Public Health

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Senate in a hurry

The Senate, that body that couldn’t seem to muster enough energy to do very much since 2010 except hold endless hearings about Hillary Clinton, has suddenly gotten busy.  Last night – or rather early this morning – they took the first steps toward repealing the Affordable Care Act.  The New York Times reporters wrote

The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama’s signature domestic policy achievement — a goal they believe can now be accomplished after Mr. Trump’s election.

The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.

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Senate Minority Leader Sen. Charles E. Schumer (D-N.Y.) is leading the charge to make Hill Republicans own the Obamacare repeal process.

The Democrats staged a protest on the floor, taking turns speaking even while being ruled out of order.  The vote was 51 to 48.  So, what can someone who is opposed to repeal do at this point?  I found a New York Times Op-Ed Seven Questions About Health Reform to be a useful guide to the questions we should be asking any Senator or Congressperson who supports repeal.  The piece by Harold Pollack and Timothy S. Jost should be read in full, but here are what I think are the most important of the seven questions. (The numbering is mine not theirs. And they are not in the order of importance.}

First, “How many millions of Americans will lose coverage?”  Among the issues pointed out is

Proposals by Tom Price, Mr. Trump’s choice to run Health and Human Services, and by the House speaker, Paul D. Ryan, would repeal the expansion of Medicaid and replace the A.C.A.’s income-based subsidies with less generous tax credits. Another plan from the House Republican Study Committee would offer deductions. We particularly need to know how this would affect low-income Americans, to whom tax deductions are nearly worthless, and who would generally not be able to afford coverage under these plans.

Second, “Will people over 55 pay higher health premiums for the same coverage?”  If the repeal is paired with cuts to Medicare, all of us over 55 will be in trouble.  And younger folks who may not have saved much for retirement yet will find it impossible to save enough.

Third, “… how much more will those with costly illnesses or injuries have to pay in out-of-pocket costs?”

Critics of the A.C.A. often argue that the law has made health care unaffordable. But many Americans would pay much more without it. The A.C.A. capped out-of-pocket spending at $7,150 for individuals and $14,300 for families for 2017. Republican proposals appear to offer no protection from high deductibles and other cost-sharing.

This could be devastating to millions, including older Americans who often develop chronic illnesses.

Fourth on my list. “Will the new plan let insurers charge women higher premiums than men while offering them less coverage?”

Before the A.C.A. banned gender-based premiums, insurers in many states charged women more than men of the same age — some as much as 50 percent more. The A.C.A. also required all insurers to cover preventive health services without co-payments; for women, this includes birth control, Pap smears, mammograms and a host of other crucial services. Maternity care is fully covered as well. Republican replacement plans offer no such protection. And many Republicans want to defund Planned Parenthood, too, which would deprive women not just of coverage but also of care.

And, as we have learned, many men, particularly Republican men, have no idea of how a woman’s anatomy works.  For those opposed to choice on abortion, this could have the effect of increasing the number of abortions – legal and illegal.

I think there is time while President Trump argues with Congress and Congress argues with itself about what should be in any new law.  If your Senator and/or Congressperson favors repeal, call or write or visit and ask some of the seven questions.  And express your support for those that oppose wholesale repeal.  Should you agree with what is happening, leave me a message explaining why you think this is OK.

Photograph:  Alex Wong/Getty Images

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Repealing the Affordable Care Act

The Republicans have made a mantra out of repealing the ACA aka Obamacare.  I’ve lost track of how many times they have voted to repeal it, but close to 60, I think.  The surprising thing is how unprepared they really are to “repeal and replace”.  They seem to have the repeal part down, but in all the years it has been since the law was enacted, they haven’t come up with a replacement plan.  I think that even supporters of the ACA know that some things need fixing but no Republicans were willing to work with Democrats and President Obama to do so.

They could just repeal it.  This would create chaos in the health care system and upset millions.  I don’t think they want to deal with loss of support right away.  I’m not sure that voters who say they don’t like the ACA understand that things like free vaccinations, physical exams, and mammograms are part of the Act.  On the other hand, Republicans cannot seem to agree on a plan to replace the ACA.  There are a lot of ideas, but no plan and not even a framework for a plan as far as I can tell.

In the January 4 edition of the New York Times, Robert Pear had an interesting and informative article, Republicans’ 4-Step Plan to Repeal the Affordable Care Act.  In it he outlines the things that have to happen before Repeal.

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Vice President-elect Mike Pence, second from right, listened as the Senate majority leader, Mitch McConnell, spoke after a Republican luncheon on Wednesday.

Step One is to pass a budget resolution that is filibuster proof in the Senate.

