Tag Archives: Morton Tavel

Looking Ahead

It’s easy to lapse into despair at the daily destruction of the America we once inhabited. There’s no use whitewashing the fact that an anti-science “health” administration threatens the lives of thousands of people unnecessarily, that insane trade “policies” will inflict enormous damage on the economy, and that– thanks to the Mad King– our global stature may never recover.

Those things and many others even worse are all true. But it’s also true that our government was far from perfect, and that the wholesale destructruction we are experiencing will–when the fever breaks–leave us with a task that is arduous, but that also will represent an opportunity to–in Biden’s phrase–build back better.

I have occasionally quoted my cousin, an eminent cardiologist, for insights into America’s fragmented healthcare system. Today, I’m sharing an op-ed he recently published with a co-author whose expertise is financial. They are looking beyond the devastation, and explaining how we might eventually build a better health system.

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HOW THE DEMISE OF MEDICAID MAY BENEFIT US ALL

By Morton Tavel, MD, and Paul Nolan, CPA

The recently passed “Big Beautiful Bill,’’ among its many deficiencies, contains changes that will negatively impact the already suboptimal nationwide Medicaid programs. Among these changes is a reduction of the federal funding for these various state programs, which, according to estimates of the Congressional Budget Office (CBO), these provisions could result in 11.8 million fewer people enrolled in Medicaid over the next decade, meaning a loss of all financial support of healthcare for many of our neediest citizens. But, as is suggested by this title, how could such an apparently egregious act pave the way for better national healthcare? Let us now delve into the obvious answer:

PRESENT HEALTHCARE IN THE UNITED STATES

Currently, national healthcare is provided through a fragmented healthcare system, with private health insurance companies competing with each other and the government. Private insurers offer health insurance primarily through employers. The government also supports healthcare coverage through programs such as the Affordable Care Act (ACA), Federal Employees Health Benefit Plans, and Veterans Benefits, Medicare, and Medicaid. In many plans, premiums are collected through payroll taxes and general tax revenue, often leaving significant out-of-pocket costs (copays, deductibles, and coinsurance), at an unsustainable cost. The overall healthcare cost in the United States is approximately 18 percent of Gross Domestic Product (GDP), the highest in the world. This compares with costs in other western nations that generally range from 10-12% or lower, yielding national health and mortality rates equal or better than those of the U.S.

WHY ARE HEALTHCARE PRICES SO HIGH IN THE U.S.?

Although comparison shopping makes sense when we buy consumer goods, such normal market forces do not apply to healthcare. Negotiation of prices of various treatments is seldom available, and as costs of tests and treatments constantly rise, the multiple private insurance plans provide no effective means to control prices, simply passing on the expenses to consumers. Although the Affordable Care Act (ACA) has introduced insurance reforms that reduce the average costs to individuals, this nation’s presently excessive overall price tag continues to rise, and given our current healthcare structure, there is no evidence that these costs can be controlled. Thus, more measures are needed to solve this problem.

Insurance companies, in addition to their inability to limit prices, have balked at ACA’s requirement to spend at least 80-85 percent of their revenue on health care. By contrast, more than 98 percent of Medicare’s expenditures are devoted to this end. Estimates vary, but one-quarter to one-third of our current healthcare costs are driven by insurance companies’ profits together with their administrative costs.  Thus, roughly half of these costs could be recovered under a single-payor system.

