Author Archives: jpwmd

Dear friends, 

Thank you for being a subscriber to The Medical Beat.  It is now a year and a half old, with a couple of new features.  You can now access all the posts by clicking the “Blog Archive” on the home page, then scrolling backwards to the first entry on September 5, 2021.  Also, the invitation to subscribe is now at the top of the home page.

I am ever interested in more readership, so I urge you to tell friends and family about the blog.  The address is “medicalbeat.net” and, as mentioned above, subscribing is easy.  You can assure people that subscribing will not put them on any list that will produce email clogging ads.

Your readership is important to me and I particularly enjoy comments, even contrary ones.  At best, the blog could spark an on-line dialogue about issues that do not receive sufficient attention in popular media.

Cheers, 

Jim

Dr. Don Berwick, who founded the Institute for Health Improvement, is a prominent figure in American healthcare.  He recently wrote an opinion piece in the Journal of the American Medical Association that sounds the alarm about creeping “kleptocapitalist” behaviors in medicine that threatens the quality of medical care in the US.  The litany of financial depredations is impressive.

The Brief

Profiteering afflicts all areas of medicine from administration to practice.  

Drug companies’ behaviors are well known–they raise prices indiscriminately and preserve a monopoly on drugs with legal legerdemain that insures profits beyond normal expiration periods for patents.  Only recently has the government been able to overcome the powerful pharmaceutical industry’s lobby (over $350 million spent in 2022) to begin to cap drug prices that are insupportable for average patients.  Nethertheless, a major hospital in Chicago billed a patient $73,800 for two doses of Lupron, a treatment for prostate cancer.  In the UK, the drug is available for $260 per dose.

Health organizations can be relentless in pursuit of medical debt (see the November 28, 2022 posting on The Medical Beat for more information).  58% of all debt collections are for medical bills.  In Massachusetts, for example, 13% of the adult population owes more $10,000 in medical bills, causing 46% to forgo, or unwisely reduce, medical care.

Hospitals are complicit too.  Consolidations of healthcare systems result in closing of hospitals that don’t produce.  Even not-for-profit systems close hospitals in poor neighborhoods in favor of opening new ones in wealthy suburbs.  

CEO salaries in healthcare are staggering: according to Dr. Berwick, the CEO of Oak Street Health, an organization with a chain of primary care sites, has a salary and benefits package that totals $568 million.  That organization has three of the top ten paid corporate executives in the US (not just healthcare).

Insurers have gotten on the gravy train through, for example, participation in Medicare Advantage (MA), an option for Medicare beneficiaries that was ostensibly designed to provide better care than traditional Medicare.  Almost 50% of seniors now get healthcare under this plan.  This was supposed to save money and provide better managed care, but over the next eight years, MA will cost $600 billion more than traditional Medicare.  The “advantage” is profit for major insurers, not improvement in medical care. 

How do companies manage these greater profits?  The answer lies in behaviors that are on the edge of legality, or frankly illegal.

Here Is How It Works: Upcoding and Unbundling

Upcoding occurs when a healthcare provider (e.g., a physician, hospital, etc.) bills for a service that inflates reality.  For instance, a hospital consultant may legitimately bill for a comprehensive evaluation and treatment of a complex patient (an appropriately well reimbursed activity), but, on follow-up, may continue to bill as though other comprehensive evaluations have taken place when the followup visit may have taken only a few minutes.

Or billing for something that simply did not take place.  A psychiatrist billed Medicare for 30 to 60 minute visits, when he was only doing 10 to 15 minute reviews of medications (he had to reimburse Medicare $400,000 and lost his participation in both Medicare and Medicaid).

Unbundling is the practice of fragmenting a service for which there is normally a comprehensive fee.  A hospital, for instance, may get an inclusive set fee for a cardiac procedure.  This includes blood tests, anesthesia, hospital rehab, etc.  Breaking out each billable element of the process, however, results in a far greater reimbursement.  This is illegal, but very hard to detect.

These practices cost the healthcare system an estimated $11 billion from 2002 to 2011.

