserve health care — even if they can’t pay, and even if they've made some bad choices.
Nurses Catch Assembly Speaker in Lie About Healthy California Bill
California Nurses Association - Press Release - January 4, 2018
The nearly 100,000 registered nurses of the California Nurses Association (CNA)—co-sponsors of SB 562, the Healthy California Act, which would guarantee healthcare to all Californians—strongly condemn California Assembly Speaker Anthony Rendon’s statement this week that SB 562 sponsors have “sat on their hands and done nothing the past six months.”
“Perhaps Speaker Rendon is confusing his own inaction, after undemocratically parking SB 562, with the clear, loud stand thousands of Californians have taken for months, demanding Rendon unfreeze this lifesaving bill so it can move forward,” said CNA Associate Executive Director, Bonnie Castillo, RN. “Nurses have watched our patients suffer and die for far too long, and that’s why we are unrelenting in our demand for guaranteed healthcare. We expect our elected officials to work on the bill, not breach the public’s trust by halting the normal legislative process or waste time.”
The Healthy California Act, SB 562 passed the full Senate in June and was set for consideration in the Assembly when Speaker Rendon abruptly refused to let it out of the Rules Committee. In response, RNs and other backers of the bill have rallied, canvassed and organized in support of SB 562, in a grassroots movement across the state.
SB 562 sponsor and advocate actions in the past six months include:
- Published study by expert economists at UMass Amherst, setting forth a mechanism on how to pay for SB 562
- 17 amendments proposed
- 200 canvassing events held statewide, covering all 80 Assembly districts
- 15,000 supporters gathered at in-person events across California
- 6,000 doors knocked
- 1,500 new volunteers added to canvassing efforts
- 35 district office visits conducted
- Thousands of phone calls made
- 21 more canvasses are scheduled for January, 2018 alone
“SB 562 supporters don’t have time to sit on our hands, because our hands have been too busy knocking on doors, picking up phones, opening legislative office doors, and holding up ‘Medicare for All’ signs all over California,” said CNA co-president Deborah Burger, RN. “It’s beyond insulting that Speaker Rendon would tell working people, including the nurses who have spent countless hours standing up for our patients’ right to life saving care, that WE haven’t done enough. Allowing this bill to move forward is Rendon’s job, and he needs to stop shifting blame and get to work.”
“Every day that the Assembly members keep talking about it, people get sick and die. They’re inside [the state capitol] with their suits and ties and good health care, and every day people are dying,” said RN Cathy Kennedy. “We’ve done the research, and we know that in California there is money to provide health care for all. It’s time they stop talking about it and do something about it!”
A recent survey showed that a full 70 percent of Californians favor establishing a public, Medicare for all type system providing universal single-payer health coverage. CNA also sponsored the aforementioned study by expert economists at University of Massachusetts Amherst on how to pay for SB 562—revealing that enacting the bill would save Californians $37 billion off our current cost for healthcare.
With widespread public support and a funding mechanism, nurses say Rendon’s recent comments only reveal that elected officials need to stop standing in the way of what their constituents want: guaranteed healthcare.
Trump Administration Says States May Impose Work Requirements for Medicaid
by Robert Pear - NYT - January 11, 2018
WASHINGTON — The Trump administration said Thursday that it would allow states to impose work requirements in Medicaid, a major policy shift in the health program for low-income people.
Federal officials said they would support state efforts to require able-bodied adults to engage in work or other “community engagement activities” as a condition of eligibility for Medicaid.
“Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries, and today’s announcement is a step in that direction,” said Seema Verma, the administrator of the federal Centers for Medicare and Medicaid Services.
Ms. Verma said the Trump administration was responding to requests from Medicaid officials in 10 states that wanted to run demonstration projects testing requirements for work or other types of community engagement like training, education, job search, volunteer activities and caregiving.
The proposals, she said, came from Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin.
Advocates for Medicaid beneficiaries said the new policy was likely to be challenged in court if people were denied coverage for failure to meet a state’s work requirement.
Federal law gives the secretary of health and human services broad authority to grant waivers for state demonstration projects that promote the goals of the Medicaid program. In the past, federal officials said that work was not one of the purposes of Medicaid.
But Trump administration officials said Thursday that work requirements were consistent with the goals of Medicaid, because work and other community engagement activities could improve the health of Medicaid beneficiaries.
“Productive work and community engagement may improve health outcomes,” Brian Neale, the director of the federal Medicaid office, said Thursday in a letter to state Medicaid directors. “For example, higher earnings are positively correlated with longer lifespan.”
In addition, Mr. Neale said, researchers have found “strong evidence that unemployment is generally harmful to health,” while employment tends to improve “general mental health.”