MEDICAID

Medicaid began in the 1960s, as was Medicare; however, Medicaid was not created as medical insurance but rather as a broad public welfare program to provide states with the opportunity to receive federal funding for services given to eligible, needy people, providing many important supportive, non-medical, functions. By contrast, Medicare was formed to provide broad healthcare insurance coverage for all citizens, but it has been limited to the elderly, for reasons explained below. As a result, Medicaid functions by default as a broad welfare safety net for more than 70 million impoverished Americans with spending of over $860 billion in combined state and federal funds. On average, the federal government covers about 70 percent of the program’s costs. In addition to hospital care, Medicaid recipients are covered with a broad range of custodial services that include helping those with chronic illnesses, disabilities, or age-related self-care limitations with activities of daily living that include eating, bathing, dressing, toileting, walking, and continence, etc. Although Medicaid is a joint federal and state program, each state has the flexibility to administer the program differently within broad federal guidelines. Therefore, eligibility criteria for Medicaid inclusion varies unevenly from state to state, relating to factors such as personal income, assets, dependents, disability status, and age. Although all states are required by federal law to provide Medicaid’s mandatory healthcare benefits, each state decides its own criteria for covering many specific medical procedures and payments. The average yearly national Medicaid expenditures for all needy individuals are placed at approximately $8,800. But these amounts vary widely from state to state, ranging from $10,000-$13,000 in most New England and middle west, south central, and mountain states. This is contrasted with approximately $4,000-$6000 in east, south central, west south central, and mountain states.  Florida falls in this latter, lowest spending group, at approximately $5,500.

Thus, Medicaid is an inherently inequitable low-level healthcare system. In addition to relegating a substantial number of people into an inferior status, it also compensates physicians less, and in comparison to Medicare, Medicaid caregivers receive an average two-thirds of these fee amounts, often barely sufficient to support office expenses. This leads to substandard care and frustration for the caregivers. This factor alone causes many physicians to limit or refuse care for such recipients. By contrast, Medicare’s Physician Fee Schedule pays more fairly and consistently across the nation.

Although Medicare is a primary payor of hospital charges, one vital role played by Medicaid is in the support of long-term care in the U.S., covering a major portion of spending on nursing home services. In 2022, Medicaid spent approximately $154.4 billion on these long-term care services, paying for nursing home care for periods that meet the program’s eligibility limits that vary by state. Abetted by support of patients’ hospital charges, Medicaid also acts as a financial lifeline to rural hospitals, which is a major factor contributing to their viability.

COULD A SINGLE PAYOR (MEDICARE-STYLE) PROGRAM PROVIDE A SOLUTION?

At its inception in 1965, the architects of Medicare believed that establishing a successful program for the elderly would serve as a steppingstone toward future general coverage. To gain support, their approach was to introduce a program that could be incrementally expanded later, rather than presenting a universal health insurance plan upfront. However, the political landscape during the cold war era was marked by much anti-communist sentiment, and the idea of universal healthcare was derided as “socialized medicine;” however, because of Medicare’s current wide public acceptance and satisfaction, this label is no longer applicable.  Nevertheless, political fears of excessive costs have limited the idea of Medicare expansion. Contrary to popular belief, this method, as we explain, could be far more economical than our current system. Moreover, if we wish to adhere to our egalitarian principles, i.e., basic healthcare available to all, an effective remedy is to replace the entire system with a single payor entity, resembling “Medicare for all.”

Ideally, Medicare and Medicaid would be best combined into a single administratively efficient financing system. Eliminating Medicaid’s role in healthcare is justified because, as noted, such a low-level system provides substandard, poorly compensated medical care. Billing under a single entity would save medical care providers vast amounts of overhead, while also reducing the headaches that trigger much provider burnout that is increasingly being recognized. If properly structured, this consolidation would allow Medicare to assume support for all hospital expenses, both rural and metropolitan, thus providing for evenly distributed, cost efficient, and national support of long-term care.

CONTROL OF DRUG PRICES

The cost of prescription drugs varies widely among health plans from state to state. In efforts to decrease drug prices, pharmacy benefit managers (PBMs) work as middlemen between drug manufacturers, insurance companies and pharmacies, leveraging their large buying power to negotiate lower drug prices to benefit users such as Medicare Part D plans. PMBs, through negotiation, do obtain price concessions and rebates from drug companies, retaining a portion and remitting the rebate balance to insurance companies which in turn are expected to reduce prescription costs for consumers. However, depending upon the portion of the rebates retained by the PBMs, this can even drive up the price of available drugs. Since the Inflation Reduction Act was enacted, Medicare now negotiates directly with drug companies, which could, if expanded, eliminate the PBMs and provide a means for a single payor to control the entire pricing structure. The U.S. Department of Veterans Affairs provides a model for this process by direct negotiation of drug prices, resulting in payments of roughly half the retail price of drugs.