The Senate intends to pass a budget resolution next week that would shield repeal legislation from a Democratic filibuster. If the Senate completes its action, House Republican leaders hope that they, too, can approve a version of the budget resolution next week. Whether they can meet that goal is unclear.

Step Two would add details.

Republicans say they will delay the effective date of their repeal bill to avoid disrupting coverage and to provide time for them to develop alternatives to Mr. Obama’s law. They disagree over how long the delay should last, with two to four years being mentioned as possibilities.

Step Three adds in ideas from President Trump.

Within days of taking office, President-elect Donald J. Trump plans to announce executive actions on health care. Some may undo Obama administration policies. Others will be meant to stabilize health insurance markets and prevent them from collapsing in a vast sea of uncertainty.

“We are working on a series of executive orders that the president-elect will put into effect to ensure that there is an orderly transition, during the period after we repeal Obamacare, to a market-based health care economy,” Mr. Pence said at the Capitol on Wednesday.

Step Four is replacement.  For which there is no consensus.

Meanwhile Democrats are also taking action.

In the Senate next week, Democrats will demand votes intended to put Republicans on record against proposals that could protect consumers. Defenders of the law also hope to mobilize groups like the American Cancer Society and the American Heart Association to speak up for patients.

This process is far from over.  Even Republicans put implementation of a new health care law a minimum of 2 years out – just in time for mid-terms- and more likely, 4 years away – just in time for the next Presidential election.

Photograph:  Doug Mills/The New York Times

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Guns and public health

There are too many guns in the United States.

Last October Christopher Ingraham wrote in the Washington Post’s Wonkblog

It’s tough to know exactly how many guns we have in the United States. Most estimates of the number of guns in the U.S. use federal tallies of the firearms manufactured, imported and exported by U.S. gunmakers. A 2012 Congressional Research Service report published exactly one month before the Sandy Hook school shooting put the number of civilian firearms at 242 million in 1996, 259 million in 2000, and 310 million as of 2009.

If that 310 million number is correct, it means that the first year of Barack Obama’s presidency was an inflection point: It marked the first time that the number of firearms in circulation surpassed the total U.S. population.

It is clear that the Obama years have been a boon to gun manufacturers regardless of whether the number of guns is 245 million, 270 million, or 300 million.

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Do they keep us safe?  Some gun owners point to falling homicide rates, but there are studies showing that places with few guns have lower rates.  Ingraham writes

It’s important to note that even as the number of guns has increased since the early-to-mid-90s, the per-capita gun homicide rate has fallen by nearly half over the same time period. On the other hand, it’s also true that when you make comparisons between states and countries, you see that places with more guns have more gun homicides, as research from the Harvard School of Public Health shows.

These two seemingly unreconcilable facts form the factual basis for much of the contemporary gun policy debate. Defenders of gun rights can point to falling homicide rates and rising gun numbers and argue that the solution to gun violence is more guns. Gun control advocates, meanwhile, can point out the correlations between gun ownership and gun crime and push for tighter restrictions on gun ownership.

Ingraham concludes

Is there a way to reconcile these divisions? It’s hard to tell. I keep coming back to this quote, from the Economist earlier this year in response to the Charleston massacre.

Those who live in America, or visit it, might do best to regard [mass shootings] the way one regards air pollution in China: an endemic local health hazard which, for deep-rooted cultural, social, economic and political reasons, the country is incapable of addressing.

Which brings me to Margaret Talbot’s comment in the January 18 issues of The New Yorker.  Talbot writes about President Obama’s Executive Order on background checks.

Last week at the White House, as President Obama announced a set of executive actions aimed at blunting gun violence, he seemed anything but numb. He wept as he invoked the first graders killed at Sandy Hook Elementary School, in Newtown, Connecticut—a response for which some gun advocates mocked him. He quoted Martin Luther King, Jr.,’s words about the “fierce urgency of now.” But he also acknowledged the numbness that can overcome people in the face of one mass shooting after another. That numbness puts proponents of unfettered gun rights at an advantage. People can easily start thinking of gun violence as something native to America’s angry, intractable soul—the armed, anti-federalist takeover of wildlife-refuge buildings in Oregon this month seemed like proof. And when, time and again, Congress thwarts gun reforms that are supported by majorities of Americans it can be hard to imagine that the status quo will ever change.