The Purpose of Healthcare

Dr. Berwick is one of the most respected physicians in the US.  He has a string of accomplishments few can match, and his well reasoned and insightful commentary deserves attention.  He has essentially called out organized medicine to examine its goals: does healthcare have a mission to improve the health of the population or is it another industry organized solely to prioritize profit?

In the late 1990s, the respected British medical journal, The Lancet, published a report that linked vaccines to autism.  This was met with a fusillade of objections from credible sources, followed by study after study that proved there was (and is) no association between vaccines and autism.

Nevertheless, the fuse on the already significant anti-vaccination movement was lit.  And irresponsible commentary fed the fire.  For instance, US Senator Rand Paul, a physician, told of a friend with a child who was vaccinated for measles, mumps and rubella, and then, presto, contracted autism.

Measles

In 2000, due to an aggressive public health campaign, measles was declared eradicated in the US, with a few cases being documented from unvaccinated US citizens who had traveled in countries with high rates of measles.   

Measles can be much more than an irritating skin rash.  It carries a death rate that is small (one or two per one thousand cases), but still results in serious complications such as pneumonia and encephalitis.  In 2011, for instance, 40% of people with measles were hospitalized, almost all of  them unvaccinated.  In the last 10 years, the incidence of measles in the US has been as low as 18 per year  and as high as 1,274, almost all of it in unvaccinated individuals.  Worldwide, before 1963 (the year measles vaccines became widely available), there were 2.6 million deaths per year from measles.  Since then, with widespread measles vaccination initiatives, the yearly mortality averages about 140,000.  A two stage vaccination for measles results in a 97% protection rate against the disease. 

Medical Reports Gone Astray

Recently, The Economist, a popular and highly regarded British magazine for lay people, published a piece by a health journalist entitled “Fake research is influencing medical care.”  Without citing specific instances, the author points to studies that contain allegedly fabricated data, which then eventually find their way into “many, if  not most,” clinical treatment guidelines for physicians.  The writer also presents information that editors are slow, or even resistant, to correcting errors.  

I think, or hope, that the import of the article is overstated, but I too am suspicious of a lot of the medical literature.  When, while perusing a medical journal, I see the heading of an article that may interest me, I immediately look to see how the study was sponsored.  If it was funded by a pharmaceutical company, I may not go any further.  I know the proprietary interest drug companies have in finding that a medicine is safe and effective, and I understand how data can be fudged to fit the “right” conclusion.  I also know that the authors of such studies are often compensated, or even employed, by the company manufacturing the product.

But even studies done by authors without “skin in the game” face great challenges in executing research with integrity.  The gold standard for clinical studies is randomization, that is, study subjects have to agree, prospectively, to be assigned to either the intervention group or the placebo group.  At the heart of this is “informed consent.”  Patients are supposed to understand randomization, “blind” analysis of results, etc.  Can someone in the throes of a heart attack really make an informed choice regarding entering a study that will randomize him/her to, say, cardiac angioplasty (i.e. opening heart arteries mechanically) versus the usual approach to care?  

Unequivocal Fraud

It took 11 years, but The Lancet withdrew the study on autism, when fraud was conclusively proven.  Mistakes, honest mistakes, occur in medical research all the time, and this is acceptable.  Outright fraud is not acceptable, and the case of the autism publication is exhibit A for the harm such lies can do.  The article is still at the root of much of the anti-vaccination movement, and it could be argued that the deceitful author is responsible for the loss of millions of lives.

Decades ago, the New England Journal of Medicine published an article that implicated coffee as a cause of pancreatic cancer.  The study was terribly flawed and was soon debunked.  For a while, researchers looked into coffee as a cause of heart disease.  In a reversal of fortunes for the coffee industry (and for millions who need a launching pad to start the day), recent studies have shown that coffee, in moderation, helps to prevent heart disease.  Eggs have been on a roller coaster ride too.  Currently, eggs are in the nutritionists’ “good for you” category.  Seven eggs per week is OK.

