Gambling as a public health issue (Lancet)

 Here's a warning about gambling from the Lancet:

The Lancet Public Health Commission on gambling   October 24, 2024

"Executive Summary: Gambling is not an ordinary kind of leisure; it can be a health-harming, addictive behaviour. The harms associated with gambling are wide-ranging, affecting not only an individual's health and wellbeing, but also their wealth and relationships, families and communities, and deepening health and societal inequalities. By examining these harms, the Commission unveils the intersections between the social, commercial, legal, and political determinants of health. The Commission sheds light on the increasingly complex commercial ecosystem for gambling and its digital transformation which offer unparalleled capacities for gambling. The Commission calls on governments and policymakers to treat gambling as a public health issue—just as for other addictive and health-harming commodities, such as alcohol and tobacco—and provides recommendations to prevent and mitigate the broad range of harms associated with gambling.

Do Americans Drink Too Much? Politics and science in the debate over guidelines

 The WSJ has the story:

 Do Americans Drink Too Much? Alcohol Is Driving a Debate in Washington. Agencies, lobbyists and lawmakers are fighting over alcohol guidelines due to be updated next year By Kristina Peterson  and Julie Wernau 

"For nearly three decades, federal dietary guidelines have said it is safe for men to have two or fewer drinks a day, and for women to have one. That could change next year when the Agriculture and Health and Human Services departments update recommendations that are part of federal dietary guidelines.

...

"Alcohol-industry officials and lobbyists have sent materials to government officials questioning the research methods of scientists drafting the recommendations. Alcohol companies have spent millions of dollars lobbying lawmakers, more than a dozen of whom wrote to HHS and USDA on May 30 demanding more information on the process. 

“We don’t want arbitrary decision-making by these agencies that’s not rooted in real science,” said Rep. Andy Barr (R., Ky.), who is co-chair of the Bourbon Caucus, a bipartisan group of lawmakers. The group was founded in 2009 by a lawmaker from Kentucky, which considers itself the birthplace of bourbon, and now has around 40 members. 

...

"Guiding Americans to drink less would be a blow to an industry that is already losing some customers. Younger generations have moved away from alcohol over health concerns. For the first time, the U.S. has more daily cannabis users than alcohol users. 

“If they want us to drink two beers a week, frankly they can kiss my ass,” Sen. Ted Cruz (R., Texas) said on Newsmax in August of the potential for lower alcohol-consumption guidelines. 

...

The six-member HHS panel includes three researchers whose studies have demonstrated that any amount of alcohol can be harmful: Tim Naimi, director of the Canadian Institute for Substance Use Research; Jürgen Rehm, senior scientist at the Center for Addiction and Mental Health; and Kevin Shield, an independent scientist who runs a World Health Organization center on addiction."

Gaming the health care system; David Cutler's concerns

 The eminent Harvard health economist  David Cutler is worried by, among other things, the takeover of many healthcare facilities by private equity

Financial Games in Health Care—Doing Well Without Doing Good, by David M. Cutler, , JAMA Health Forum. 2024;5(5):e241591. doi:10.1001/jamahealthforum.2024.1591

"One form of gaming is asset looting—businesses taking money out of health care and then extorting state governments to replenish the funds. In an earlier publication,1 Song and I discussed how this works. Typically, a private equity firm owning a hospital sells the land the hospital is on and agrees to lease it back to the hospital at a high interest rate. The money from the sale is paid out to private equity investors; the hospital is saddled with the debt. If the hospital cannot repay the loan, the private equity firm threatens to close the facility unless the government covers the debt. Quality suffers during this process. Quality indicators at hospitals and nursing homes bought by private equity firms worsened after these changes in ownership.

...

"A third gaming strategy involves “coding intensity” and “upcoding,” which is coding and billing for more complex (and thus more expensive) care. These practices seek to maximize risk-adjusted reimbursements based on diagnostic codes. With coding intensity, the insurer codes all diagnoses ever received by an individual so that disease-based reimbursement is higher. Medicare pays private plans based on the health risks of their enrollees (measured by reported diagnoses). Thus, private insurers participating in Medicare Advantage spend enormous sums to find and code additional diagnoses. Estimates are that coding intensity will cost Medicare $50 billion in 2024.⁶

...

