PNHP

Let’s help cities join the Medicare for All bandwagon

Let’s help cities join the Medicare for All bandwagon

Long Beach Mayor Robert Garcia Launches Medicare For All Advocacy Group

By Harry Saltzgaver
The Grunion, September 10, 2020

Mayor Robert Garcia said Thursday, Sept. 10, he and the mayor of Oakland have created an organization to promote Medicare for All in the country as a whole.

The announcement was in the form of a press release out of Garcia’s office. Oakland Mayor Libby Schaff is partnering with Garcia to create Mayors for Medicare for All (Mayors 4 Medicare).

One of the group’s goals, according to the release, is to have a resolution of support in front of the U.S. Conference of Mayors to be adopted as a policy position of that group.

The organization supports Medicare for All legislation introduced by Senator Bernie Sanders and Congresswoman Pramila Jayapal. A single-payer health care system would cover all Americans, including vision, dental, hearing, prescription drugs, mental health care and more.

“The clearest lesson from the COVID-19 crisis is that healthcare must be a right for all — and not a path to bankruptcy and deeper racial disparities,” Schaaf said in the release. “We’re mobilizing local leaders to build a national movement so the next Congress will adopt legislation that brings healthcare access to all.”

There already is a logo and a website — mayors4medicare.com — that includes a place for mayors to sign up and basic information about the group.

https://www.gazettes.com…

Mayors for Medicare for All

Our coalition has 3 goals:

  1. Create a network of mayors who will endorse Medicare for All.
  2. Submit a formal resolution of support for Medicare for All to the U.S. Conference of Mayors for adoption and as a policy position of the conference.
  3. Work with the next administration and Congress to adopt Medicare for All.

https://mayors4medicare.com

Medicare for All Would Help End Racial Disparities in the South

We must take a stand against a for-profit health care system that too often devalues Black lives.

By Jason Williams, Amelia Parker
Common Dreams, September 9, 2020

The coronavirus pandemic and ongoing protests over racial disparities in the U.S. have highlighted just how broken our health care system is, especially for Black Americans.

As local elected officials, we have witnessed first-hand in our cities how our for-profit health care system fails so many of our residents.

In Louisiana, Black people account for 53% of all coronavirus deaths in Louisiana despite making up 32% of the state population, according to the Louisiana Health Department. Black coronavirus patients also made up three-fourths of hospitalization in the state.

These disparities are underscored by broader racial trends. Black children in New Orleans are 3.5 times more likely to be uninsured than white children—8.5% compared to 2.5%—and Black adults are twice as more likely to be uninsured than whites—32.3% to 16.6%.

In Tennessee, Black residents make up 12% of the population, but account for 33% of coronavirus deaths. Black Tennesseans are 40% more likely to be uninsured than White Tennesseans.

Latinx communities are also experiencing a disproportionately high rate of positive COVID-19 cases in our communities. In Knox County, Tenn. Latinxs represent 30% of the county’s positive and probable COVID-19 cases, while only representing 5% of the county’s total population. A study in New Orleans Parish, La., found that 20% of Hispanics tested positive to COVID-19 vs. just 3% of Whites. Latinx Tennesseans are three times as likely to be uninsured that White Tennesseans, and Latinx Louisianans are 3.6 times as likely to be uninsured then White Louisianans.

In this moment of reckoning on racism in so many aspects of society, we must take a stand against a for-profit health care system that too often devalues Black lives.

Our economic health depends upon our physical health. This is not a red issue or a blue issue, it’s a red white and blue issue. The future of the U.S. is depending on universal health care.

That’s why the New Orleans and Knoxville City Councils joined cities and towns across the country in passing resolutions recently in support of Medicare for All. These resolutions send a powerful signal to Congress that our cities stand with the majority of Americans who demand guaranteed health care.

Jason Williams is the New Orleans City Council President.

Amelia Parker is a Knoxville City Council Member.

https://www.commondreams.org…

Comment:

By Don McCanne, M.D.

When you study all of the inefficiencies and injustices of our health care system, it does not take much to understand the health care issues that cities face. Although some of our larger cities are able to supply some of the basic infrastructure in health care, perhaps with the backup of counties and states if they are so inclined, the role of the federal government is essential.

If you look at the Medicare program as a model, you can easily see that it would be possible for a federally financed program to ensure health care for everyone. We would merely need to improve Medicare and then expand it to cover everyone as a single payer Medicare for All program.

Today’s articles demonstrate that some city officials do recognize that the solution for their cities’ health care deficiencies would be to establish a national Medicare for All program. We should encourage our city governments to seriously consider this approach and help them to establish a national movement of Cities for Medicare for All, or Mayors for Medicare for All, or whatever name floats. Let’s just do it.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Medicare for All Explained Podcast: Episode 42

Interview with Prof. Matthew Lawrence

September 15, 2020

Emory University law professor Matthew Lawrence outlines both the benefits and the drawbacks of state-based single-payer programs. He says one notable challenge is that the Department of Health and Human Services would have to approve the use of federal dollars earmarked for Medicare, Medicaid, CHIP, and other programs to be used in a state’s single-payer program. Unfortunately, both current and previous administrators have dismissed this idea.

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Are lung function algorithms perpetuating health disparities experienced by Black people?

By Adam W. Gaffney, Steffie Woolhandler, and David U. Himmelstein
STAT, September 15, 2020

“I can’t breathe” became a rallying cry against racism in the wake of the deaths of George Floyd and Eric Garner at the hands of the police. But chokeholds are far from the main cause of race-based disparities in respiratory deaths in the U.S.

The Covid-19 pandemic is more likely to asphyxiate Black people than white people. They are also more likely to die from asthma, pneumonia, and non-Covid-19 acute respiratory distress syndrome.

Many studies have found that, on average, Black individuals have lower lung volumes than white people. Race-based lung function algorithms — equations used to convert raw lung volumes into age-, sex- and height- adjusted metrics that are more interpretable and useful to physicians — assume that lower lung volumes are expected, and hence “normal,” in Black people. Yet the widespread racial disparities in respiratory illness should provoke a reappraisal of the appropriateness of race-specific prediction equations that use statistics to “adjust away” the racial gap in lung function.

By using these lung function algorithms, are we blinding ourselves (and society) to the health harms of structural racism, effectively normalizing lung damage that Black Americans suffer from dirtier air, dirtier jobs, and substandard medical care?

Today’s race-based lung-volume algorithms rest on more than two centuries of assumptions and observations. In 1783, Thomas Jefferson argued that “difference[s] in the structure in the pulmonary apparatus” made Black people particularly suited for plantation labor, as the scholar Lundy Braun describes in her history of the spirometer, an apparatus used to measure lung volumes. The spirometer, first developed in the 1840s, is still used today. It measures how much air an individual breathes out and in, and how fast. The device made it possible to objectively measure the volume of the lungs, and hence their function. Soon after its development, Samuel Cartwright, a plantation owner and prominent physician in the South, found that Black slaves had smaller lung volumes than white people.

Lower lung function in Black Americans was subsequently documented in other contexts, including assessments of large, well-conducted, nationally representative samples. In the U.S., Black individuals have, on average, lower values on two key tests relative to white individuals: forced expiratory volume in one second (FEV1), which is the amount of air an individual can forcefully exhale in one second, and forced vital capacity (FVC), which is total amount of air an individual can forcefully exhale.