A 2013 Gallup poll found that unemployed Americans are more than twice as likely as those with full-time jobs to say they have or are being treated for depression, Mr. Neale said.
Health Insurer Centene Is Sued Over Lack of Medical Coverage
by Reed Abelson - NYT - January 11, 2018
People who bought policies from Centene, a large for-profit health insurance company, filed a federal lawsuit on Thursday claiming the company does not provide adequate access to doctors in 15 states.
“Members have difficulty finding — and in many cases cannot find — medical providers,” who will accept patients covered under policies sold by Centene, according to the lawsuit filed in federal court in Washington State.
“Centene misrepresents the number, location and existence of purported providers by listing physicians, medical groups and other providers — some of whom have specifically asked to be removed — as participants in their networks and by listing nurses and other non-physicians as primary care providers,” the lawsuit claims.
People signed up for insurance and “they suddenly discovered there were no doctors,” said Seth Lesser, a partner at the law firm of Klafter Olsen & Lesser who is representing some of the policyholders.
A spokeswoman for Centene said that the company had not seen the lawsuit. “We believe our networks are adequate and we work in partnership with our states to ensure our networks are adequate and our members have access to high-quality health care,” she said in an email.
Centene, which also provides coverage to low-income individuals under the government Medicaid program, has proved to be one of the mainstays of the Affordable Care Act. After many other large insurers abandoned the individual market created by the federal law and as President Trump has sought to dismantle the law, Centene doubled-down and has become one of the largest insurers still offering policies.
But the lawsuit underscores a critical question about whether Centene offers plans that provide its customers with access to the level of care required under the law. The suit claims that many doctors won’t accept patients covered by Centene because of the company’s refusal to pay legitimate claims.
As insurers like Centene have relied on smaller networks to control costs and better manage the care of patients, consumer advocates and others have raised concerns about whether some plans offered under the law provide sufficient access to doctors and hospitals. The law requires plans to meet certain minimum requirements.
The lawsuit recounts numerous examples of patients unable to find in-network doctors. In Washington State, Cynthia Harvey was billed for hundreds of dollars in medical costs after she discovered some of her care was out of network. When Ms. Harvey went to the emergency room last year, she was billed $1,544 by the doctor, and the lawsuit claims Centene had no emergency physicians participating in its network in the Spokane area at the time.
The insurer also denied some of the claims from a colonoscopy she had because she was at high risk for cancer, according to the lawsuit. Ms. Harvey successfully appealed many of the denials to state regulators, the lawsuit said.
The lawsuit comes on the heels of a decision last month by Washington State regulators to fine Centene up to $1.5 million for having an insufficient network of doctors to treat people who signed up for plans sold under the Affordable Care Act. State officials said they received more than 140 complaints from people who had trouble finding a doctor, particularly a specialist like an anesthesiologist, who accepted the insurance or from individuals who received a surprise bill after they received treatment.
In a statement about the consent order the company reached with the state to be allowed to continue selling policies for 2018, Centene said it was committed to addressing “known issues in our network in select regions of the state” and said it had taken actions to make sure its customers had access to services.
The company announced this week that it now covers more than 1.4 million people through the state marketplaces, with its chief executive, Michael F. Neidorff, describing its growth in the market as “so dramatic.” Centene attributes some of its success to its experience providing care under the Medicaid program or in its low-cost networks.
Steven A. Milman, a periodontist in Round Rock, Tex., who is one of the plaintiffs in the lawsuit, signed up for an Affordable Care Act plan from Centene last year. He and his wife, both 59, paid about $1,200 a month for coverage. Dr. Milman had a previous policy from UnitedHealth Group. “They had a good panel of doctors and easy access,” Dr. Milman said in a telephone interview. But UnitedHealth lost money in the market and stopped selling policies, so he and his wife were forced to find another insurer.
Choosing between the local Blue Cross plan and one offered by Centene, Dr. Milman picked Centene after seeing that its network included a large medical group in Austin and getting recommendations for several doctors at that group. “I bought Centene on that promise,” he said.
But Dr. Milman soon found out finding a doctor within the network was much harder than he anticipated. The medical group he had picked was no longer in the network. When he called the doctor’s office assigned to him by Centene, it turned out to be a obstetrician/gynecologist. “We don’t see men,” he was told.
Dr. Milman’s wife had no better luck. When she came down with an earache, she was on the phone with the plan for five hours before being sent to a clinic where she was treated by a nurse with no doctor on site.
By the summer, Dr. Milman was fed up. He continued to see the doctor he had under the UnitedHealth plan, paying out of pocket for the visits. But he said he worried about what would happen if he were hospitalized and felt like he didn’t really have insurance. He switched last summer to a Blue Cross plan that he could get because he was self-employed. “Blue Cross is a good plan with a good panel of doctors,” he said.
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