However, addressing coding practices is challenging because it may encourage risk selection. If payments for care provided to a patient are less than the costs incurred for that patient, insurers and clinicians may seek to treat only profitable patients and drive away the unprofitable ones. There are countless ways to do this. At the plan level, leaving prestigious hospitals out of a network and putting expensive medications in high cost-sharing tiers will drive away sicker patients.^9,10 Clinicians engage in risk selection as well. Widespread nonparticipation in Medicaid is evidence of the consequences when profitability varies with patient insurance status.

Because setting optimal health care reimbursement is difficult, less scrupulous clinicians and insurers will always have incentives to cut corners. Recently, it seems that the norms preventing this tendency are fraying. Thus, policymakers need to deter the idea that doing well can come at the expense of doing good. Whenever possible, malfeasance must be prevented in advance and punished when it occurs. Such a strategy will require willpower on the part of policymakers, not just tough words."

Global pacemaker retransplantation

 There are innovative approaches to global health care.  Here is one, that involves reusing pacemakers recovered from deceased donors and refurbished for use in countries where pacemakers are too expensive for wide use.  Unlike some of what we encounter in kidney transplants across borders, the legal bans that have to be overcome may not come from the war against the poor.  A careful clinical trial is underway. There is also an unregulated black market...

Here's the encouraging story from Helio.com:

After death, a new life for refurbished pacemakers in low-, middle-income countries, February 23, 2024

"Lack of access to pacemakers is a major challenge to the provision of CV health care in low- and middle-income countries; however, postmortem pacemaker utilization could offer an opportunity to deliver this needed care, according to Thomas Crawford, MD, an electrophysiologist and associate professor of internal medicine at University of Michigan Health and the medical director of My Heart Your Heart, a cardiac pacemaker reuse initiative at the University of Michigan Cardiovascular Center

...

"Crawford: The need is great. Each year, somewhere between 1 million and 2 million people worldwide die due to a lack of access to pacemakers and defibrillators. There is literature reflecting this. When you query pacemaker implantation data for the United States, it is roughly 800 pacemakers per 1 million population. When you query countries like, for example, Nigeria, it says four pacemakers per million. Quite a difference.

"Per capita gross domestic product is such that, in many countries, a pacemaker costs more than a person’s annual income.

...

"Healio: What are the regulations around using a refurbished pacemaker?

"Crawford: Pacemaker reuse is illegal in all jurisdictions. The FDA states that pacemaker reuse is an “objectionable practice.” We know we can do it, but we need to develop partnerships with other entities to give us credibility. One of those methods to do this is by engaging the government. FDA issues export permits for this type of activity. We created a protocol where we reprocess the device, working with Northeast Scientific, which provides the pacemaker cleaning and sterilization. We have received permission from the FDA to export them. We have to put a sticker on them saying “not for use in the United States.” We are doing this in countries in which governments will allow it. One of the limitations is needing a government letter from each of the recipient countries. We have about 12 countries now, and the collection of countries we are working with is purely accidental. It is not a normal methodological process. A lot of it is through contact with individuals and opportunities that arise.

...

"Healio: You are leading a randomized controlled trial called Project My Heart Your Heart: Pacemaker Reuse. What is the study design, and what do you and your colleagues hope to learn?

"Crawford: The objective of the clinical trial is to determine if pacemaker reutilization can be shown to be a safe means of delivering pacemakers to patients in low- and middle-income countries without resources. The target enrollment is 270 patients, all from outside the United States, who each have a class I indication for pacing and who attest that they do not have the ability to purchase a device on their own. They must consent to be randomly assigned to receive either a brand-new pacemaker, which we purchase, or a reprocessed pacemaker, for which we provide the leads and accessories. Donated devices are inspected according to specific protocols that evaluate physical and electrical suitability, including battery longevity, for future use. Devices deemed to be acceptable are shipped to a third-party vendor, Northeast Scientific, for disassembly, cleaning and re-sterilization. There will be about 130 participants in each arm. We will follow those patients and report any adverse events. The countries that have contributed patients include Kenya, Nigeria, Paraguay, Sierra Leone and Venezuela. We hope to soon begin enrolling patients in Mexico and Mozambique.