COMPENSATION OF CAREGIVERS AND HOSPITALS

Medicare has a detailed method of setting compensation for both physician and hospital services, all of which are lower than those of private insurers. According to the findings of 19 recent studies comparing Medicare and private health insurance payment rates for all services, private insurers paid nearly double Medicare rates for all hospital services, ranging from 141% to 259% of Medicare rates. For physician services, private insurance paid an average of 143%, ranging from 118% to 179% of Medicare rates. As noted, a single payor would eliminate Medicaid’s meager present caregiver’s  compensations.

VARIED COVERAGE PLANS

Instead of adopting a strict single-payor system, the U.S. may need additional tiers of care as provided presently by private insurers. These strata could offer extra services beyond basic care, such as private room options, shorter waiting times for non-urgent issues, elimination of co-pays, long-term care, and dental care. Such extras could be provided for patients who are willing and able to pay them in addition to a basic single-payor system. Such a structure would also allow the privately run insurance companies to continue involvement, much as they are presently providing in the form of Medicare “supplement” or “gap” plans.

OTHER ADVANTAGES OF UNIVERSAL COVERAGE

Since the entire population would ultimately participate in a basic single payor system, automatic coverage would be provided for everyone, including those with pre-existing conditions, another stumbling block eliminated! This would also eliminate the controversial need for an individual mandate.

Although employer-financed coverage could simultaneously be continued, individuals so covered could opt out at any time to enter a single-payor governmental sponsored system. This choice would provide a means for employers to reduce their financial burdens, while allowing patients the flexibility to move freely within a national system without losing coverage.

WHY HEALTHCARE MORE COST-EFFICIENT IN OTHER ADVANCED COUNTRIES AND COULD PROVIDE A MODEL FOR US.

Advanced western nations have adopted universal healthcare as a basic right that is mandatory for all citizens. In all systems, (Canada and Germany are two examples) the government acts as a central authority that supervises universal fee schedules, either by direct mandates or through other means such as by negotiation among a combination of insurance providers, public funds, and caregivers. This usually results in lower, fixed costs for all services.

In this nation, the federal government, specifically through the Centers for Medicare & Medicaid Services (CMS), sets the prices for hospital and physician services. These prices are not negotiated like in the commercial insurance sector. CMS uses different payment systems for various types of services, such as inpatient and outpatient prospective payment systems for hospitals and for the fee schedule for physicians. CMS updates the payment rates for both hospital and physician services annually, incorporating changes in costs and other relevant factors. If the U.S. were to establish a uniform overall pricing structure in a single payer system, this would closely parallel those of the other advanced nations noted above and result in reduced healthcare costs for the entire nation.

CONCLUSION

Although no system is perfect, the federal Medicare system works reasonably well; by contrast, the federal-state Medicaid system doesn’t. Folding Medicaid into Medicare-for-all would adopt the long-delayed visionary 1965 universal healthcare plan. We are now presented with a timely opportunity to make important corrections, permitting the replacement of Medicaid in its present form, while at the same time, embarking on a truly effective healthcare system for all that has been long overdue.

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Florida Man

Wikipedia defines “Florida Man” as an “Internet meme first popularized in 2013, referring to an alleged prevalence of male persons performing irrational or absurd actions in the US state of Florida.”

Governor Ron DeSantis is the embodiment of a Florida Man.

I have previously cited my cousin Mort– a nationally respected cardiologist who has written about the various kinds of “snake oil” routinely touted by  crazy folks or those out to make a buck– in prior posts. (If you are interested in his book on the subject, you can find it here.) He and his wife recently moved to Florida, and he has periodically shared his frustration with the DeSantis administration in op-eds published in the local newspaper.

Mort is especially appalled by DeSantis’ recent all-out attack on vaccines–an attack that depends for its effectiveness on ignorance of–and a broad repudiation of– medical science. As his recent op-ed began,

Florida Gov. Ron DeSantis has recently embraced COVID-19 vaccine skepticism, and has formed a state-wide group to investigate vaccine “wrongdoing” But in so doing, he is testing the limits of how far political interests can usurp the role of science.