The FEV1 and FVC are difficult to interpret when given as they are measured, in liters of air. That’s because lung volume gets smaller with age, is larger in taller individuals, and is smaller in women than in men.

An understanding of these relationships led to the development of prediction lung function algorithms that convert FEV1 and FVC measurements in liters into a percent predicted adjusted for age, sex, and height. At the same time, longstanding observations of racial differences led to so-called correction factors that “adjust” for race, and later, to racially specific prediction equations that basically do the same thing. One of us (A.G.) uses them with his pulmonology patients, as is standard practice.

Here’s an example of how these equations work: Using one commonly used prediction equation, an FEV1 of 3.5 liters would be in the normal range (91% of predicted) for a 40-year-old, 6-foot-tall Black man, but the exact same value would be considered abnormally low (78% of predicted) for a 40-year-old, 6-foot-tall white man.

Using race-adjusted lung function algorithms has important social and medical ramifications. The percentage predicted values are used in surveillance programs to detect the development of lung disease in potentially hazardous workplaces. For individuals who already have lung disease, they are used to guide the selection of medical therapies, surgical interventions, and decisions about lung transplantation. The United Network for Organ Sharing, which administers the only network in the U.S. for organ procurement and transplantation, incorporates the percent predicted FVC in its algorithm for assigning priority for getting an organ, with individuals who are sicker being assigned a higher priority.

The upshot is that two otherwise identical patients may be treated differently based on the color of their skin: a white patient might receive treatments not offered to a Black patient; might be referred for lung transplantation earlier in their disease course; and could be assigned a somewhat higher priority for receiving a lung.

If the aforementioned Black man with an FEV1 of 91% predicted actually had a better prognosis than the white man with an FEV1 of 78% predicted, even though both had an identical FEV1 of 3.5 liters, the use of these race-specific equations might be appropriate, with the race-specific equations more accurately reflecting each individual’s prognosis than the use of a colorblind equation, which would suggest they had similar prognoses. But there is no evidence this is the case, and the lone study of the issue suggests the opposite: that Black and white individuals of the same age, sex, height, and FVC (expressed in liters) have similar long-term mortality.

The use of race-specific lung function algorithms, then, may be leading to inappropriate — and inadvertently discriminatory — differences in diagnosis, protection from occupational exposures, and treatment. Similar concerns have been raised about the use of race-based kidney function equations, prompting petitions that have led multiple institutions to abandon them, and national nephrology societies to reassess their use.

But in the case of lung function, there’s a hitch: Using spirometry equations without adjusting for race would increase the number of Black individuals diagnosed with restrictive lung disease, a type of disorder characterized by smaller lungs, sometimes due to scarring. Whether the potential benefits of fewer missed diagnoses would outweigh the harms of mislabeling some healthy people as having a lung disease is currently unknown.

Clinical implications aside, an important underlying question is why Black Americans have smaller lung volumes than their white counterparts. Nature or nurture? Genes or environment?

The strong correlation between lung volume and socioeconomic status argues against a solely genetic cause. Studies in many nations have demonstrated a class gradient in lung function, suggesting that social disadvantage — perhaps mediated by exposure to air pollution, inadequate nutrition, occupational hazards, lung infections, and other exposures — accounts for some or all of the “racial” difference. Yet even studies that statistically adjust for socioeconomic status, by controlling for income and education, still find substantial racial differences in spirometric measures.

And therein lies a conundrum. Statistical adjustments for differences in education and current income can’t fully account for the disadvantages that racism imposes on African Americans. The legacy of slavery and discrimination has led to a wide gap in housing and wealth between white and Black families, forcing them to endure less-healthy living and working conditions than white people with similar incomes and education.

Black people in America have endured racism since 1619, and as Floyd’s and Garner’s deaths make painfully clear, racism persists today. Until we eliminate redlining, unequal access to housing and medical care, racially biased hiring and job assignment, environmental racism, and the psychosocial toll that racism imposes, we cannot know whether Black people’s lower-than-average lung function is normal, or merely the norm.

Adam Gaffney is a pulmonary and critical care physician at the Cambridge Health Alliance and an instructor in Medicine at Harvard Medical School. Steffie Woolhandler and David U. Himmelstein are primary care physicians and professors in urban public health at the City University of New York Hunter College and lecturers in Medicine at Harvard Medical School. The authors serve as leaders of Physicians for a National Health Program, a nonprofit organization that favors expanding insurance through a single payer program. None receive compensation for that work, though some of Gaffney’s travel on behalf of the organization has been reimbursed by it.

https://www.statnews.com…

“Why do we have racial health inequities?” panel

PNHP president-elect Dr. Susan Rogers moderated a panel discussion for DSA’s Black Health + Black Liberation webinar series on September 14, 2020. Dr. Rogers was joined by Drs. Claudia Fegan (PNHP’s national coordinator), Linda Rae Murray (former APHA president), and Mary Bassett (former commissioner, NYC Department of Health and Mental Hygiene) to address the historic, economic, social, and political roots of racial health inequities.

Unionized nursing homes have lower COVID-19 mortality rates

Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes

By Adam Dean, Atheendar Venkataramani, and Simeon Kimmel
Health Affairs, September 10, 2020 (Ahead of print)

Abstract

More than 40% of all reported coronavirus disease 2019 (COVID-19) deaths in the United States have occurred in nursing homes. As a result, health care worker access to personal protective equipment (PPE) and infection control policies in nursing homes have received increased attention. However, it is not known if the presence of health care worker unions in nursing homes is associated with COVID-19 mortality rates. Therefore, we used cross-sectional regression analysis to examine the association between the presence of health care worker unions and COVID-19 mortality rates in 355 nursing homes in New York State. Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions. Unions were also associated with greater access to PPE, one mechanism that may link unions to lower COVID-19 mortality rates.

From the Introduction

Labor unions representing health care workers perform several functions that may reduce SARS-CoV-2 transmission. Unions generally demand high staff-to-patient ratios, paid sick leave, and higher wage and benefit levels that reduce staff turnover. They educate workers about their health and safety rights, work to ensure that such rights are enforced, demand that employers mitigate known hazards, and give workers a collective voice that can improve communication with employers. In the specific context of the COVID-19 pandemic in New York, labor unions advocated for access to PPE and new infection control policies.

Study design and data sources

We conducted cross-sectional regression analyses to estimate the association between the presence of a health care worker union and COVID-19 mortality rates in nursing homes in New York State during the 2020 COVID-19 pandemic. We used publicly available data from the New York State Department of Health (NYSDOH) on COVID-19 mortality. We used proprietary data from 1199SEIU United Healthcare Workers East (1199SEIU), the International Brotherhood of Teamsters, and the Communication Workers of America (CWA), as well as publicly-available data from the New York State Nurses Association (NYSNA) to determine if a labor union represented health care workers in each facility.