"I have had clinicians outside the U.S. who tell me they removed a pacemaker device, cleaned it, reprocessed it and then implanted it in someone else — but the government does not know about it. This practice does happen and it is not regulated in any way; patients and physicians know about it and keep it quiet. The difference with what we are doing and these other efforts is we bring it to a much higher level, because that is what the FDA requires. "

Who Shall Live? (3rd edition) by Victor R. Fuchs and Karen Eggleston

Shortly before he passed away in September at the age of 99, Vic Fuchs finished the third edition of his book Who Shall Live?, now with a coauthor, Karen Eggleston.

It just came out now, in time for his 100th birthday next month.

********

Sunday, September 17, 2023

Vic Fuchs (1924-2023)

Saturday, November 25, 2023

Memorial service for Vic Fuchs

Vic Fuchs (1924-2023)

My friend and neighbor Vic Fuchs, the dean of American health economists, passed away on Friday.  

He was just a few months short of 100, but in the last year he finished revising the third edition of his 1975 book,  Who Shall Live? Health, Economics, and Social Choice.

He bravely bore some physical ailments, but his mind remained sharp, and he was always a pleasure to talk to. (He used to joke "I'm in perfect health: my psychiatrist says its all in my body.")

He kept abreast of current events, and remained informed and concerned about the state of the health care system in the U.S., and democracy.

Vic Fuchs speaking at the memorial conference for Ken Arrow, Oct. 9, 2017

##########

Update: here's a Stanford obit:

Victor Fuchs, pioneer of health care economics, has died

Fuchs’ influence and tireless devotion to the field of health care economics and the Stanford community spanned decades.

September 18, 2023 | Krysten Crawford

Can Britain Fix Its National Health Service?

 The NYT has the story

A National Treasure, Tarnished: Can Britain Fix Its Health Service? As it turns 75, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history. By Mark Landler

"As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either joining strikes or leaving for jobs abroad.

...

"More than 7.4 million people in England are waiting for medical procedures, everything from hip replacements to cancer surgery. That is up from 4.1 million before the coronavirus pandemic began in 2020.

"Mortality data, exacerbated by long wait times, paints a bleak picture. In 2022, the number of excess deaths rose to one of the highest levels in the last 50 years, and those numbers have kept rising, even as the pandemic has ebbed.

"In the first quarter of 2023, more than half of excess deaths — that is, deaths above the five-year average mortality rate, before the pandemic — were caused by something other than Covid-19. Cardiovascular-related fatalities, which can be linked to delays in treatment, were up particularly sharply

...

"Seeking to solve the problem, Prime Minister Rishi Sunak last month announced a 15-year plan to recruit and train 300,000 nurses and doctors, budgeting 2.4 billion pounds (about $3 billion) for the first five years. But critics point out that the plan does not fund wage increases, the only surefire way to prevent workers from leaving.

...

"No mainstream politician proposes to privatize the N.H.S.: The specter of the inequitable U.S. health system still horrifies many Britons. And in some ways, the service remains a marvel, one of the world’s most comprehensive, taxpayer-funded health care providers — “free at the point of delivery,” in the words of its utopian motto. It still offers annual physical exams, mammograms, vaccinations and other services at a level that visiting Americans find impressive."

Harm reduction is not a panacea: drug use and drug policy in Portugal, and San Francisco

 The Washington Post has a story about Portugal, and the SF Chronicle has one as well. Both stories touch on the tensions between treating drug addicts with respect, and assuring that cities remain safe and livable.  

Here's the Washington Post:

Once hailed for decriminalizing drugs, Portugal is now having doubts  By Anthony Faiola and Catarina Fernandes Martins

"Portugal decriminalized all drug use, including marijuana, cocaine and heroin, in an experiment that inspired similar efforts elsewhere, but now police are blaming a spike in the number of people who use drugs for a rise in crime. In one neighborhood, state-issued paraphernalia — powder-blue syringe caps, packets of citric acid for diluting heroin — litters sidewalks outside an elementary school.

"Porto’s police have increased patrols to drug-plagued neighborhoods. But given existing laws, there’s only so much they can do. 

...