In the 1980s, the “French Paradox” surfaced.  Investigators noted a low prevalence of heart disease among the French, despite eating a diet rich in fatty foods.  The French also enjoy quantities of red wine in excess of almost all other countries, and studies began to appear that it was not only protective from heart disease, but was also a factor in warding off dementia.  Some studies said that the positive effect, if there is a positive effect, was from alcohol itself, not necessarily the wine.

Research over the years on this matter of alcohol ingestion has been all over the place.  Recently, alcohol’s reputation has hit a bad patch.  Some experts are now claiming that the best level of imbibing is no imbibing.  

Good News for the Liquor Industry

Now along comes a study from South Korea that must find the Budweiser execs toasting that peninsula.  Investigators there looked at the drinking habits of four million people over the course of two years, and followed them up on average about seven years later with tests to detect dementia.  They categorized all of the subjects into five groups (“cohorts” in the medical lexicon): sustained non-drinkers; quitters; those who reduced alcohol ingestion but did not stop; those who maintained the same of level of drinking throughout the two years; and those who increased the intake of alcohol, including those who started the study as non-drinkers.  Questionnaires that subjects filled out determined the category they fell into. 

Compared to teetotalers, mild and moderate drinkers had a 21% and 17% reduced risk for dementia, respectively.  Heavy drinkers (those who drank three or more alcoholic beverages per day) had an eight percent increase in the risk for dementia.  Most remarkably, non-drinkers who became mild drinkers during the two year period had an eight percent reduction in risk for dementia, compared to sustained mild drinkers.

The Study Is Far from Definitive

The study has its weaknesses.  As with all cohort studies, one group might have undetected characteristics independent of what is being studied that affects the outcomes.  Also, self reporting in nutritional and dietary studies is notoriously unreliable.  It must be noted that this study did not look at cardiovascular risk, and that no one is recommending the institution of drinking as a preventive intervention for general health.

Nevertheless, the liquor industry will probably jump on this study and begin to highlight the supposed beneficial effects of mild drinking.  Executives in the alcohol industry should probably send a present to the South Korean investigators at Christmas… maybe a case or two of scotch. 

On January 25 (2023) I posted a blog (How Have We Been Doing with the COVID Pandemic?) that documented the tepid performance of the United States in mortality statistics as a consequence of the pandemic compared to other wealthy countries.  I also documented the statistics that compare states’ excess death rates (i.e., number of deaths above what would be expected compared to recent historic trends before the pandemic) during the pandemic, showing staggering differences.  For instance, Mississippi, with the highest excess death rate, had almost 6 times the rate of Hawaii, which had the lowest rate.  There is also a strong negative correlation across the country between deaths and vaccine status, i.e. the more people that are fully vaccinated, the fewer the deaths.

Stimulated by comments on that post, I decided to undertake a more granular analysis of the situation.

Approach

Because states took markedly disparate approaches to the management of the pandemic, this “experiment of nature” afforded the opportunity to compare results of differing pandemic policies.  California and Florida provide a useful contrast.  Based on the amount of restrictions in place in each state (lockdowns, school and business closures, mask and vaccine mandates, etc.), California ranked as the fifth most restrictive state, while Florida was the second least restrictive state.  How have they done?

Economy

The per capita Gross Domestic Product (or Gross State Product) in 2021 was about $73,000 in California and $47,000 in Florida.  Of course Florida has a lot of retirees, so a better gauge of the economic impact of Covid looks at recent increases in the GDPs of each state.  The latest data show that, in the third quarter of 2022, the real GDP in California rose 7.8%, while Florida’s rate increased by 6.9%

Education

The handling of school closures was a hot button issue during the worst of the pandemic.  The National Assessment of Educational Programs (NAEP) is a respected vehicle that assesses student achievement over time.  Its national test scores (on a scale of 0 to 500) have shown a steady improvement over the last few decades, but this slammed to a halt with Covid.  In 2022, 8th graders in Florida lost seven points in their math scores, and four points in reading.  California 8th graders lost six points in math scores, and zero in reading.