From the Discussion

Among 355 nursing homes in New York State for which data on COVID-19 mortality rates were available, the presence of a health care worker union was associated with a 30% lower mortality rate from COVID-19 among nursing home residents. The findings were robust to adjustment for a range of covariates and specification checks for bias from missing data. We also found that nursing homes with labor unions had greater access to PPE and lower COVID-19 infection rates, two important mechanisms that may link unions to lower COVID-19 mortality rates.

However, more research is needed to understand the numerous mechanisms through which unions may influence COVID-19 mortality rates, such as staff training, reducing use of part-time workers, implementing infection protocols, and giving workers a collective voice in the workplace.

Our finding that unions are associated with reduced COVID-19 mortality rates in nursing homes is consistent with previous findings that unions improve safety and health standards for workers, help to co-enforce those standards with employers, and also reduce workplace injuries and accidental deaths. Health care worker unions, in particular, are also associated with improved patient outcomes.

We also found that chain nursing homes were associated with higher COVID-19 mortality rates. Previous research similarly finds that nursing home chains are associated with lower quality care.

Conclusion

Residents in nursing homes have been disproportionately affected by COVID-19. The presence of a health care worker labor union was associated with a 30% relative decrease in the COVID-19 mortality rate compared to facilities without unions in the State of New York. Health care worker unionization may play an important role in ensuring access to appropriate PPE and implementing infection control policies that protect vulnerable nursing home residents.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

“The presence of a health care worker labor union was associated with a 30% relative decrease in the COVID-19 mortality rate compared to facilities without unions in the State of New York.” Not only that, but “chain nursing homes were associated with higher COVID-19 mortality rates.”

How do health care labor unions reduce COVID-19 mortality in nursing homes? “Labor unions representing health care workers perform several functions that may reduce SARS-CoV-2 transmission. Unions generally demand high staff-to-patient ratios, paid sick leave, and higher wage and benefit levels that reduce staff turnover. They educate workers about their health and safety rights, work to ensure that such rights are enforced, demand that employers mitigate known hazards, and give workers a collective voice that can improve communication with employers. In the specific context of the COVID-19 pandemic in New York, labor unions advocated for access to PPE and new infection control policies.”

On these pages we frequently differentiate business ethic from service ethic in health care. With a business ethic, profit rules. For example, chain nursing homes are expected to manage the operations in a manner that maximizes profits for their passive investors. With a service ethic, the expectation is that everyone involved in the nursing home strives to provide the best care possible with the available resources. Professionalism on all levels drives the care provided. This study confirms that the difference is very real. Unionized health care workers save more lives.

As another example, when you see demonstrations in support of Medicare for All, the participants are frequently members of California Nurses Association/National Nurses United. They are not there to advocate for more profits for Wall street investors. They are using their own time to advocate for affordable, comprehensive health care not only for their own patients, but for everyone.

Health care unions are about professional service for the patients. We need to have them everywhere throughout the health care system. In fact, we need unions everywhere to help correct the scourge of excessive inequality in income and wealth, which is a major contributor to health care injustice and other injustices throughout our society. We can do better, much better.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

British Columbia rules health care access to be based on need and not ability to pay

Cambie Ruling a Victory for Public Health Care in Canada

Business Wire, September 10, 2020

In today’s landmark ruling in the Cambie Surgery Centre case, Justice Steeves dealt a strong blow to the efforts of Dr. Brian Day and others to undermine Canada’s publicly-funded health care system. The decade-long legal attack launched by one of the largest for-profit surgical centres in Canada sought to invalidate key sections of the BC Medicare Protection Act (MPA). This decision ensures that access to health care will continue to be based on need and not on ability to pay.

“This is a historic victory against profit-driven health care in Canada,” said Dr. Danyaal Raza, Chair of Canadian Doctors for Medicare. “We know that single-payer publicly-funded health care is the fairest way to pay for health care, rather than forcing patients to pay out-of-pocket or buy private insurance. This case was never about wait times – it was always about profit.”

The sections of the MPA that the plaintiffs sought to strike down are in place to preserve a public health care system in which access to necessary medical care is based on need and not an individual’s ability to pay. This case has always been about increasing profits for doctors and investor-owned health care facilities.

“As a group of patients, doctors and health care advocates, we became involved in this case in order to defend and protect public health care,” said Edith MacHattie, co-chair of the BC Health Coalition. “This is a victory for everyone who uses health care in Canada. Even though the attack had been launched in BC, it took aim at the very heart of the Canada Health Act and every provincial health care insurance plan.”

Justice Steeves’ ruling affirmed that access to health care be based on need and not the ability to pay. He wrote that the sections of the MPA challenged in this case are in keeping with the “objectives of preserving and ensuring the sustainability of the universal public healthcare system and ensuring access to necessary medical services is based on need and not the ability to pay.”

The recent public health emergency caused by COVID-19 has underscored just how important our public health care system is. This decision protects our ability to endure crises and care for one other into the future.

https://www.businesswire.com…

IN THE SUPREME COURT OF BRITISH COLUMBIA

Cambie Surgeries Corporation v. British Columbia (Attorney General), 2020 BCSC 1310
September 10, 2020

From the Summary of Judgement

[21] In the context of a complex social program such as healthcare where there is a need to balance conflicting interests and claims over limited resources, a high degree of deference is owed to the government under s. 1 (paras. 2885-2893, 2898, 2922, 2931, 2936). Bearing this in mind, I find that the objectives of the impugned provisions, preserving and ensuring the sustainability of the universal public healthcare system and ensuring access to necessary medical services is based on need and not the ability to pay, are pressing and substantial (paras. 2895-2903). I also find that there is a rational connection between deterring the emergence of a competitive duplicative private healthcare system and these objectives (paras. 2904‑2909). Finally, the evidence also supports the defendant’s claim that the impugned provisions are minimally impairing and their effects are proportionate to their objectives (paras. 2910-2934).

[22] Thus, even if I had found a violation of ss. 7 or 15 of the Charter, I would have nonetheless concluded that the impugned provisions are a reasonable limit on those rights and are demonstrably justified in a free and democratic society under s. 1 (paras. 2935-2937).

[23] The plaintiffs’ claim is dismissed (paras. 2938-2940).

The Honourable Mr. Justice Steeves

https://www.bccourts.ca…

Comment:

By Don McCanne, M.D. 

This landmark decision has preserved Canada’s single payer health care system, ruling against the establishment of a two-tiered, parallel private system, which basically would allow higher fees in the private system plus an avenue for the wealthy to bypass the public queue.

One of the more important findings is that relieving the public sector of the private patients would not shorten the public queue, but, in fact, would lengthen it. It would have opened the doors to U.S.-style profit-driven care. Instead, health care will continue to be based on need and not the ability to pay.

The legal process has been exhaustive – the British Columbia Supreme Court phase of the trial alone began in 2016 – but it is not over. The plaintiff, Brian Day, stated that he plans to appeal, beginning with applying for a stay to prevent his private clinics from being closed.