"Portugal became a model for progressive jurisdictions around the world embracing drug decriminalization, such as the state of Oregon, but now there is talk of fatigue. Police are less motivated to register people who misuse drugs and there are year-long waits for state-funded rehabilitation treatment even as the number of people seeking help has fallen dramatically. The return in force of visible urban drug use, meanwhile, is leading the mayor and others here to ask an explosive question: Is it time to reconsider this country’s globally hailed drug model?

“These days in Portugal, it is forbidden to smoke tobacco outside a school or a hospital. It is forbidden to advertise ice cream and sugar candies. And yet, it is allowed for [people] to be there, injecting drugs,” said Rui Moreira, Porto’s mayor. “We’ve normalized it.”

...

" In the United States alone, overdose deaths, fueled by opioids and deadly synthetic fentanyl, topped 100,000 in both 2021 and 2022 — or double what it was in 2015. According to the National Institutes of Health, 85 percent of the U.S. prison population has an active substance use disorder or was jailed for a crime involving drugs or drug use.

"Across the Atlantic in Europe, tiny Portugal appeared to harbor an answer. In 2001, it threw out years of punishment-driven policies in favor of harm reduction by decriminalizing consumption of all drugs for personal use, including the purchase and possession of 10-day supplies. Consumption remains technically against the law, but instead of jail, people who misuse drugs are registered by police and referred to “dissuasion commissions.” 

...Other countries have moved to channel drug offenses out of the penal system too. But none in Europe institutionalized that route more than Portugal. Within a few years, HIV transmission rates via syringes — one the biggest arguments for decriminalization — had plummeted. From 2000 to 2008, prison populations fell by 16.5 percent. Overdose rates dropped as public funds flowed from jails to rehabilitation. There was no evidence of a feared surge in use.

...

"But in the first substantial way since decriminalization passed, some Portuguese voices are now calling for a rethink of a policy that was long a proud point of national consensus. Urban visibility of the drug problem, police say, is at its worst point in decades

...

"A newly released national survey suggests the percent of adults who have used illicit drugs increased to 12.8 percent in 2022, up from 7.8 in 2001, though still below European averages.

...

"Porto’s mayor and other critics, including neighborhood activist groups, are not calling for a wholesale repeal of decriminalization — but rather, a limited re-criminalization in urban areas and near schools and hospitals to address rising numbers of people misusing drugs."

...

"After years of economic crisis, Portugal decentralized its drug oversight operation in 2012. A funding drop from 76 million euros ($82.7 million) to 16 million euros ($17.4 million) forced Portugal’s main institution to outsource work previously done by the state to nonprofit groups,

...

"Twenty years ago, “we were quite successful in dealing with the big problem, the epidemic of heroin use and all the related effects,” Goulão said in an interview with The Washington Post. “But we have had a kind of disinvestment, a freezing in our response … and we lost some efficacy.”

*******

And here are some related paragraphs about San Francisco, in a story in the San Francisco Chronicle about a concentration of drug dealers from Honduras:

THIS IS THE HOMETOWN OF SAN FRANCISCO’S DRUG DEALERS By Megan Cassidy and Gabrielle Lurie |  July 10, 2023

"Like many other U.S. cities, San Francisco shifted years ago to treating drug use more like a disease than a crime. The heavy policing approach of the War on Drugs era failed to slow dealers or decrease demand while overcrowding jails and disproportionately punishing people of color, studies show.

"Now one of the most progressive cities in the nation is fracturing over concerns that it has become too permissive. What to do about the Honduran dealers is a key political issue as a major citywide election approaches in 2024.

"On a weekday afternoon in June, a man in his early 30s lay motionless on a SoMa sidewalk outside the Federal Building. On his right, a dozen users smoked fentanyl and crack cocaine or hung bent at the waist, heads suspended at their knees. To his left, a handful of dealers, cloaked in black but for the space around their eyes, continued selling while a passerby revived the man with Narcan, the nasal-spray antidote to opioid overdoses, and as paramedics arrived to treat him a few minutes later.