If numbness benefits gun-rights absolutists, uninformed numbness might serve them even better. In 1993, The New England Journal of Medicine published a study showing that “keeping a gun in the home was strongly and independently associated with an increased risk of homicide” in that home. The researchers had been funded by the C.D.C.’s National Center for Injury Prevention, and the N.R.A. responded by trying to get the prevention center defunded. It didn’t succeed, but, in 1996, Congress amended an appropriations bill to the effect that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” It was a little like saying that no research on the health effects of smoking should be interpretable as anti-smoking. Congress also removed $2.6 million from the C.D.C.’s budget—the precise amount that had gone to the prevention center’s research—and then restored it, earmarked for an entirely different purpose. As a result, one of the study’s authors said in a public-radio interview last spring, “many, many people stopped doing gun research.”

With gun research, maybe we could have safer weapons as we have safer cars.  Maybe we would better understand the dangers of gun ownership.  Maybe we wouldn’t have to read about the six year old who finds Daddy’s gun and kills his two year old sister.

Jay Dickey, the Republican representative and N.R.A. member from Arkansas who sponsored the amendment, came to regret it. Dismayed by the continuing toll of gun violence, he was eventually persuaded that firearm deaths could be reduced without violating the Second Amendment. He now believes that research on gun violence can help prevent it, much as similar work on highway safety resulted in innovations like seat belts, air bags, highway dividers, and minimum drinking ages, and prevented hundreds of thousands of traffic deaths. In December, in a letter to Mike Thompson, the chairman of the House Democrats’ Gun Violence Prevention Task Force, Dickey wrote, “Research could have been continued on gun violence without infringing on the rights of gun owners, in the same fashion that the highway industry continued its research without eliminating the automobile.” He added, “We should slowly but methodically fund such research until a solution is reached. Doing nothing is no longer an acceptable solution.”

Talbot cites a recent study (not government funded) comparing the repeal of a permit and background check law in Missouri and the initiation of more stringent laws in Connecticut:  Gun homicides dropped around 40% in Connecticut and rose by a similar percentage in Missouri.

Those opposed to background checks, bans on weapons with large capacity magazine, or even trigger locks often say that the issue is one of mental health not guns.  I think our national obsession with guns IS the mental health issue.  They are a public health issue.  Talbot concludes

In part, Obama is trying to reframe the gun discussion not as a Second Amendment issue but as one of public health. This approach acknowledges that, while we can’t eliminate gun crime, we can reduce it, and that doing something is better than fatalistically doing nothing.

Photograph:  M&R Glasgow/Flickr

 

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Trying to make sense of the anti-vaccine movement

Why don’t some parents get their children vaccinated?  Religious grounds?  Maybe for a few.  Philosophical grounds?  I still haven’t figured out what that means.  Misinformation?  Probably more of a reason than religious grounds.  But I have concluded that it is having no personal history that maybe the biggest reason.

Like most of my generation – born before the early 1960s – I suffered from all the childhood diseases as they were called back then.  I had the measles, rubella (then called the German measles), and chicken pox.  I was somehow immune to the mumps even though I attended a birthday party after which all the attendees but me got them.  I particularly remember chicken pox.  It was miserable.  I felt terrible and I itched all over.  It was worse than having poison ivy which I seemed to get almost every summer until I was old enough to recognize the plant.  My experience was typical of almost everyone I knew.  Margaret Talbot provided some history in her piece for the New Yorker, “Not Immune”.

Twenty-five years ago, when a doctor named Robert Ross was the deputy health commissioner of Philadelphia, a measles epidemic swept the country. Until this year’s outbreak, which started at Disneyland and has so far sickened more than a hundred people, the 1989-91 epidemic was the most alarming that the United States had seen since 1963, when the measles vaccine was introduced. Nationwide, there were more than fifty-five thousand cases and eleven thousand hospitalizations; a hundred and twenty-three people died. Most of those infected were unimmunized babies and toddlers, predominantly poor and minority kids living in cities. Ross thought that the blame for the outbreak could be placed partly on poverty and partly on crack cocaine, which was “making a lot of families forget how to raise children.”

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The epidemic spurred the creation, in 1993, of a federal program, Vaccines for Children, which subsidized shots for children who were uninsured or onMedicaid*. Immunization rates soared. Then a new skepticism about vaccination settled in—this time, more often than not, among affluent parents who were drawn to holistic living and were dubious about medical authority. An infamous 1998 study in The Lancet, which claimed that the rising incidence of autism was linked to vaccinations, was particularly influential with some of those parents—even though the data were found to be falsified and the author’s medical license was revoked. Another theory, tying autism to thimerosal, a preservative added to vaccines, has also been debunked. Since 2001, thimerosal has been used only in the flu vaccine—and there is a thimerosal-free alternative—but the incidence of autism continues to rise.