Although this case may not be over, the cause for health care justice for all has carved another major victory notch. Laws may be made and interpreted by legislators and judges, but the moral authority in a democracy still belongs to the people, though they have to exercise their right to keep it.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Americans home sick from work with Coronavirus symptoms disproportionately low-income, people of color, uninsured, and unable to afford food: Harvard study

New study sheds light on the disproportionate impact of the COVID-19 pandemic — and the health and economic vulnerabilities of American workers

For Immediate Release: Sept. 10, 2020

CONTACT:
Adam Gaffney, M.D., M.P.H., Harvard Medical School and Cambridge Health Alliance, agaffney@cha.harvard.edu
Steffie Woolhandler, M.D., M.P.H., City University of New York Hunter College and Harvard Medical School, swoolhan@hunter.cuny.edu


As the first wave of the COVID-19 pandemic was receding in mid-May, some 1.3 million working-age adults reported being home sick with symptoms they attributed to the coronavirus. A new analysis finds that, compared to those still working or those absent with other illnesses or disabilities, the adults home sick with COVID-19 had lower incomes, were more likely to be racial/ethnic minorities, and had less education — national-level evidence of the disparate impact of the COVID-19 pandemic that bolsters other studies based on diagnosed cases and deaths. The study, published September 10 in the Journal of General Internal Medicine, also found that these adults had very high rates of uninsurance and food insecurity that could compound the health harms of the pandemic, findings with relevance to ongoing debates over coronavirus relief legislation in Washington.

The researchers analyzed the Census Bureau’s Household Pulse Survey, a new survey that provides information on the health and financial impact of the COVID-19 pandemic in the U.S. Using data from two weeks of the survey conducted in April and May, the researchers identified working-age adults who reported being out “sick with coronavirus symptoms” (previous research has found that some 83.0% of Americans correctly identify the leading coronavirus symptoms).  Compared to those at work the previous week, researchers found that these individuals were more likely to be Black (24.2% vs. 11.5%), Asian (11.7% vs. 5.6%), and Hispanic (26.5% vs. 17.2%). The study authors observed similar patterns when comparing the adults home sick with coronavirus to those not working because of a non-coronavirus illness or disability. Those reporting coronavirus symptoms also had lower incomes and less education, and tended to live in larger households and states with high levels of COVID-19 incidence.

The researchers additionally found that those out sick with coronavirus symptoms had disturbingly high levels of social vulnerability: 29.2% of these individuals were uninsured, compared to 8% among the two comparison groups; and 36.2% reported not being able to obtain enough food, compared to 7.5% of those working and 20.8% of those out of work for another illness or disability.

“We know that Black and Hispanic communities have been the hardest hit by the COVID-19 pandemic, as measured in diagnoses and deaths,” noted study author Dr. Steffie Woolhandler, distinguished professor at City of University Hunter College and a Lecturer at Harvard Medical School. “But our study suggests that the disparate impact is larger yet, because many people recover at home without ever being diagnosed. Our study also reveals remediable social vulnerabilities — lack of health insurance and food insecurity — that could further compound the inequitable health impact of the coronavirus,” she added.

The study builds on previous studies from this research group. An earlier study, also published in the Journal of General Internal Medicine using data that predated the pandemic, found that some 18.2 million adults who were at increased risk of severe COVID-19 because of age or chronic disease were either uninsured or underinsured, and that these individuals were disproportionately people of color and lower income. In another study, published in JAMA: Internal Medicine, the researchers identified a historic rise in work absence for illness of any cause, with a disproportionate impact on immigrants, in April.

“The COVID-19 pandemic has been a disaster for working class Americans of all backgrounds, and for Black and Hispanic communities in particular,” noted study author Dr. Adam Gaffney, a pulmonary and critical care physician at Harvard Medical School and the Cambridge Health Alliance.  “But in so many ways, this disaster has been manmade. The high levels of uninsurance and food insecurity we observed in those reporting coronavirus symptoms is not an act of nature — it could be solved today by action from Washington. Universal health coverage, and economic aid to American workers, is an urgent necessity.”       

“Home Sick with Coronavirus Symptoms: a National Study, April–May 2020,” by Adam W. Gaffney, MD, MPH, David Himmelstein, MD, David Bor, MD, Danny McCormick, MD, and Steffie Woolhandler, MD, MPH, Journal of General Internal Medicine, September 10, 2020. 

DOI: 10.1007/s11606-020-06159-5

MIPS penalizes physicians who take care of vulnerable populations

Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System

By Dhruv Khullar, M.D., M.P.P.; William L. Schpero, Ph.D.; Amelia M. Bond, Ph.D.; Yuting Qian, M.S.; Lawrence P. Casalino, M.D., Ph.D.
JAMA, September 8, 2020

Key Points

Question: Was there an association between patient social risk and physician performance in the first year of the Merit-based Incentive Payment System (MIPS), a major Medicare value-based payment program?

Findings: In this cross-sectional observational study of 284 544 physicians, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with physicians with the lowest proportion (mean, 64.7 vs 75.9; range, 0-100; higher scores reflect better performance).

Meaning: Physicians with the highest proportion of socially disadvantaged patients had significantly lower MIPS scores, although further research is needed to understand the reasons underlying the differences in MIPS scores by levels of patient social risk.

From the Discussion

These results are consistent with prior research in other value-based programs, suggesting that clinicians and health care organizations serving poorer patients tend to have lower performance scores. Many value-based payment programs may thus penalize clinicians for social factors outside their control and inadvertently transfer resources from those caring for less affluent patients to those caring for more affluent patients—the so-called reverse Robin Hood effect.

While the Medicare Payment Advisory Commission has recommended eliminating MIPS in its current form, Congress has not provided any indication it intends to do so.

https://jamanetwork.com…

Association of Clinician Health System Affiliation With Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System

By Kenton J. Johnston, Ph.D.; Timothy L. Wiemken, Ph.D.; Jason M. Hockenberry, Ph.D.; Jose F. Figueroa, M.D., M.P.H.; Karen E. Joynt Maddox, M.D., M.P.H.
JAMA, September 8, 2020

Key Points

Question: Did clinicians affiliated with health systems composed of hospitals and multispecialty group practices have better performance ratings than their peers under the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS)?

Findings: In this cross-sectional study of 636 552 clinicians with MIPS data for 2019 (based on clinician performance in 2017), those with health system affiliations compared with clinicians without such affiliations had a mean MIPS performance score of 79 vs 60 on a scale of 0 to 100, with higher scores intended to represent better performance. This difference was statistically significant.

Meaning: Clinician affiliation with a health system was associated with significantly better 2019 MIPS performance ratings, but whether this reflects a difference in quality of care is unknown.

From the Discussion

Whether the MIPS will meaningfully improve quality or reduce costs over time is unknown. Research on prior Medicare value-based payment programs in the outpatient setting, notably the Shared Savings Program and the Value-Based Payment Modifier Program, have produced mixed results, finding modest to no cost savings or improvements in the quality of care. Longer-term studies are needed to examine this program as future years of data become available.

https://jamanetwork.com…

Editorial: Potential Adverse Financial Implications of the Merit-based Incentive Payment System for Independent and Safety Net Practices

By Carrie H. Colla, Ph.D.; Toyin Ajayi, M.D., M.Phil.; Asaf Bitton, M.D., M.P.H.
JAMA, September 8, 2020

In 2019, US clinicians began to be rewarded or penalized up to 4% of revenue under the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS). Clinicians can choose measures for evaluation from 3 categories: quality, meaningful use, and improvement activities.