“I’m so mad at them for ruining my neighborhood,” said Kevin DeMattia, who owns Emperor Norton’s bar and has lived in the Tenderloin for the past 25 years. “Businesses are dying because people don’t want to come to the Tenderloin.  They’re ruining the neighborhood in so many ways. They’re poisoning people. … They’re this cancer, this aggressive, metastasizing cancer on the Tenderloin — the dealers and the addicts.”

Canada to require health warnings on individual cigarettes

 The Washington Post has the story:

Canada to require health warnings on individual cigarettes  By Sarah Dadouch

"Beginning next year, cigarettes sold in Canada will bear one of six messages in English and French. They include “TOBACCO HARMS CHILDREN,” “POISON IN EVERY PUFF” and “SMOKING CAUSES IMPOTENCE.” Health Canada announced the regulation Wednesday for World No Tobacco Day.

“This bold step will make health warning messages virtually unavoidable,” mental health and addictions minister Carolyn Bennett said. With updated graphic images on cigarette packages, she said in a statement, the labels “will provide a real and startling reminder of the health consequences of smoking.”

...

"Around 48,000 people in Canada die as a result of tobacco use each year, according to Health Canada. That’s more than those who die as a result of alcohol, opioids, suicides, murders and traffic collisions combined."

Market Shaping at the University of Chicago: Promoting needed innovation

 One of many exciting talks yesterday at the first day of the New Directions in Market Design conference was by U. Chicago's Rachel Glennerster who announced the new market design initiative at U. Chicago:

Introducing the University of Chicago's Market Shaping Accelerator. Designing market shaping mechanisms to spur innovation to help solve some of the biggest global challenges.

"Accelerating Innovation

"Threats to the global community — such as climate change and pandemics — demand urgent innovation and action at scale. But when commercial incentives for innovation trail behind the social value, market shaping instruments are required to credibly signal demand and spur and scale up innovation.

"The Market Shaping Accelerator aims to harness the momentum and interest in these tools generated from global successes in vaccine development to accelerate their adoption by governments, multilateral institutions, and philanthropies to solve the world’s most pressing challenges.

"Nobel Laureates, Leading Scholars and Innovators Advance the Use of Market Shaping Instruments to Address Global Challenges​

"The Market Shaping Accelerator brings together the world’s leading market shaping experts. The team behind the Accelerator has contributed to both foundational research and prominent policy successes of market shaping mechanisms, including the Pneumococcal and Frontier Advanced Market Commitments (AMCs)."

Rachel Glennerster speaking about market shaping

The World Health Organization (WHO) at 75

 An editorial in Nature considers the complicated history of  the World Health Organization. 

The WHO at 75: what doesn’t kill you makes you stronger. The World Health Organization is emerging from the peak of the pandemic bruised. Its member states must get back to prioritizing universal health care.

"When thinking about the WHO’s 75 years, it’s worth remembering the time and circumstances of its creation. In the aftermath of the Second World War, the newly established United Nations and its specialized agencies, including the WHO, were designed to future-proof the world from another global conflict. Around 80 million people died during the two world wars, many from famine or disease.

"The WHO deserves more money for its core mission — and more respect

"The WHO’s founding constitution states unequivocally: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

"And yet, the agency’s creators chose not to prioritize robust systems of universal health care that would meet these goals. This absent focus is one factor in why infectious diseases continue to impact populations in low- and middle-income countries. The eradication of smallpox in 1980 was a big win. But for other diseases, the agency and its donors have been unable to reach targets, including in the elimination of HIV and AIDS, malaria and tuberculosis.

"The WHO does, however, have a consistent record for establishing itself as the go-to organization for setting global standards for the efficacy, safety and quality of vaccines and medicines. As we have seen during the pandemic, the agency is central to alerting the world to new infectious diseases, helped in no small measure by the revolution in biomedicine and health data, especially genomics."

In general I think the WHO does important work reasonably well, but I have reservations about their policies concerning blood and transplants, which seem to me to reflect some now outdated repugnance to the complexities of “Substances of Human Origin (SoHO)." (Not that these issues don't remain complex.)