Deaths by Party Affiliation

I was unable to find a breakdown of the rate of Covid deaths by political party in each state.  There is plenty of national information though.  In the years from 2018 to 2020, death rates were similar for Republicans and Democrats.  Spikes in death rates from Covid were also similar before Covid vaccines became available.  After vaccines became available, the death rates have diverged dramatically: according to a study from Yale, as of April 2021, excess death rates were 153% higher in registered Republicans than in registered Democrats.  

Vaccination Status

To date, the percentage of the population in California that has received one vaccination, two vaccinations, or more than the two doses is, respectively, 84%, 74%, and 41%.  For Florida, the figures are 81%, 68%, and 29%.

Nationally, 90% of Democrats have been vaccinated in contrast to 58% of Republicans.  Independents have been vaccinated at the rate of 68%.  Party affiliation has become a more prominent predictor of vaccination status than race or ethnicity. 

Excess Death Rates

For a more complete explanation of the concept of “excess death” rates, please refer to the previous blog (January 25, 2023).  In a nutshell, it is a statistic that documents the rate of deaths in excess of an average over the previous four to six years.  During the course of the pandemic through the middle of January, 2023,

the excess death rate in California is 288.7.  In Florida, it is 373.7.

Conclusion

From the data above, It may be tempting to conclude, based on excess deaths rates, that California, by reason of a more favorable excess death rate, has fared better than Florida.  And despite the implementation of rather draconian social measures compared to Florida, the impact of California’s policies on the economy and education is at least as favorable as Florida’s.

In gathering all this information, I have relied on authoritative sources, but I am somewhat skeptical of some of the data.  For instance, I can hardly believe that California 8th graders suffered no diminution of reading test scores over the course of the pandemic. 

But what if the evidence did show that the restrictive social policies have a negative impact on the economy?  No one can argue with the cold facts of an excess death rate almost 100 points per 100,000 people lower in California as compared to non-interventionist Florida.  This presents a dilemma well known to medical ethicists: how to weigh the value of human life against economic well being?  This is a discussion far beyond the scope of The Medical Beat.

Note: information in this essay is retrievable in the notes referenced in the January 25th blog and the internet citations  below:

https://www.science.org/doi/10.1126/science.abd9338

https://www.medicaleconomics.com/view/more-republicans-than-democrats-died-after-covid-19-vaccines-were-available

https://www.brookings.edu/blog/fixgov/2021/10/01/for-covid-19-vaccinations-party-affiliation-matters-more-than-race-and-ethnicity/

As of January 14, 2023, the United States has officially experienced 1,094047 deaths from Covid-19 infection.  There is, however, a remarkable difference in the mortality statistics broken down by state.  And the accuracy of these stats are in question anyway.  

In the tables below, I am using the concept of “excess death rates,” because raw Covid mortality data can be misleading.  For instance, hospitals may count patients with diseases such as end-stage heart disease as Covid deaths, when in reality the virus was an innocent bystander.  Conversely, a suicide, for instance, may not be explicitly counted as a Covid death, but financial dislocations attendant upon the pandemic are surely a factor in many suicides during the pandemic.  Deaths from all causes is a figure no one can argue with, so deaths beyond what would be statistically predicted is a powerful way to gauge the impact of the pandemic. 

Excess Deaths 

So I prefer the  “excess deaths” statistic when tracking the severity of the Covid pandemic.  This figure simply looks at the number of deaths from all causes that is greater than expected compared to recent average mortality statistics. The difference is “excess deaths,” which captures all deaths regardless of cause.  For example, a state may have averaged 100 deaths per 100,000 people (I am making these numbers up for purposes of illustration) for six years prior to the pandemic.  If this figure jumps to 120, the excess death rate is 20 per 100,000 people higher than what would have been expected absent the pandemic.