Nevertheless, the skepticism endured, and one result has been the decisive return of infectious diseases. First, it was whooping cough: in 2012, more than forty-eight thousand cases and twenty deaths were reported to the Centers for Disease Control, the greatest number since 1955. Now it’s measles….

Child in later stages of measles rash (probably has had rash for 4 or 5 days)

Child in later stages of measles rash (probably has had rash for 4 or 5 days)

The level of misinformation and fear is incredible.  Nothing that anyone says or does seems to lower the volume.  There is no known link to autism from any vaccines.  What remains are religious ground and some vague notion of philosophical grounds.  A couple of Sunday’s ago, Gina Bellafante tackled the question of religious grounds in her New York Times column.

New York already allows parents to seek vaccine exemptions for medical or religious reasons. In effect, philosophical exemptions are superfluous because religious exemptions perform the same function. A state form requires that parents provide a written passage, in their own words, explaining why they are requesting the exemption, and the principles that guide the objection. A head of school can accept the submission or reject it, ask for supporting documents — a letter from a priest or a rabbi, for instance — or not. Anyone whose request is denied can appeal to the education commissioner.

That religious exemptions are available at all to any but Christian Scientists, whose disavowal of medicine is foundational, remains a subject debated not nearly enough. It is not just that the waivers are used to conceal the discredited anti-vaccination sentiments shared by parents with no theological commitments whatsoever. (As one Manhattan school nurse put it to me, “It would be practically impossible, not to mention a huge pain, to prove that they are lying.” Of the 25 percent of students at the School for Young Performers in TriBeCa who received religious exemptions last year, how many have parents prepping them for the seminary?) It is that among the major religions there is virtually no canonical basis for vaccine aversion; the Bible, the Quran and the texts of Sanskrit were all obviously written before the creation of vaccines, and most religions privilege the preservation of life.

Read the end again:  “…most religions privilege the preservation of life.”

So today I saw a snopes.com piece debunking (there is that word again) the new internet factoid that 

In the last ten years no one has died of measles in the U.S., but more than 100 people have died due to the MMR vaccine.

Snope.com responded

During a then-current measles outbreak, on 4 February 2015 an alternative health site published an article claiming no one in the United States died of the measles between 2004 and 2015.

Furthermore, the article stated, more than 100 people (mostly young children) had died after receiving the MMR (measles, mumps, rubella) vaccine.

The claim circulated widely during a time of increased debate over parental decisions about vaccinations, particularly among those who are opposed to the practice. In some iterations the claim was amended to specify “child deaths,” but the article itself stated there were zero deaths (among all age groups) from measles in the United States in the timeframe cited. That claim was provably false, as two people in the U.S. died from the measles in 2009, and another two deaths from measles were recorded in 2010. As such, in two of the ten to eleven years cited in the claim, at least four people have died of measles. And according to the World Health Organization, 145,000 people around the world died of measles in 2013 alone.

Likely one of the reasons there have not been more deaths in the U.S. is the push in the 1990s to get kids vaccinated under the Vaccines for Children program.  Snopes.com concludes

Few people died of measles in the U.S. between 2004 and 2015 because measles was classified as eliminated in 2000. Relatively few people in the U.S. contracted the viral infection after that, so it stands to reason far fewer would go on to die of it. And while more than 100 reports of suspected adverse reaction or death may have been reported to VAERS in the years cited, that number references unconfirmed public reports, not verified vaccine-related fatalities.

Finally, the possibility of death is not the only reason one should (or should want to) vaccinate a child against measles. As the CDC notes in their measles fact sheet, in some children measles can lead to pneumonia, lifelong brain damage, and deafness.

The number of deaths cited seems rather small compared to the number of persons vaccinated especially since it is not clear that there was a death for each reported case.

Now, of course, the progressive parents who don’t want their kids vaccinated for philosophical grounds have lots of company from the right who have politicized the issue.  Talbot writes

On Fox News, Sean Hannity declared that he wasn’t “trusting President Obama to tell me whether to vaccinate my kids.”

 I argue that parents are vulnerable to all that is floating out there – the misinformation and the politicization – because they have no history of the diseases.  Very few people in the United States born after the introduction of vaccines have had measles, chicken pox, or mumps.  I would venture to guess that most adults who have children were themselves vaccinated when they were children.  I base that simply of the fact that there have been few outbreaks since the early 1960s.  No parent who had any of the once common childhood diseases would want their children to suffer.  Unfortunately, I think this cycle has to play itself out which means some kids will die or suffer long-term consequences.

[By the way, if you were part of the generation that had chicken pox be sure to get the shingles vaccine.  I watched my mother suffer and you can bet I got vaccinated the first chance I had.]