After reviewing for readers the rigorous testing process that all medications , including vaccines, must go through before they are made available to the public, Mort shared the results of multiple peer-reviewed studies of the COVID vaccines. These studies–which involved thousands of individuals–confirmed the efficacy of the vaccines in preventing serious illness and death.

DeSantis–playing to the anti-science, anti-intellectual MAGA base– insists that these results ignore dangerous side-effects.

One of the research studies Mort cited provides a fascinating insight into the incidence of side-effects. It found that. “general adverse systemic reactions were experienced by 35% of placebo recipients after the first dose and 32% after the second. Those receiving the active vaccine experienced initially such symptoms in 46%.”

Placebos, of course, are harmless substances with no therapeutic effect–make-believe medications used by researchers as a control when testing new drugs. And yet, 32% of those receiving what were essentially sugar pills reported adverse side-effects.

What have these studies found to be the actual incidence and severity of side-effects?

Serious allergic reactions to both Pfizer and Moderna vaccines reportedly average between 2 and 10 per million doses. If this happens, healthcare providers can effectively and immediately treat these reactions. More common reports of inflammation of the heart muscle (myocarditis) or its coverings (pericarditis) are also rare and usually not severe. Reports of deaths after COVID-19 vaccination are also rare. The FDA requires healthcare providers to report any deaths after COVID-19 vaccination even if it’s unclear whether the vaccine was the cause. More than 657 million doses of COVID-19 vaccines were administered in the United States from December 14, 2020, through December 7, 2022. During this time, 17,868 preliminary reports of deaths (0.0027%) among people who had previously received COVID-19 vaccine, a percentage not significantly higher that those receiving placebos.

DeSantis’ call for a grand jury investigation of wrongdoing connected to the vaccines has been roundly debunked. As FactCheck reported,

While announcing a request for a grand jury probe into “crimes and wrongdoing” related to the COVID-19 vaccines, Florida Gov. Ron DeSantis and his panel of contrarian experts repeatedly suggested the shots were too risky. But such claims are unsupported and based on flawed analyses.

The vast majority of scientists, public health officials and other experts have endorsed the vaccines because the original randomized controlled trials and subsequent safety and effectiveness studies have shown the shots provide good protection against severe disease and death, with few safety concerns.

Leading this effort to misrepresent and politicize public health is Joseph Ladapo, DeSantis’ chosen surgeon general, who has promoted disproved treatments such as hydroxychloroquine and ivermectin, and questioned the safety of masking and vaccines. Ladapo has also recommended against vaccinating babies and children below the age of 5 and against vaccinating healthy children between the ages of 5 and 17. As FactCheck has reported, this advice is also at odds with that of the American Academy of Pediatrics, the CDC and numerous medical experts.

This deliberate effort to dissuade Florida residents from getting vaccinated is appalling. To the extent those residents believe DeSantis–and a majority of them did recently vote for him–the state will see many unnecessary deaths. I recently shared statistics showing that Republican deaths from COVID have greatly exceeded Democratic deaths, mainly as a result of lower vaccination levels among Republicans.

Worse still, Florida has a large elderly population, and the elderly are much more likely to die from COVID than younger, healthier individuals.

In his zeal to appeal to the GOP’S lowest common denominator, DeSantis is obviously willing to cause a few hundred extra deaths. He is thus the personification of a “male person performing irrational or absurd actions in the state of Florida.”

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COVID Facts And Fictions

Okay–you are all probably as tired of discussing COVID and the insanity of anti-vaxxers as I am, but my cousin the cardiologist has written an important summary of the issues, and maybe–just maybe–sharing considered information from a medical professional might trigger productive discussion.

Yeah, I know. Dreaming…

As Mort says, as a member of the conventional medical/scientific community, he grieves at the number of needless deaths that have occurred, and he agrees with the Surgeon General about the need to understand and counter the large amounts of disinformation  flooding social media. He proceeds by offering facts about the vaccines–their efficacy, a history of their development, where they can be accessed, the fact that they’re free, and much more…He’s compiled a very useful, one-stop overview of most of the questions people have. You should click through to see the entire compilation.

