Author: Ann Marie Marciarille

In one part of the world, women celebrate the announcement that in June, 2018, they will be allowed to drive automobiles. It is both something small to some (something some fear is too small and perhaps diversoinary) and a highly symbolic thing to others. Asma Alaboudi was quoted in the New York Times, noting:

“That I am driving means that I know where I am going, when I’m coming back and what I’m doing,” said Ms. Alaboudi, the social worker.

“It is not just driving a car,” she said, “it is driving a life.”

In another part of the world, women absorb the announcement that an employer soon need no longer offer contraceptive coverage as an essential benefit in employer sponsored health insurance. No rationale of cost savings offered (as with the announcement about needing to spare the military debt for those transitioning genders) this time — as there is none. No rationale of improved women's mortality as that is also a hard one to claim.  Facts have a way of being sticky.

The rationale relies on a reading of the Religious Freedom Restoration Act, where an employer's sincerely held religious scruples and principles clearly trump an employee's religious scruples and principles.  No matter that an employer's sincerely held religious scruples may combine with the ACA's lack of requirement that employer sponsored health insurance include family health insurance coverage to produce an employer who can say that a female employee's contraception is their business but actually providing health care for the children that will result from a contraception coverage veto are not.  

American women also want to drive their own lives. This dispute is not just about contraception. Just as with driving an automobile, it is about taking charge of your own fate.  As Katherine Parkin's Women at the Wheel tells us, by the 1970's only half of American women had a driver's license. 

Apparently, we are still not fit to guide the direction of our own lives.

 

No, the optics on your use of charter planes instead of general commercial aviation for ordinary course of business travel as Secretary of HHS don't look good, Secretary Don Price. You are correct.

You know where else the optics don't look good? Your twitter feed. The optics haven't been good there for a while.

Maybe it was your attack on the CBO director you placed in office in 2015 that got me wondering about your optics. Or, maybe it was your many posts attacking the ACA that focused on the anecdotal rather than evidence. Sure, I'll agree your PR flacks probably handle your twitter feed but it is your apparent abandonment of an interest in statistical evidence that made me doubt you as a man of science. Bring on the anecdotal videos, then, where selected Americans display their insurance illiteracy by arguing, for  example, that the price of comprehensive health insurance for a sixty one year old man will likely fall dramatically under Trumpcare. After all, affordable comprehensive health insurance for a sixty one year old man outside of employer sponsored health insurance was difficult to come by before the passage of the ACA. And you  had to have known the various iterations of Trumpcare, allowing anywhere from greater age based underwriting to potentially  unlimited age based underwriting (Graham-Cassidy), were not going to improve this situation. 

There is something particularly reprehensible about attempting to play on the ignorance of your earnest fellow citizens.

I know being Secretary of HHS is a bully pulpit. You appear to have wanted the position of Secretary of HHS very badly.  I also know that you have long associated yourself with an organization identifying participation in Medicare as immoral.  

But the idea that is it only the optics that look bad regarding your performance as Secretary of HHS, Mr. Price, is not correct.  The way in which your conduct and actions are perceived by the public may, in fact, be entirely accurate. Watching a grown man cower before the threat of termination from his post if he did not deliver ACA repeal, as you cowered  in the public eye at President Trump's now famous Boy Scout Jamboree speech, tells the public something unflattering about you.

No, the optics of your commitment to your job are not good and neither is the objective evidence.

 

 

With 16 dead and well over 400 documented as infected, it is fair to say San Diego is in the midst of an epidemic of Hepatitis A. Now, the perfect storm of a large population of individuals who are homeless,a significant number of individuals who use injectable drugs, a conspicuous absence of public bathrooms, and a push to consolidate those who are homeless in a concentrated geographic region in the city all appear to have combined to produce this epidemic.  San Diego's homeless population is reported to have grown by over 25 percent in the last year, which may also play some role here.  Still, other cities with large populations of homeless individuals should be afraid, very afraid. I'm looking at you: Detroit, Salt Lake City, Santa Cruz, and others. It is significant that there already appears to be a satellite outbreak in Santa Cruz. We are, at present, witnessing the second largest U.S. based Hepatitis A outbreak in decades.

Maybe all of this would have stayed below the radar, given the populations involved, but it is all hands on deck in full crisis mode now that public health authorities have had to try to reach customers of a popular tourist restaurant who may have been exposed through contact with a kitchen worker, who may have been exposed through a partner.  I note that responsible articles go out of the way to elaborate that restaurant transmission is not a common ocurence, though a drop off in business at the particular restaurant has already been reported.