Photograph:  From the CDC

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Ebola, the flu and other health risks

I just got my flu shot.  I get one every year.  While it might not keep me from getting sick this winter, in all likelihood it will keep me from getting really sick.  I just hope that everyone else I interact with has also gotten a flu shot.

Frank Bruni wrote about this in this morning’s New York Times.

During the 2013-2014 flu season, according to the Centers for Disease Control and Prevention, only 46 percent of Americans received vaccinations against influenza, even though it kills about 3,000 people in this country in a good year, nearly 50,000 in a bad one.

These are deaths by a familiar assassin. Many of them could have been prevented. So why aren’t we in a lather over that? Why fixate on remote threats that we feel we can’t control when there are immediate ones that we simply don’t bother to?

On matters exotic, we’re rapt. On matters quotidian, which are nonetheless matters of life and death, we’re cavalier. Tens of thousands of Americans die in car crashes annually, and according to a federal analysis from 2012, more than half of them weren’t wearing seatbelts.

I think part of the reason people are so panicked about Ebola is because so far the medical community in the United States seems very inept at treating it and, particularly, in preventing its spread.  Amy Davidson’s piece “Amber Vinson’s Airplane Ride” in the New Yorker is particularly instructive.

Amber Vinson called the Centers for Disease Control, on Monday, to say that she had a temperature of 99.5 degrees and planned to get on a commercial flight from Cleveland to Dallas; should she? Vinson, a nurse, had cared for Thomas Eric Duncan, a patient with Ebola, in Dallas—she had put a catheter in him and been in close contact when he was vomiting and in the throes of diarrhea. The day before Vinson made her call, one of her colleagues, Nina Pham, had tested positive for Ebola. There was, supposedly, a system in place for monitoring Duncan’s contacts. And yet, as the C.D.C. confirmed late on Wednesday, the official Vinson spoke to cleared her to fly. Vinson got on Frontier Airlines Flight 1143, with a hundred a thirty-two other passengers. She landed in Dallas at 8:16 P.M.. The next morning, her fever was worse; around midnight, she tested positive for Ebola.

There is much that is seriously wrong here. The first is that Pham and Vinson, who are both in their twenties, were so exposed. Their hospital, Texas Health Presbyterian, sent Duncan home the first time he showed up in the emergency room, with a fever and pain and the information that he’d just been in Liberia. But it’s also emerging that, in the first days after he was admitted for the second time, on September 28th—with his family saying that they thought he had Ebola, and all the full-blown symptoms on display, but as yet no laboratory test confirming it—he was not properly isolated, according to records obtained by the Associated Press. The nurses caring for him had to improvise their own protection.

Tom Frieden, the director of the C.D.C., addresses the media on the Ebola case, on October 5th.

Tom Frieden, the director of the C.D.C., addresses the media on the Ebola case, on October 5th.

Thomas Frieden, the head of the CDC, has said they should have had people there to help them “do it right”, but then someone from his own agency told Amber Vinson it was OK for her to fly.  And we are left to wonder who is in charge and if anyone knows what they are doing.  If President Obama wants to do something to help regain public confidence that the health care system here can deal effectively with Ebola, maybe Mr. Frieden’s departure would be a good start.

Amy Davidson writes

Frieden himself represents an even bigger problem. His account of how Vinson got on the plane, related in the conference call on Wednesday, was at least evasive and, depending on what he knew and what exactly Vinson was told, may have been worse. He was asked three different ways if Vinson had been told not to fly, and each time dodged the question in a way that left the impression that Vinson was some sort of rogue nurse who just got it into her head that she could fly wherever she wanted. He talked about her “self-monitoring,” and that she “should not have travelled, should not have been allowed to travel by plane or any public transport”—without mentioning that his agency was who allowed it.

It is things like this, and the lack of protocols at Texas Health Presbyterian, that create fear, probably unwarranted, among the American public that there will be a major outbreak of Ebola here.

As Bruni says

I’m not dismissing the horror of Ebola, a full-blown crisis in Africa that should command the whole world’s assistance. And Ebola in the United States certainly warrants concern. We’re still searching for definitive answers about transmission and prevention.

But Americans already have such answers about a host of other, greater perils to our health, and we’d be wiser to reacquaint ourselves with those, and recommit to heeding them, than to worry about our imminent exposure to Ebola.

So, use seat belts, get a flu shot, get your kids vaccinated, don’t use your cell phone while driving and use sunscreen.  And try not to worry about getting Ebola.

 Photograph by  KEVIN C. COX/GETTY