Undoubtedly the most important part of his message, however, has to do with safety. With his permission, I am quoting that section at length.

Even before the vaccines were given emergency use authorization, the FDA reviewed months of safety data on tens of thousands of participants in vaccine trials. Since then, regulators have tracked people who received a vaccine in the real world, because it’s possible that very rare side effects might emerge once millions of people receive a shot.

In the U.S., more than half of adults are now fully vaccinated, and even more have received at least one dose. With more than 300 million doses of vaccine administered and an intense safety monitoring program that’s able to track even extremely rare side effects, researchers have been able to track vaccinated people for months, and are confident that the COVID-19 vaccines currently authorized for use by the FDA are safe.

For the vast majority of people, side effects have been similar to those from other vaccines, like the shingles vaccine, though they have been more common and severe than they are with the typical flu shot. These side effects include fever, headaches, feeling run-down, and soreness in the arm. These are more common after the second shot than the first, and generally go away within a few days. A few rare side effects have been detected, now that millions of vaccine doses have been administered.

After receiving the J&J vaccine, a very small number of people—primarily women younger than 50—have developed a type of rare but serious blood clot. In women between 18 and 49, there have been about 7 cases per million vaccinations, and the FDA and CDC still recommend this vaccine. Similar rare blood clots have been observed with the Astrazeneca vaccine in Europe. In July, the CDC also announced that the agency had detected preliminary reports of about 100 cases of Guillain-Barré syndrome, a neurological disorder, among 12.8 million people who received the J&J vaccine. Most were men, many of them 50 and older. Another concern is that early data suggest that this vaccine may not be quite as effective as the other vaccines against the delta variant of the virus.

After receiving either the Moderna or Pfizer vaccines, a small number of people have had a severe allergic reaction, called anaphylaxis, which can occur after any type of vaccination. These have occurred in about two to five people per million vaccinated, and while serious, they are treatable—this is why people are asked to stick around for 15 to 30 minutes after getting a shot.

The CDC is currently investigating higher than normal rates of suspected myocarditis (heart inflammation) in adolescents and young adults who have received the Pfizer or Moderna vaccines. These incidents are rare, and in 81 percent of suspected cases with a known outcome, patients have fully recovered. Any longer-term side effect is extremely unlikely, according to the CDC. Typically, any vaccine side effects would emerge during these first two months after immunization. Moreover, it’s difficult to clearly link any adverse health events that occur after two months with a vaccination. But regulators will continue to monitor vaccine trial participants for two years to see how long immunity lasts and note any adverse events.

Initial reports of several severe but treatable potentially life-threatening allergic reactions called anaphylaxis raised concern about whether the vaccines would be safe for people with severe allergies. There were 71 cases of anaphylaxis reported after the first 18 million vaccine doses were administered in the U.S. That works out to 2.8 cases of anaphylaxis per 1 million people vaccinated with the Moderna vaccine and 5 cases per 1 million doses of the Pfizer vaccine, with no reported deaths linked to anaphylaxis. The risks of dying from COVID-19 are much worse—about 16,500 people per 1 million diagnosed with COVID-19 will die. Now, the only people being told to avoid the vaccine are those allergic to vaccine ingredients such as polyethylene glycol or the related substance polysorbate.

Of course, the most dangerous allergy is the allergy to science and fact that apparently afflicts a significant percentage of the American population.

Share his post with any non-vaccinated folks for whom facts might still be persuasive…

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Lie Detectors and the First Amendment

Anyone who watches dramatized detective shows–especially those of the CSI variety–knows that the real starring role is played by technology: cool, highly sophisticated devices that virtually no real-life crime lab can afford. These shows are fun, but accuracy isn’t the strong suit of storylines that need to be resolved in an hour’s time. (Fingerprint identification isn’t the slam dunk that Abby’s computer makes it seem on NCIS.)

Even the popular culture shows that don’t rely on “gee whiz” gadgetry, however, routinely use lie detectors. So the general public can be forgiven for thinking that lie detectors work.