Incarceration isn't always the best treatment for drug addiction

 Here's a NY Times editorial:

America Has Lost the War on Drugs. Here’s What Needs to Happen Next.  Feb. 22, 2023

It begins with this bit of history, and ends with a call for evidence-based solutions:

"For a forgotten moment, at the very start of the United States’ half-century long war on drugs, public health was the weapon of choice. In the 1970s, when soldiers returning from Vietnam were grappling with heroin addiction, the nation’s first drug czar — appointed by President Richard Nixon — developed a national system of clinics that offered not only methadone but also counseling, 12-step programs and social services. Roughly 70 percent of the nation’s drug control budget was devoted to this initiative; only the remaining 30 percent went to law enforcement.

"The moment was short-lived, of course. Mired in controversy and wanting to appear tough on crime, Nixon tacked right just months before resigning from office, and nearly every president after him — from Reagan to Clinton to Bush — followed the course he set. Before long, the funding ratio between public health and criminal justice measures flipped. Police and prison budgets soared, and anything related to health, medicine or social services was left to dangle by its own shoestring.

...

"Study the solutions. Leading public health agencies, including the Food and Drug Administration and the Centers for Disease Control and Prevention, failed to prevent or even adequately respond to the opioid epidemic that has engulfed the nation. But health officials can still step up. As opioid settlement funds are deployed (along with federal dollars) and harm reduction programs are begun, the C.D.C. especially should impartially study what is working and what is not. The response to this crisis should finally be based on evidence.

"The nation’s leaders are not the only ones with work to do. To fully replace the war on drugs with something more humane or more effective, the public will have to come to terms with the prejudices that war helped instill. That means accepting that people who use drugs are still members of our communities and are still worthy of compassion and care. It also means acknowledging the needs and wishes of people who don’t use drugs, including streets free of syringe litter and neighborhoods free of drug-related crime. These goals are not mutually exclusive. In fact, they go hand in hand. But to make them a reality, lawmakers and other officials will have to lead the way."

Gay couples, surrogacy, IVF and health insurance

 The Guardian has a story about the obstacles consulting a married gay couple in New York. They have an ongoing lawsuit regarding discrimination in health insurance for IVF. (Much of the article is also about the debate over whether surrogacy is ethical or exploitative):

‘We are expected to be OK with not having children’: how gay parenthood through surrogacy became a battleground  by Jenny Kleeman

"That’s when they first became aware of the eye-watering cost of biological parenthood for gay men. Maggipinto reels off the price list in a way that only someone who has pored over every item could. There’s compensation for the egg donor: no less than $8,000 (£6,600). The egg-donor agency fee: $8,000-10,000. The fertility clinic’s bill (including genetic testing, blood tests, STD screening and a psychiatric evaluation for all parties, sperm testing, egg extraction, insemination, the growing, selecting, freezing and implantation of the resulting embryos): up to $70,000. And that’s if it all goes well: if no embryos are created during a cycle, or if the embryos that are don’t lead to a successful pregnancy, they would have to start again.

"Then there’s the cost of a surrogate (called a “gestational carrier” when they carry embryos created from another woman’s eggs). Maggipinto and Briskin were told agency fees alone could stretch to $25,000, and the surrogates themselves should be paid a minimum of $60,000 (it is illegal for surrogates to be paid in the UK, but their expenses are covered by the intended parents). “That payment doesn’t include reimbursement for things like maternity clothing; lost wages if she misses work for doctors’ appointments or is put on bed rest; transportation; childcare for her own children; [or] lodging.” It takes 15 minutes for Maggipinto to run me through all the expenses they could incur if they tried to have a child genetically related to one of them. The bottom line? “Two hundred thousand dollars, minimum,” he says.

...

"Briskin used to work for the City of New York as an assistant district attorney, earning about $60,000 a year. His employment benefits had included generous health insurance. But when they read the policy, they discovered they were the only class of people to be excluded from IVF coverage. Infertility was defined as an inability to have a child through heterosexual sex or intrauterine insemination. That meant straight people and lesbians working for the City of New York would have the costs of IVF covered, but gay male couples could never be eligible.

...

"There’s a stark contrast between American and Ukrainian surrogates, Maggipinto says. “Here you have to be a woman who has already had children, who is over a certain age, who can prove that she is independently financially capable of sustaining herself without her surrogate compensation. You effectively cannot be a poor surrogate.” He is referring to the American Society for Reproductive Medicine’s guidelines, but with no official regulation in the US, there’s no compulsion for anyone to follow them.