The reports in this issue of JAMA by Johnston et al and by Khullar et al evaluated the MIPS performance scores of clinicians and the potential financial implications associated with the MIPS program. The authors found meaningful advantages for clinicians associated with health care systems and among those who treated fewer patients with low socioeconomic status and complex medical needs.

The findings of these studies have important implications for MIPS specifically, and broadly for payment reform. This compelling evidence supports the notion that system-affiliated practices are more likely to be rewarded by pay-for-performance programs than independent practices. However, a large amount of skepticism remains about whether this pay-for-performance approach correlates with better patient outcomes. The proportion of physicians employed by hospitals or health systems has been rapidly increasing from about 28% of primary care physicians in 2010 to almost 50% in 2018.3,4 There are consequences from this consolidation, such as increasing prices in commercial markets without meaningful improvements in care quality and patient outcomes.5 In addition, choice in referrals to inpatient settings, specialty physicians and centers, or ancillary services may be limited.

Because the quality measures were chosen by practices and were process based, the investigators could not disentangle whether their results represent better quality of patient care or reflect resources available to support selection and reporting of quality measures.

The second major finding raised by these reports is the uncomfortable recognition that the MIPS and other alternative payment models consistently appear to penalize physicians who care for low-income and vulnerable populations. Khullar et al used dual eligibility status as a proxy for social, medical, and behavioral health complexity in the Medicare population. This population requires complex medical care, behavioral health services, and long-term supports, all of which must be coordinated to achieve outcome improvements. Dually eligible beneficiaries are approximately 3 times as likely to have significant limitations in activities of daily living than non–dually eligible beneficiaries (30% vs 9%, respectively) and to experience serious mental illness (30% vs 11%). Dually eligible beneficiaries are also twice as likely (48% vs 21%) to belong to racial or ethnic minority groups than non–dually eligible beneficiaries, reflecting the complex interplay between race, geographic location, racism, poverty, and poor health outcomes.

Physicians and other health care professionals who provide care for large proportions of dually eligible beneficiaries must engage in a number of complex, costly activities to improve patient health. Consequently, primary care clinicians who serve medically and socially complex populations have greater process and operational challenges (and clinical difficulties) in providing quality and accessible care to dually eligible populations.

Yet instead of adjusting reimbursement to reflect the differential cost of caring for these populations, it appears that the MIPS may further disadvantage safety net clinicians who provide care for dually eligible beneficiaries. The results reported by Khullar et al are consistent with prior research that demonstrated value-based payment programs disproportionately penalize clinicians and practices that serve low-income patients and reflect design flaws of the payment system.

The Medicare Payment Advisory Commission has recommended replacing the MIPS because it is unlikely to help beneficiaries choose clinicians, help clinicians improve value, or help the Centers for Medicare & Medicaid Services reward clinicians for value. Rewarding improved performance is a laudable policy goal. Programs like the MIPS, however, appear to be disproportionately rewarding well-off health systems while penalizing smaller practices and those serving disadvantaged populations.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D. 

One of the papers says, “Longer-term studies are needed to examine this program as future years of data become available.” Don’t they always say that?

Once more, MIPS does not work, and it has to go. No more studies, please! We already have a proven model that will work for all of us: single payer improved Medicare for All. When the next Congress convenes and the new administration is installed, our roar has to be deafening and unrelenting.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Medicaid managed care plans reduce spending by providing less of everything

Are All Managed Care Plans Created Equal? Evidence from Random Plan Assignment in Medicaid; NBER Working Paper No. 27762

By Michael Geruso, Timothy J. Layton, Jacob Wallace
National Bureau of Economic Research, August 2020

Abstract

Exploiting random assignment of Medicaid beneficiaries to managed care plans, we identify plan-specific effects on healthcare utilization. Auto-assignment to the lowest-spending plan generates 30% lower spending than if the same enrollee were assigned to the highest-spending plan, despite identical cost-sharing. Effects via quantities, rather than differences in negotiated prices, explain these patterns. Rather than reducing “wasteful” spending, low-spending plans cause broad reductions in the use of medical services—including low-cost, high-value care—and worsen beneficiary satisfaction and health. Supply side tools circumvent the classic trade-off between financial risk protection and moral hazard, but give rise instead to a cost/quality trade-off.

From the Introduction

Regulated competition between private health plans is becoming the dominant form of social health insurance in the United States. In 2017, 54 million Medicaid beneficiaries (69%) and 19 million Medicare beneficiaries (33%) were enrolled in a private managed care plan. In the same year, almost $500 billion of the $1.3 trillion spent on public health insurance programs went to private managed care plans.

In this paper, we identify the causal effects of the health plan in which a beneficiary enrolls on her healthcare utilization, the quality of care received, and proxies for satisfaction and health. The context of our analysis is Medicaid Managed Care (MMC), the privatized system through which most Medicaid beneficiaries receive benefits today.

In our setting, all plans are required to provide care at zero marginal cost to beneficiaries. It is therefore an ideal context for studying whether various non-cost-sharing plan features (e.g., networks, negotiated provider rates, patient follow-up and medication adherence programs, etc.) can constrain healthcare spending. In contrast, nearly all of the prior econometric literature studying how health plans affect utilization and health outcomes has focused on consumer cost-sharing provisions like copays, coinsurance, and deductibles. But a modern health plan is more than a set of consumer-facing prices, and our analysis sheds new light on the range of impacts generated by supply-side (non-cost-sharing) plan features. To facilitate a transparent comparison between our results and results from cost-sharing studies including the RAND Health Insurance Experiment (Manning et al., 1987) and more recent quasi-experimental work (Brot-Goldberg et al., 2017), we focus our analysis on the types of outcomes that have been the focus of this prior literature. These include overall service utilization and spending, utilization of high- and low-value care, conventional measures of healthcare quality, and surrogate health outcomes like avoidable hospitalizations.

As our first main result, we document statistically and economically significant causal variation in spending across plans. If an individual enrolls in the lowest-spending plan in the market she will generate about 30% less in healthcare spending than if the same individual enrolled in the highest-spending plan in the market. We show that risk-adjusted observational measures and causal estimates of plan spending effects are correlated, but find that the risk-adjusted measures tend to overstate causal differences in spending across plans. Plans that attract healthier patients thus do more to constrain spending—i.e., provide less care—consistent with a classic adverse selection model, where sicker individuals select plans providing more care. This fact has important implications for the use of observational measures of spending and quality as a basis for regulatory rewards or penalties.

After establishing important differences between risk-adjusted (OLS) plan spending effects and causal (IV) estimates, we investigate which factors drive the bottom-line causal differences. First, we find that almost all services are marginal. That is, lower spending plans tend to provide less of nearly everything. This includes inpatient and outpatient visits, primary care physician office visits, and high-value/cost effective drugs. Second, unlike in other markets, differences in provider prices do not explain the differences in healthcare spending across plans in our setting. In a decomposition, prices account for very little of the cross-plan spending differences.

Instead, spending differs because enrollees in low-spending plans use less care, with much of the utilization gap driven by the extensive margin. Importantly (and similar to the effects of deductibles in Brot-Goldberg et al., 2017), utilization reductions do not seem to focus on “low-value” care or “waste”: We estimate that low-spending plans reduce utilization of high-value drugs used to treat diabetes, asthma, and severe mental illnesses, as well as high-value screenings for diabetes, cancer, and sexually transmitted infections.