The Numbers

Here are the states with the ten highest rates of excess death rates per 100,000 people in 2022:

Top 10 States Excess Death Rates 

Mississippi 596

West Virginia 585

Alabama 503

New Mexico 495

Arizona 494

Louisiana 458

Tennessee 454

Arkansas 453

Wyoming 438

Montana         423        

Here are the states with the lowest ten excess death rates per 100,000 people in 2022

Bottom 10 States       Excess Death Rates

Hawaii       110

New Hampshire       156

Washington       194

Massachusetts 204

Utah 211

Minnesota 218

Maryland 234

Nebraska 251

Maine 251

Wisconsin 276

The top ten average 490 excess deaths per 100,000.  The bottom ten average 211.

What is Going On?

There are many factors to consider when analyzing states’ mortality data (e.g., stringency of state rules like vaccine requirements, mask mandates, lockdowns, etc.), but vaccination rates are a good place to start… and maybe end.  Ever since effective vaccines have been available, the ten states with the highest rate of excess deaths have been vaccinated at a rate that is about half that of the states with the lowest rate of excess deaths.  For example, the states with the highest rates of excess deaths are accessing the current bivalent vaccine at a rate of 12.3% of eligible people (five years of age and older).  The number for the states with the lowest excess death rate is at 22.1

Standing in the World

Compared to the 20 best performing high income countries in terms of reducing deaths from Covid-19 between June of 2021 and March of 2022, the excess death rate in the US was higher than in most developed countries.  In the US, the excess death rate was 111 per 100,000.  In New Zealand, it was 3.7 and in Japan, it was 10.4.  Germany, which is about in the middle of western European countries, had a rate of 52.3.  To date, the vaccination rates, as defined by two doses, is 80% in New Zealand, 83% in Japan, 76% in Germany, and 69% in the US.

5

The total number of excess deaths in the US from the beginning of the pandemic to the present (mid-January, 2023) is 1,261,192.  With a more effective vaccine campaign, estimates of the number of deaths that could have been averted had we had near universal vaccinations range from 150,000 to 470,000.

NOTE: all of the data referenced in this article can be found in the following web sites:

https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-booster-percent-pop5

https://www.statista.com/statistics/1109011/coronavirus-covid19-death-rates-us-by-state/

https://cdn.jamanetwork.com/ama/content_public/journal/jama/939060/jld220087t1_1671563416.70121.png?Expires=1677006352&Signature=GtGUOKCiWQUVVeTqjfU~NjffeRualoX8dHo7I4jqiFPOyMGI3v3apl~TYpVgoAOZUOKkAsxVazt9rzE9skOFqH40PRWZEeitULa-n7qFILucLieze0Pzbr3EP-Xx5T2oRKQ~qdfoNz4e~S634ycLIUpQjQm8O-2TVhqtCkym087LznPrD3SUTF-Eul2wdCUuWHHVBZqjqnwMM5VdkqLtfhC-FqL9jm8GaNzlN9FERoqJpjiv8ehAXqCSrmGpbW1e09MWHIyOwsyhtSd-zeO7pYHZtoVQp1UTC7Sq850RhgTvKMcMtZb~6rMxydZvom~zbBfMe6Ji-r1G7tE~rmHpgA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA

2022 Scorecard on State Health System Performance COVID-19 | Commonwealth Fund

If you have pain in the lower portion of your back, or if you have had such discomfort at some time, you are not alone.  Up to 80% of adults in the US have acute low back pain at some time in their lifetimes.

Dr. Richard Deyo, an internist on the faculty at the University of Washington in Seattle, investigated this important condition and published seminal papers on back pain in the latter part of the 20th century.  He documented that low back pain, after upper respiratory complaints, accounts for the second most common reason for symptom related visits to physicians.  Back pain is also the most common cause of work related disability, and the most expensive, especially when the loss in work productivity is considered.

Definition 

Acute lower back pain (emphasis on acute–this article does not address chronic pain) may be sharp or achy and it may spread to the buttock or down the back of a leg, in which case it is called sciatica.  It may come on for no discernible reason, or after activities such as lifting improperly or twisting.  