This means the fear of Hepatitis A  transmission in California has officially made the leap from what I call "them to us." Restaurant and food service workers are statistically likely to be younger and lower income. This also means, in the United States, that they are more likely to lack health insurance. Hepatitis A, with its fecal-oral transmission route is not the only contagious disease that may appear in this group.  The American Public Health Association has been concerned with the health of food service workers since the 1920's.  

Then why are we so laissez-faire? First, it is and was invasive to require physical health examination of all food service workers for contagious diseases, even in the 1920's. Second, it costs money, whether born by public health authorities or by food service employers and it is money spent examining a low wage workforce with high employment turnover. Third, we do not want to acknowledge that our health as food service product consumers is deeply intertwined with the health status of our food service industry workers. Admitting otherwise punctures two popular American myths — the first that we are all almost completely in control of our own health and disease status as individuals and, the second,  that your lack of health insurance or lack of easy access to health maintenance care is your problem and not mine.

I always ask my students who contend that the individual choice to obtain health insurance and health care is just that– an individual choice– if they eat out much.

It is absolutely fascinating to  read that that Allergan and the St. Regis Mohawk Tribe have reportedly made arrangements for transfer of certain patent rights, in exchange for a substantial fee, to a sovereign, such as a Native American tribe, that may invoke sovereign immunity to defeat patent challenge litigation. The hot new dry eye drug Restasis would then be licensed back to Allergan by the tribe.

The article in the New York Times described this approach as "novel" and made me curious about other such transfers of intellectual property rights to defeat patent challenges in this way.  I can't find any others.

It takes a kind of genius to think of such a method of gaming the legal system but no one seems to want to take credit, publicly at least. My favorite part of the narrative is the one that says the St. Regis Mohawk Tribe proposed the arrangement after being schooled in it by an apparently free floating law firm.  Right.

OK, I watched it too and smiled.  That astonishing home video of the Houston man diving into his flooded living room to try to catch a storm delivered fish with his bare hands made me laugh.  I think that video has gone viral. The comments to the posting I visited said things like "making the best of a bad situation."

Well, it could get a whole lot worse.  The way I see it, that fisherman diving around his living room was quite possibly swimming in cholera.  Now the New York Times sees it too.  Of course, when I first made the observation to my students I was not aware of the high number of Houston area residents who use individual home well water as their water supply. No, I'm not talking about town-owned and operated huge aquifer-replenished wells that sometimes date back to colonial times (though those may have some of the same issues) but the huge number of tiny individual wells associated with single homes.  The significance is that it is harder to monitor water quality with so many small wells pretty much exclusively under individual owner control.

Be afraid. When it was reported that Anheuser-Busch had switched production lines from beer to bottled and canned water, I wondered if anyone at FEMA was talking to the CDC about supplies of Vaxchora, the single dose oral cholera vaccine. 

Who is talking to PaxVax?  Vaxchora is not something many American households can afford to access easily at about $290 a pop.

I would like to hear how much Vaxchora is actually in the Strategic National Stockpile of vaccines. How many push packages are available today?

 

 

The noting of Social Security's 82nd birthday on August 14 prompted a few tips of the hat to Frances Perkins, in many ways the force behind Social Security.  Every year, I take time to read more about Frances Perkins and the origins of Social Security. Sometimes, I listen to Frances Perkins narrate the development of the Social Security Act in her own words and in her own voice.

I commend all of this to you. But if you have never heard Frances Perkins' eye witness description of the Triangle Shirtwaist Company Fire on March 25, 1911, something she later referred to as the day the New Deal began, you should.

 

Despite considerable uncertainty — some created on the federal level and some created on the state level — on the way forward, health insurance markets are stabilizing in many places. Where they are not stabilizing, there is much interest in using Section 1332 waivers as market stabilization devices. Section 1332 waiver proposals, also known as innovation waivers, are also being particularly encouraged by the Trump Administration.

It was always contemplated that Section 1332 waivers would play a significant role in some states, particularly in states like Hawaii that have long organized some version of state specific health care reform.

Now we see Section 1332 proposals arriving from all over the map. Iowa's recent Section 1332 waiver proposal is an interesting example of how state insurance regulation decisions can help to create a crisis that, apparently, only an emergency innovation waiver can resolve. It merits a closer look.