Finally, we show that the low-spending plans also increase avoidable hospitalizations and decrease consumer satisfaction, as measured by the propensity of auto-assigned enrollees to switch out of their plan post-assignment. These results suggest a clear trade-off between spending and beneficiary satisfaction and health.

We show that there is substantial causal heterogeneity across plans in spending and utilization that arises without any differences in consumer cost-sharing exposure.

Our findings complement a large literature extending back to the RAND health insurance experiment (Manning et al., 1987) that documents how consumer prices impact healthcare utilization. In RAND, and the studies that have followed, patient cost-sharing has proven to be a blunt instrument, affecting the use of low- and high-value services alike (Brot-Goldberg et al., 2017). These findings sparked interest in whether managed care tools offer a scalpel that can target inefficient spending and better manage the high-cost patients responsible for the majority of spending. But our results, along with prior work studying managed care in Medicare (Curto et al., 2017), indicate that supply-side tools exhibit many of the same features and limitations as demand-side tools. Their impacts on healthcare spending are blunt. They indiscriminately reduce utilization, limiting both high- and low-value care rather than targeting “waste.” In another similarity to the effects of consumer cost sharing (as found in Brot-Goldberg et al., 2017), lower-spending managed care plans in our setting do not appear to generate savings by steering patients to lower-cost providers or lowering negotiated prices.

Lastly, our work highlights how supply side tools can achieve spending reductions while circumventing the classic trade-off between financial risk protection and moral hazard noted by Zeckhauser (1970) and Pauly (1974). The spread of plan effects we estimate are similar to the utilization difference between the 0% and 95% coinsurance rate treatment arms in the RAND HIE. Thus, significantly constraining healthcare spending need not require exposing consumers to out of pocket spending. But there is no “free lunch” here, as we also document that these spending reductions come at the cost of beneficiary satisfaction and, ultimately, health.

Conclusion

Our results are important for understanding the potential for managed care to constrain healthcare spending growth. We show that the baskets of rationing devices implicit in managed care can have spending and utilization impacts significantly larger than what could be accomplished by exposing consumers to high deductibles and reasonable coinsurance and copays.

Importantly, rationing via managed care reduces spending without exposing consumers to financial risk, circumventing the classic trade-off between financial risk protection and moral hazard noted by Zeckhauser (1970) and Pauly (1974). These findings are particularly relevant for public insurance programs—including the low-income segments of HIX Marketplaces and Medicare—where policymakers have been reluctant to expose low-income consumers to financial risk.

However, these spending reductions appear to come with a utility cost. Willingness to remain enrolled in a plan is negatively related to that plan’s cost savings. And cost reductions are blunt—reducing utilization of all types of care, lowering traditional measures of healthcare quality, and increasing the likelihood of adverse health events.

https://www.nber.org...

Comment:

By Don McCanne, M.D.

Medicaid managed care plans have become very popular in states for the obvious reason that they reduce spending. This paper is important because it reveals how the cost savings are achieved.

Most Medicaid programs do not use cost sharing and thus they do not reduce spending that way, but, even if they did, these authors state that “managed care can have spending and utilization impacts significantly larger than what could be accomplished by exposing consumers to high deductibles and reasonable coinsurance and copays.” They also find that differences in provider prices do not explain the differences in health care spending across plans in this setting.

So how does managed care control spending? The plans consider all services to be marginal and thus they reduce utilization of all services regardless of the value of those services. “Lower spending plans tend to provide less of nearly everything. This includes inpatient and outpatient visits, primary care physician office visits, and high-value/cost effective drugs.”

This gives rise to cost/quality trade-offs. Reduction in beneficial health care services obviously reduces the quality of care. Low-spending plans increase avoidable hospitalizations. This cavalier attitude does not go without notice; beneficiary satisfaction is diminished.

How many more studies do we need? The private insurance industry has to go. And, yes, we have a replacement: single payer improved Medicare for All.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The CO-OP failure should be a lesson for a Medicare public option

Only three of 26 Obamacare-era nonprofit health insurance co-ops will soon remain

By Phil Galewitz and Kaiser Health News
Fortune, September 6, 2020

New Mexico Health Connections’ decision to close at year’s end will leave just three of the 23 nonprofit health insurance co-ops that sprung from the Affordable Care Act.

Lauded as a way to boost competition among insurers and hold down prices on the Obamacare exchanges, the co-ops had more than 1 million people enrolled in 26 states at their peak in 2015. Today, they cover about 128,000 people, just 1% of the 11 million Obamacare enrollees who get coverage through the exchanges.

The nonprofit organizations were a last-minute addition to the 2010 health law to satisfy Democratic lawmakers who had failed to secure a public option health plan — one set up and run by the government — on the marketplaces. Congress provided $2 billion in startup loans. But nearly all the co-ops struggled to compete with established carriers, which already had more money and recognized brands.

https://fortune.com…

CO-OP Health Plans under the Affordable Care Act

From the Comment by Don McCanne, M.D.
PNHP, Quote of the Day, July 2011

The proposed rule has now been released for the establishment of CO-OPs under the Affordable Care Act. The CO-OPs are private, nonprofit organizations that sell insurance, like HMOs and PPOs, under the same rules as the other private insurers.

These are new organizations, and, as such, require a new infusion of capital to meet the reserve requirements for future claims.

Private, for-profit insurers have the capability of establishing start-up costs and solvency reserves by selling shares of stock. Since the CO-OPs are nonprofit, they don’t have this resource to tap. Recognizing this, the Affordable Care Act included provisions for government loans for start-up costs and other loans for solvency (reserve funds for future claims). It is important to understand that these are not grants but are loans that must be repaid, with interest, within five years for start-up loans and fifteen years for solvency loans.

Think about that. The CO-OPs are required to compete with the private insurers under the same terms, while having the additional requirement of paying back these loans. Since their only revenue source is premiums for the insurance they are selling, these loan costs that their competitors don’t have will have to be recovered through higher premiums. Under these terms, how could they possibly compete with the private insurers?

There are many other issues. How long would it take to establish a critical threshold of enrolling enough members to create a viable entity? Since it is likely that the CO-OPs would be subject to adverse selection (enrolling a larger share of patients with greater health care needs), there would be further upward pressure on their premiums (death spiral) since current risk adjustment tools do not recover the full excess losses (as if health care is a “loss”).

It’s too bad. CO-OPs should have offered us the opportunity to establish altruistic health care organizations. Instead, the politicians bent over backwards not only to keep the government out of these programs, but also to protect the private insurers’ marketplace by being sure that the CO-OPs were not allowed a fair playing field by saddling them with insurmountable debt.

We needed a seat at the table.

https://pnhp.org…

There is very little difference between the co-ops and the “public option”

By Kip Sullivan, J.D.
PNHP, September 29, 2009

Advocates of a “public option” have been extremely critical of the health insurance cooperatives proposed by Sen. Kent Conrad last June and incorporated in the draft legislation released by Senate Finance Committee Chairman Max Baucus on September 16 (2009). “Option” advocates claim the co-ops either will not survive or will be so small they will be unable to force the insurance industry to lower its premiums. This is legitimate criticism.