What To Do About It

When I was a young doctor in the late 70s and early 80s, the conventional wisdom for treatment of low back pain was bed rest for three days, with mild analgesia such as aspirin or acetaminophen (Tylenol) as needed.  With solid clinical research and extensive review of the medical literature, Dr. Deyo debunked this intervention.  In fact, he laid waste to a lot of the common interventions, including chiropractic manipulation, physical therapy for acute episodes of back pain, acupuncture,  traction, injections, electrical nerve stimulation, massage and surgery.  Each of these treatment modalities appears to have some advantage, mostly because low back pain is self-limited.  90% of patients so afflicted recover within two weeks no matter what they do.

He also highlighted the uselessness of x-rays in acute situations, noting that x-rays, even fancy ones like CT scans, correlate poorly with symptoms.  Many people with no back complaints have radiographic evidence of severe spinal problems (e.g., slipped disks), while some patients with significant back pain have pristine x-rays.

Because the natural history of low back pain is quite favorable, Deyo found that no specific diagnostic or therapeutic interventions should be undertaken in the acute phase of discomfort.  Patients can be reassured with the knowledge of the benign nature of the pain and can be allowed to pursue activity as tolerated.  Of course, recalcitrant cases justify further investigation and treatment, even to the point of surgical intervention in a small number of cases.  Importantly, “red flag” cases of back pain would require prompt attention.  For instance, a patient who carries the diagnosis of cancer, especially one that is known to spread to bone (e.g., lung, breast, kidney, prostate), should seek care immediately.

Recent Research

When I read Dr. Deyo’s articles on back pain years ago, I thought his research was definitive.  Nevertheless, researchers continue to seek ways to effectively treat this important condition.  Most recently, researchers published a paper (the impetus for this article) that reported a small advantage to different forms of physical therapy for chronic back pain of less than 12 weeks duration.  This study did not address acute back pain and showed minor improvement at three months. The research was flawed, but did show a small reduction in spinal disability three months after the intervention; this advantage disappeared at one year.

Costs (and Waste)

There is an important wrinkle to the back pain issue.  And that is cost, especially given the mostly useless diagnostic and therapeutic interventions for back pain that are common in our medical system.  In 2016, the American healthcare system spent $134.5 billion on interventions for low back pain and neck pain (these are not broken out in the data). This is a little over four percent of the total amount spent on healthcare for that year ($3.3 trillion).  And a large portion of that expense was from questionably useful surgical interventions: back surgery rates are 40% higher in the US compared to any other country, and five times the amount in England and Scotland.  Some studies show that the amount of surgery correlates highly with the number of neurosurgeons and orthopedic surgeons available.  Only the most naive observer would think there is not a proprietary aspect to decision making in the care of patients with back pain.   

Disclaimer

I am making no recommendations regarding how readers should go about dealing with back pain.  I am simply reporting what is in the medical literature.  But I can say that maintaining a healthy weight and being active can go a long way in preventing back problems.  And here is a cost-free preventive measure: bending your knees when lifting something off the floor.

In a remarkable memoir about a remarkable man (Oblivion, a Memoir), the Colombian writer Hector Abad tells of his father’s passion for sweeping intercessions that would improve the health of the entire population far more than conventional curative medicine.  Hector Abad Gomez was a physician who courageously took up the banner of public health in mid-20th century Colombia with notable success, amid opposition from conventional health care.  He also became a prominent spokesperson for the poor and downtrodden, and this advocacy eventually cost him his life.

Gomez is the father of public health in Colombia and his writings tell the story of a man who probably saved more lives by his unswerving efforts to bring public health measures to a country with a population in woeful need of basic healthcare.

He believed in the power of education and public works to improve hygiene and had much success in generating measures to help all people, not just the rich, who were uniquely able to enjoy the benefits of modern medicine.  He pushed for universal pasteurization of milk (simple boiling), which eliminated a form of tuberculosis.  He said having drinkable water for the entire population saves more lives than sophisticated medical interventions, as so much disease in undeveloped countries is the product of unsafe water and poor sanitation. He highlighted the devastating effects of malnutrition. Anticipating the eradication of smallpox and the elimination of polio in countries with effective public health, he noted the power of vaccines, which have saved the lives of millions (maybe billions) worldwide, 

Public Health in the United States

The public health measures cited above are so common and elementary in the United States that we can forget their power.  But it was not that long ago that we resembled Columbia in the 1950’s.