The "Iowa Stopgap Measure" proposes  that premium subsidy determinations be made by the Iowa Department of Revenue and not by the federal government. It also proposes that ACA requirements capping health care premiums pegged to a percentage of household income be replaced by a status and income based allocation of premium subsidies, linked to age and other factors.  This would extend premium subsidies far beyond the 400 percent of the federal poverty level cap found in the ACA.  Cost sharing subsidies for those between 128 percent and 250 percent of the federal poverty level would be eliminated as well.

There is more to this  Section 1332 waiver proposal but Iowa's officials are reported in the press to candidly disclose that one of the purposes of the waiver proposal is to move government subsidization of health insurance access to higher income households. The justification is that without those higher income and on average healthier lives in the insurance pool, a crisis will ensue.Of course, in the meantime a crisis might ensue for those who can afford to enroll but not actually afford to use their health insurance because of the elimination of cost sharing subsidies for their demographic. 

Iowa's identified "emergency" rationalization is that only one insurer will sell ACA compliant plans in the state for 2018. What  created that emergency is, at least in part, Iowa's own  state level decision to continue to allow non-ACA compliant plans to be sold in the state, where an estimated 85,000 Iowans rest easily or uneasily in their own risk pool in the land of thin insurance.

Even an emergency Section 1332 proposal has some review components, however. CMS has recently reduced these to a checklist format. It will be interesting to see whether the notice and comment period produces any discussion about Iowa's role in constructing its own unstable health insurance markets.

Tomas Philipson's appointment to a position on the Council of Economic Advisors has me thinking back on some of his more interesting health policy and health economics pieces for Forbes.

i especially remember his assertion that families who bankrupt themselves for cancer care, admittedly a choice put to them by poor health insurance coverage, are the best choosers of the value of a cancer patient's life, as distinct from some bureaucratic or regulatory calculation. 

I am troubled by the thought that the woefully underinsured are somehow best situated to place the most accurate value on health care. "What's it worth to ya?" is a measure, after all, of what you have to spend as much as of what you choose to spend. Celebrating the freedom to achieve familial bankruptcy in the pursuit of health care is an interesting way to celebrate freedom. If it is a powerful celebration of freedom, it is one that many Americans have experienced, although an exact number is difficult to calculate.  

But I am even more troubled by the easy assertion that "families" make these value based care or  bankruptcy decisions — whether to hold 'em, fold 'em, or double down with a household's financial future.  Is that how it really works? Families caucus, lay their cards on the table (one more year of life for Dad compared with a year of college tuition for Junior) with everyone from Dad to Junior voting their preferences or striving for consensus while reaching a "family" decision?  Even without any kind of serious health care price transparency?  Even when the role of families in cancer care decision making is not always uniform or consistent?

 

The death of Glen Campbell on August 8, 2017 may encourage some of us to watch the remarkable I'll Be Me documentary made around the time of Glen Campbell's public announcement of his Alzheimer's diagnosis and  farewell tour.  It is not particularly easy to watch. It is painful to see  an intelligent, generous, and talented man struggle to make sense of what is happening to him. But it is also hard to watch his caregivers, his wife Kimberly Woolen in particular, struggle under the burden of caring for him — working to find the right balance between respect for his formidable intelligence and talent while picking up the slack for his increasing cognitive decline.

This week, I feel pretty sure we'll see lots of articles about the prevalence of Alzheimer's and dementia. I can only hope some of that interest will spill over into thinking about  family caregivers.  Remember, Glen Campbell was a man with substantial financial and familial resources, the kind of resources that allowed his family to muster the help they needed to care for him outside of an institutional setting until the last three years (typically the most acute phase of the disease) of his life.

How are the rest of us doing as caregivers? Alzheimer's caregiving is more of a marathon than a sprint, meaning it is a longer and later in life caregiver assignment than associated with some other diseases. The caregiver role falls disproportionately to women and is associated with health risks — most notably anxiety and  depression— itself.  It is also associated with major financial risk for the caregiver, who may in fact have neither the financial or familial resources to guarantee the same level of family caregiving will be available to them, if needed.

It is not just that we look away from dementia but we look away from the extraordinary role of being a  family caregiver for those with Alzheimer's and dementia. So, yes, go watch "I'll Be Me" on Netflix but also  read this RAND report on why we need to end this unsustainable system of dementia caregiving as well.