But “option” advocates should level the same criticism against the “option.” The “option” is no more likely to survive and thrive than the co-op program. A comparison of the legislation that would create “option” programs with the provisions in the Baucus bill that would create co-ops indicates there is only one reason to be less pessimistic about the “option,” namely, the “option” legislation requires that someone (the Secretary of the Department of Health and Human Services) attempt to get the “option” program going. There is no similar requirement for the co-op program.

Rockefeller, Dean, Hacker and their colleagues in the “option” movement are doing a great job of leveling legitimate criticism against the co-op proposal. Their criticisms are aimed squarely at the question of how the co-ops will get started and whether they will ever grow large enough to take substantial market share away from the insurance industry. But they adamantly refuse to level the same criticism at the “option.” They should tell us why. I doubt they will do that. I doubt it because there is no rational explanation for this double standard. And no one likes to admit to behaving irrationally.

https://pnhp.org…

Comment:

By Don McCanne, M.D.

The CO-OPs were only one of the multitude of defects in the Affordable care Act that we pointed out before it was enacted (and continuously since). As we stated nearly a decade ago, the CO-OPs were doomed from the beginning. Although some in the policy community had insisted that we could still make them work, the fact that only 128,000 individuals in the entire nation are insured by these programs is confirmation that they were and are an abject failure.

Since the two major presidential candidates both oppose single payer Medicare for All, the only substantial policy proposal, beyond tweaking, that remains under consideration is the public option – a version of Medicare that competes in the marketplace with private insurance plans. Much has been written about the inadequacies of such a proposal, but this is not new. Kip Sullivan warned us a decade ago that from a policy perspective, there was very little difference between the CO-OPs and the public option. Although there are many variables in design that might be considered as legislation is drafted, there is absolutely no question that the public option will not lead to a universal, single payer model of Medicare for All, as some in the policy community would hope.

In 2016, a resolution was introduced in the Senate calling for building on the Affordable Care Act by the addition of a public health insurance option. My comment at that time (2016):

This week an intensive campaign is being initiated in support of a “public option” – offering the choice of a public, nonprofit insurance plan which competes with private health plans. Our enthusiasm should be tempered.

Following are a couple of points to keep in mind, especially when you hear promises that the public option is a giant step towards single payer: 

  • A public option will be only one more player in our costly, fragmented system of funding health care. It alone will bring us none of the important features of a single payer system such as efficiency, equity, systemic cost savings, and universality. The profoundly wasteful administrative complexity will remain.
  • Previous efforts by Congress, heavily influenced by the insurance industry, to design a public option led to a highly flawed model that would prevent the “unfair” competitive advantage that a government program would otherwise have over the private insurance industry. This same insurance industry influence is precisely why the co-op models authorized by ACA are now failing. And there is absolutely no reason to believe that the insurance industry might change its tune now.
  • The public option has been characterized as a Medicare buy-in. But Medicare is an equitably funded social insurance program covering everyone who is eligible, whereas the public option would be just another individual plan in a market of private plans, likely with higher premiums because of adverse selection.
  • If a public option were to be enacted some believe that it would be only a matter of time before everyone would want in once it demonstrates its superiority, and then we would have a de facto single payer system. You need look only at the experience with the conspiracy between Congress and the private insurance industry in the establishment of the private Medicare Advantage plans that compete with traditional Medicare. Congress has given the private plans an unfair advantage so Medicare beneficiaries are moving from the public program to the private plans in ever greater numbers – the exact opposite of what the public option supporters visualize.
  • The Affordable Care Act drew support of much of the progressive community as it seemed to them to be the only politically feasible approach at the time. Thus the clamor for comprehensive reform died down. We are hearing again that single payer is not feasible, but the public option is. When the public option is enacted, it will be mislabeled as single payer, and then it will be exposed for the miserable failure that it will be because it was designed by the private insurance industry to fail (like the co-ops). The single payer concept will have been tarnished, and it could be decades before our nation would recover and be ready for reform that really works. In the meantime, millions would have gone broke, suffered, and died merely because we didn’t think single payer was feasible.

Many look to Jacob Hacker for inspiration on enacting and implementing a public option. But he has identified the greatest barrier to moving forward. In a recent Vox article, he wrote, “Private plans lobbied aggressively against the public option in 2009 on the grounds that it would amount to unfair competition. But insurers don’t want a level playing field; they want the field tilted in their favor.”

Now see if you can find a Congress that doesn’t tilt the field in favor of the private insurers. Not even on the horizon.

https://pnhp.org…

Do not let up in your advocacy for the single payer model of an improved Medicare for All.

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Warren, Pressley and Lee introduce ‘Anti-Racism in Public Health Act’

Warren, Pressley, Lee Introduce Legislation to Confront the Public Health Impacts of Structural Racism

Senator Elizabeth Warren, Congresswoman Ayanna Pressley, Congresswoman Barbara Lee, September 3, 2020

The Anti-Racism in Public Health Act would create a Center on Anti-Racism in Health at the CDC, improving the federal government’s ability to develop anti-racist health policy; Bill would also create a Law Enforcement Violence Prevention Program at the CDC

Washington, DC — United States Senator Elizabeth Warren (D-Mass.) and Representatives Ayanna Pressley (D-Mass.) and Barbara Lee (D-Calif.) today announced their bicameral bill to confront the public health impacts of structural racism through two bold new programs within the Centers for Disease Control and Prevention (CDC). Senators Mazie K. Hirono (D-Hawaii), Edward J. Markey (D-Mass.), Jeff Merkley (D-Ore.), and Tina Smith (D-Minn.) are all cosponsors of the Senate bill.

The COVID-19 pandemic has made it impossible to ignore how centuries of structural racism have created deep disparities in health outcomes for Black and Brown communities: Black and Brown people are nearly three times more likely than white people to contract COVID-19 and one to two times more likely to die from the disease. People of color are also disproportionately affected by chronic health conditions such as diabetes, asthma, hepatitis, and hypertension; infant mortality; maternal mortality and morbidity; and police brutality — and also less likely to be insured and have access to health care providers.

The federal government’s failure to adequately collect race and ethnicity data on COVID-19 testing, hospitalization, and deaths has also demonstrated why comprehensive research is needed to study the health impacts of structural racism and to develop race-conscious public health approaches and reverse disparities that have plagued our nation for too long.

To help expand research and investment into the public health impacts of structural racism, as well as to require the federal government to begin actively developing anti-racist health policy, Senator Warren, Congresswoman Pressley, and Congresswoman Lee have introduced the Anti-Racism in Public Health Act, which would:

  • Create a “National Center for Anti-Racism” at the Centers for Disease Control and Prevention (CDC) to declare racism as the public health crisis that it is and further develop the research base and knowledge in the science and practice of anti-racism. The Center would undertake such activities as:
  • Conducting research, collecting data, awarding grants, and providing leadership and coordination on the science and practice of anti-racism in the provision of health care, the public health impacts of systemic racism, and the effectiveness of interventions to address these impacts.
  • Creating at least three regional centers of excellence in anti-racism.
  • Educating the public on the public health impacts of structural racism and anti-racist public health interventions.
  • Consulting with other Centers at the CDC to ensure that scientific and programmatic activities initiated by the agency consider structural racism in their designs, conceptualizations, and executions.
  • Create a Law Enforcement Violence Prevention Program within the National Center for Injury Prevention and Control at the CDC. Physical and psychological violence perpetuated by law enforcement results in deaths, injuries, trauma, and stress, and disproportionately affects marginalized populations. This bill would take a public health approach to combating police brutality and violence by creating a dedicated law enforcement violence prevention program at the CDC.