They don’t. At least, not reliably. As Morton Tavel has noted

In 2003, the National Academy of Sciences (NAS), after a comprehensive review, issued a report entitled “The Polygraph and Lie Detection,” stating that the majority of polygraph research was “unreliable, unscientific and biased”, concluding that 57 of approximately 80 research studies—upon which the American Polygraph Association relies—were significantly flawed. It concluded that, although the test performed better than chance in catching lies—although far from perfect—perhaps most importantly, they found the test produced too many false positives.

In other words, nervous people who are telling the truth can easily fail the test. And many do.

This lack of reliability is widely understood in the legal community and among police officers; it’s why most courtrooms don’t admit lie detector results into evidence. It’s also why several ex-police officers have spoken out against their use, and why a subset of them has helped job applicants and others who face “screening” by detectors learn techniques that will help them pass.

And that brings us to a fascinating question. Is helping people pass a lie detector test a crime? What if you aren’t just helping Nervous Nellie tell the truth in a way that won’t trip the machine, but you are helping Sneaky Sam lie?

Douglas Gene Williams, a former Oklahoma City police polygraphist and the proprietor of Polygraph.com,  has been teaching individuals how to pass polygraph tests since 1979. He has recently been indicted for mail fraud and witness tampering for allegedly “persuad[ing] or attempting to persuade” two undercover agents posing as customers “to conceal material facts and make false statements with the intent to influence, delay, and prevent the testimony” of the undercover agents “in an official proceeding….”

Williams’ defenders say this is entrapment, that the attempt to shut him down is implicit acknowledgment that the tests don’t work, and that Williams has a free speech right to criticize their use by demonstrating their manifest unreliability. Others–including many polygraph critics and yours truly–say that helping guilty people fool the tests goes beyond advocacy, and is a bridge too far.

What say you?

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Health and the Market

Well, I see that the Congressional GOP is threatening to shut down the government in October if the Democrats block repeal of the Affordable Care Act, aka Obamacare, and the partisan rhetoric is predictably flying.

A Democratic friend sent me an email listing the multiple sins of the Bush Administration, from wars of choice to decimation of the economy to the massive increase in the national debt; the message was something like “You didn’t get mad about any of these things, but now a black guy wants to provide healthcare to Americans who don’t have it, and that makes you mad!?” A Republican friend sent me a similarly incendiary message insisting that Obama is a “socialist” who hates capitalism and wants to destroy the market “that made American health care the best in the world.”

Let’s stipulate that not everyone who opposes Obamacare is a racist, and that American healthcare before the ACA was not only not the best in the world, but actually ranks around 37th. Other than that, my purpose is not to engage these arguments, but to point to a perfect example of the way “the market” works in areas like healthcare, where buyers and sellers are not on equal footing, and do not possess the sort of equivalent information that is necessary for markets to work.

I have previously referred to a book written my cousin, Morton Tavel, in which he takes on the “snake oil” aspects of the healthcare industry. He has now created a blog devoted to the subject, and his first post is a perfect example of “the market” in medicine–a discussion of all the ads about “low T”–testosterone deficiency. I encourage you to click through and read the whole post, but the bottom line is that  “low T” is extremely rare. The numbers the manufacturers are hyping are misleading at best and fraudulent at worst, and the “remedy” they are promoting is expensive, unnecessary and unlikely to restore the virility of the aging men who miss their morning erections.

Markets are wonderful where they work. And they work more often than they don’t. But in those areas where they don’t work, they enable the snake oil salesmen who prey on the unwary and drive up costs for everyone.

As with so many policy debates, this isn’t an “either-or” debate between all market all the time and socializing every aspect of the economy. We “socialize” functions that markets cannot efficiently provide–police and fire protection, infrastructure provision, national defense, public education. We leave to the market those economic areas where markets have proven their effectiveness.

The decision whether to leave an activity to the market or provide it through government should be based on evidence, not ideology. And as every other western industrialized country has long recognized, the evidence for government’s role in healthcare is overwhelming, just as the evidence for the market in consumer goods and manufacturing is overwhelming.

The evidence also tells us a lot about elected representatives who–having lost the argument–are willing to shut down the American government in order to protect the profits of health insurers and drug companies.

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