Congress created the US Public Health Service in 1912, authorizing it to investigate tuberculosis, hookworm, malaria, leprosy, sanitation, water supply, and sewage disposal.  Johns Hopkins University founded the first school of public health in 1916.  Today, the public health establishment includes multiple agencies, including the National Institutes of Health, the Federal Drug Administration, the Center for Disease Control, the Health Resources and Services Administration, and a few more.  

The reach of these agencies is broad, and, with some occasional but important glitches, they have had a profound positive effect on the health of the US population.  One public health official estimated, perhaps somewhat immodestly, that public health added 25 years to the life expectancy of the average American between 1900 and 2000.

This assertion is not hard to believe when some great public health successes are highlighted.  These include a 90 percent reduction in deaths due to motor vehicle travel since 1925, despite a phenomenal increase in vehicular traffic.  Between 1980 and 1995, work-related deaths decreased by 28 percent.  The US enjoys a water supply that is virtually free of microbial contamination.  In 1900, tuberculosis killed 194 people per 100,000 in the US.  In 2020, it was .2 per 100,000.  Malaria does not exist in the US, except in people who contract the disease in other countries and then travel to our country.  HIV/AIDS has gone from a 100 percent fatal disease to a chronic one.  And tobacco!  In the 1960’s, between 40 and 45 percent of adult Americans smoked cigarettes.  Today, that figure is an astounding 13 percent.  It goes on and on.

Comparisons

Countries with developed public health systems like the US enjoy a level of safety that should be a model for so-called third world countries.  Today, 2195 children per day die of infectious diarrhea worldwide, primarily because of contaminated water supplies.  Deaths from diarrhea in the US average about 300 per year. 

In the handling of the Covid-19 epidemic, public health in the US, particularly the CDC, has come under much criticism, a lot of it merited.  On the other hand, successes like the Covid-19 vaccines cannot be ignored.  Based on research that was years in the making, the US produced the world’s best Covid vaccines almost within a year of the identification of the virus.

The Take Home

In the US, we see stupefying advances in medical technology almost weekly.  But none of it approaches the impact on well-being that public health has had.  The United States Public Health Service is the crown jewel of American healthcare.  Dr. Gomez knew what he was talking about.

In 2010, Congress passed the Affordable Care Act (aka, “Obamacare”) and President Obama signed it into law.  One of the main provisions related to Medicaid.  This is a program that provides medical insurance for people with incomes at or below 138% of the poverty line.  It is a joint program between the federal government and each state, with the feds matching state expenditures dollar for dollar.

However, in 2014, the year that Obamacare was implemented, the federal government began to pay 100% of the cost of new Medicaid enrollees in states that accepted the new benefit.  States that embraced the program are “expansion states” and those that did not accept the expanded Medicaid benefit are “nonexpansion states.”

Results

Expansion states that engaged the new Medicaid benefit in 2014 have experienced a 44% reduction in average per capita medical indebtedness compared to nonexpansion states. The regional breakdown was stark: in the Northeast, mean medical debt is now $167, whereas in the South, it is $616. In 2015, across the entire country, 23.8% of the population reported past due medical debts. The figure in 2020 was 17.8%.

Nor are the benefits limited to a reduction in medical debt. In expansion states, access and use of medical care increased.. Food and housing insecurity decreased. Medical outcomes, especially in maternal and fetal health, improved. Racial disparities in medical insurance diminished. And aggravated assaults went down.

A Ways to Go

At the time of implementation of Obamacare, 24 states opted out of the new benefit. To date, 11 states remain nonexpansion states, nine of which are in the South along with Wyoming and Wisconsin. Six states (Maine, Utah, Idaho, Nebraska, Oklahoma, and Missouri) have skirted their recalcitrant state governments and obtained the expansion benefit by means of state referenda.