“It is time we start treating structural racism like we would treat any other public health problem or disease: investing in research into its symptoms and causes and finding ways to mitigate its effects,” said Senator Warren. “My bill with Representatives Lee and Pressley is a first step to create anti-racist federal health policy that studies and addresses disparities in health outcomes at their roots.”

“For far too long, our federal government has failed to recognize and address the structural racism that has devastated Black and brown communities and denied access to quality health care,” said Congresswoman Pressley. “With the COVID-19 pandemic unveiling and exacerbating racial disparities in health outcomes, it is time we recognize and treat structural racism and police brutality as the public health crises that they are. This first-of-its-kind bill would expand federal research and investment into the public health impacts of structural racism, require the federal government to proactively develop anti-racist health policy, and take a public health approach to combatting police violence. We must have a coordinated public health response to structural racism, and this bill would do just that.”

“COVID-19 has exposed the injustices in health outcomes for Black and Brown people, and it’s no coincidence,” said Rep. Barbara Lee. “In addition to addressing the lasting impacts of systemic racism in criminal justice, economic inequality and the like, we must also commit resources to understanding racially unjust health outcomes. I’m taking steps, alongside Congresswoman Pressley and Senator Warren, toward reversing racism in our health care system with this legislation.”

“Since the advent of modern medicine, people of color have suffered from disparities in the care they receive and the health outcomes we see,” said Senator Markey. “With this legislation, we recognize that combatting racism is a public health necessity. I am honored to work with Representatives Pressley and Lee and with Senator Warren in advancing this important legislation.”

“Everyone deserves affordable, quality health care, but it’s not enough to just work for better health care for all-we need to also acknowledge and directly address the unacceptable racist disparities in health care,” said Senator Merkley. “The coronavirus has put those inequities on full display, and has further emphasized that living in a racist society is a pre-existing condition for too many people of color. Black and Brown Americans get less quality care, have worse health outcomes regardless of their incomes or other factors, and are regularly sicker because of systemic racism that has long shaped society and public health. It’s time to pass immediate reform to change that.”

“Communities of color like the Pacific Islander community in Hawaii have acutely suffered during the coronavirus pandemic, said Senator Hirono. “The federal government must take bold action to create anti-racist federal health policy, and this bill takes critical steps to study and address racial disparities in public health and safety.”

The bill is endorsed by the following organizations:

Center for Policing Equity; Center for Popular Democracy; Center for Reproductive Rights; Center for the Study of Racism, Social Justice & Health at UCLA; Hispanic Federation; The Justice Collaborative; Justice in Aging; The Lawyer’s Committee; The Leadership Conference on Civil and Human Rights; National Medical Association; National Partnership for Women & Families; NAACP; National Urban League; Physicians for a National Health Program (PNHP); PolicyLink; Poverty & Race Research Action Council (PRRAC); Public Citizen; Social Security Works; UCLA’s COVID-19 Task Force on Racism and Equity; UnidosUS; Union for Reform Judaism; We Must Count Coalition.

https://www.warren.senate.gov…

https://pressley.house.gov…

https://lee.house.gov…

“Anti-Racism in Public Health Act of 2020” (15 pages):
https://www.warren.senate.gov…

“Anti-Racism in Public Health Act of 2020” (one page summary):
https://www.warren.senate.gov…

Comment:

By Don McCanne, M.D.

This is a good start. Let’s do it.

Physicians for a National Health Program (PNHP) has endorsed this legislation.

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Racism and sickle cell disease

When Actions Speak Louder Than Words — Racism and Sickle Cell Disease

By Alexandra Power-Hays, M.D. and Patrick T. McGann, M.D.
The New England Journal of Medicine, September 1, 2020

The merciless killing of George Floyd by Minneapolis police officer Derek Chauvin and the more recent shooting of Jacob Blake by Kenosha police officer Rusten Sheskey have catalyzed the most widespread protests in American history, calling not only for an end to police brutality but also for a nation in pain to reflect on the layers of racism that allow such brutality to persist. Medicine is a mirror for the racial injustice in our society; it is a field riddled with racial disparities in everything from research funding to patient care to life expectancy. There may be no population of patients whose health care and outcomes are more affected by racism than those with sickle cell disease (SCD). Patients with SCD are too often marginalized and dismissed while seeking medical care when their bodies hurt and they cannot breathe. As medical leaders around the United States issue statements denouncing racial injustice and calling for us to “dismantle racism at every level,” we must ensure that these pledges translate into durable improvements for patients with SCD.

Unfortunately, the social construct of race in America requires the majority of patients with SCD not only to face the consequences of a serious health condition, but also to navigate a society in which the color of their skin is often an unfair disadvantage.

“Structural racism” refers to the system of discriminatory policies that assign privilege and power on the basis of race. For example, the legacy of redlining, a policy that allowed banks to deny mortgages to Black Americans who wanted to purchase homes in White-designated neighborhoods, persists today in the form of high rates of housing insecurity among Black Americans, including those with SCD. These racist policies have led to enduring cycles of poverty that result in food insecurity, fewer employment opportunities, and inconsistent health insurance coverage, all of which compound the challenges faced by people living with SCD.

United action against racism’s impact on the health of patients with SCD is long overdue. The most recent senseless murders of Black Americans and the subsequent wave of pledges to dismantle racism should be our call to action. Change begins with a conversation, but words are not sufficient; we must take action to make enduring improvements in the care of patients with SCD. In the box, we offer a framework and suggestions for initiating change. The current generation of patients with SCD should be allowed to lead full and healthy lives without fear or distrust of the health care institutions whose purpose should be to protect and serve.

https://www.nejm.org…

Comment:

By Don McCanne, M.D.

How many of us have buried in our subconsciousness the concept – a concept that we have not even bothered to formulate in words – that structural racism is a scourge that dictates that those who perpetrate it should reform their ways as a step towards creating a more just society for all? Oops. Isn’t this very attitude part of the infrastructure that supports structural racism? Sort of like responding to “Black Lives Matter” with “Well, white lives matter too.”

The New England Journal of Medicine has made the full article excerpted above available to all for free – perhaps sort of their version of instructing others to address the scourge of structural racism. In the excerpt is mentioned a box that is also included at the link above which offers a framework and suggestions for initiating change in our attitudes toward and management of not sickle cell disease itself, but the racism associated with sickle cell disease. Hopefully this would serve in opening a door to enlightenment on this topic that has been suppressed and neglected throughout the history of our nation.

Too busy to read the full article? Clairvoyant enough to recognize that you are free of even the slightest taint of racism? How fortunate you are.

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