There is much to be done. In 2020, 66.5% of bankruptcies were directly caused by medical expenses. Although the 8.6 % of medically uninsured Americans is at an all time low, this statistic could be easily reduced. If all of the states that have opted out of Obamacare’s Medicaid expansion were to join in, an additional 3.7 million Americans would gain medical coverage.

k

I recently posted a blog entry (medicalbeat.net: October 13, 2022) about guns based on opinion pieces in a recent issue of the Journal of the American Medical Association (September 27, 2022).  I presented data on gun violence in the United States, but only touched on potential interventions that might ameliorate the problem.  One could make the case that our “problem” is urgent—the US experiences 25 times the death rate from firearms compared to other high income countries.

Interventions with successful track records

I noted that CAP (child access prevention) laws and waiting periods (so-called “cooling off” periods (i.e., a required period of time between purchase and possession of a firearm) have been associated with a decrease in deaths by firearms, especially suicides.  But there are many other interventions that have been linked to a reduction in gun deaths.

– Laws requiring a license-or-permit to purchase handguns are probably effective in diverting guns from use in the commission of violent crimes.

– States with lower level of gun related deaths and injuries have more gun laws: in states with the fewest gun laws, the rate of suicides by firearms was greater than the rate in states with numerous laws.  Idaho has one measure on the books regarding gun safety, while California has 111.  The former experiences a firearm mortality rate that is double the latter.

– Domestic violence restraining orders (DRVOs) are associated with reductions in intimate partner homicides.

– Background checks?  The data to support these are thin, but, combined with permit-to-purchase laws, research suggests that universal background checks may be effective in reducing deaths from firearms.

– Large capacity magazines (LCMs: devices that enable shooters to fire as many as 50 rounds without reloading) and assault weapons were banned by Congress in1994 for 10 years.  When the ban expired, mass shootings increased along with the number of mortalities: these numbers doubled in the years after the ban was lifted.

Judicial and legislative actions: the “anti-interventions”

Some actions, or non-actions, actually abet the gun problem.  

– In the name of the preservation of Second Amendment rights, the Oklahoma legislature has banned waiting periods for the purchase of guns. 

– The US supreme court recently struck down a 109 year-old law requiring “proper cause” (i.e., a special need for self-defense) for obtaining a license to carry a concealed weapon in public.  “Right to carry” laws have been associated with increased violent crime.

– Stand-your-ground laws allow people to use deadly force when they reasonably believe it is necessary to defend against violent crimes.  In a review by the Rand Corporation, research showed that these laws increase homicides.  38 states are currently stand-your-ground jurisdictions.

– Congress did not provide funding to the Center for Disease Control and Prevention (CDC) to study the gun violence epidemic for almost a quarter of a century.  This finally changed In the 2020 federal fiscal budget, but experts in the epidemiology (the scientific study of adverse health conditions, with an eye to identifying effective interventions) of gun violence believe the US lost over 20 years in developing a database that would help researchers find ways to reduce gun deaths. 

– Last summer, Congress passed the bipartisan “Safer Communities Act.”  It mandates background checks for potential gun purchasers under 21 and incentivizes states’ implementation of extreme risk protection orders (ERPOs).  It also provides expansion of access to mental health services.  Why do I include this measure in the “anti-intervention” category?  Because ERPOs are difficult to implement and, it could be argued, background checks should be universal, not limited to minors.  Moreover, the passage of this rather tepid bill may also allow lawmakers to believe much has been accomplished to prevent gun deaths, thereby undercutting more efforts in the near future.  The reality is that much work is to be done.    

Where there is a will, there is a way

When a young man killed 35 people with a semi-automatic rifle in Australia a few years ago, the government swung into action.  Legislation was passed that prohibits the manufacture, import, and possession of these rifles.  The law also provided for a buy back program, which resulted in the surrender of one-third of all privately owned guns.

Path forward

There is a compelling trove of information that points to common sense ways to curb gun violence in the United States.  Instead, in too many jurisdictions, “guns to go” is the way purchases are made.  The will to act is lacking in Congress, though, and clearly something needs to change in politics if we are to make significant progress in controlling our gun epidemic.