...

"The EEOC will rule on whether the terms of Briskin’s health insurance were discriminatory within a few weeks. The City of New York has so far defended its policy. The couple’s attorney, Peter Romer-Friedman, tells me: “They say their healthcare plan doesn’t provide surrogacy for anyone, so it’s not discrimination to deny it to Corey and Nicholas.” Just like everyone else, the city’s first response was to assume this was all about access to surrogacy."

Opioid prescription and curtailment are associated with increased rates of suicide among rural veterans:

 Chronic pain, followed by prescription of opioid pain medicines, is sometimes followed by opioid addiction.  A recent NBER working paper shows that policies to reduce prescriptions are associated with increased rates of suicide, particularly among rural military veterans.  Presumably some of these are related to addiction, and some are related to pain.

The Opioid Safety Initiative and Veteran Suicides by Joshua C. Tibbitts & Benjamin W. Cowan WORKING PAPER 29139, DOI 10.3386/w29139,  August 2021

"We investigate the relationship between opioid diverting policy and suicides among the veteran population. The opioid epidemic of the past two decades has had devastating health consequences among U.S. veterans and military personnel. In 2013, the Veterans Health Administration (VA) implemented the Opioid Safety Initiative (OSI) with the goal of discouraging prescription opioid dependence among VA patients. Between 2012 and 2017, prescription opioids dispensed by the VA fell 41% (VA, 2018). Because this involved the aggressive curtailing of opioid prescriptions for many VA patients, OSI may have had a detrimental effect on veterans’ mental health leading to suicide in extreme cases. In addition, because rural veterans have much higher rates of VA enrollment, more prescription opioid use and abuse, and lower rates of substance abuse and mental health treatment utilization, we expect any effect of OSI on veteran suicides to be concentrated in rural areas. We find that OSI raised the veteran suicide rate relative to the non-veteran (“civilian”) rate with rural veterans suffering the lion’s share of the increase. We estimate that OSI raised the rural veteran suicide rate by a little over one-third between 2013 and 2018."

Alain Enthoven on fragmented American health care

 Writing in Health Affairs, Alain Enthoven notes that most American workers insured through their jobs work for self-insured employers, i.e. employers who themselves pay for the health care of their covered lives. This means that many of them are relatively small buyers of health insurance, which leads them to deal with fee for service providers, rather than big health maintenance organizations, which might be a better model for a national health care system.

Employer Self-Funded Health Insurance Is Taking Us In The Wrong Direction by Alain C. Enthoven

"The 2020 Kaiser Family Foundation Survey of Employer Health Benefits reports that 67 percent of employed, insured workers are covered under self-insured, or self-funded, arrangements. Under these arrangements, the employer, not an external insurer, directly bears the financial risk for the cost of employee health care.

Self-funded arrangements have grown steadily as a share of the insurance market over the past 15 years and now include many employers with less than 200 employees. While this may be the most cost-effective decision for individual employers under the current regulatory framework, it has the effect of locking in uncoordinated, open-ended fee-for-service (FFS) and locking out comparatively economical Integrated Delivery Systems (IDS)."

Guns and public health: research funds available again

 Here's the story, from the Journal of the American Medical Association:

Gun Violence Researchers Are Making Up for 20 Years of Lost Time by Alicia Ault, JAMA. Published online August 4, 2021. doi:10.1001/jama.2021.11469

"By late July, the Gun Violence Archive reported 25 370 US firearm deaths in 2021, putting the year on track to surpass last year’s 43 559 deaths. US Centers for Disease Control and Prevention (CDC) data showed that 39 707 people lost their lives to gun violence in 2019. It was the third consecutive year in which US gun violence deaths approached 40 000 and the end of a decade in which the death rate from gun violence increased by 17%, from 10.1 to 11.9 deaths per 100 000 population. The rate has remained above 11 per 100 000 population since 2015.

"Although the CDC gathers firearm mortality data, its gun violence research had largely been dormant since 1996 when the Dickey Amendment prohibited the agency from using its injury prevention funding “to advocate or promote gun control.” The amendment technically didn’t prohibit gun violence research, but the chill was numbing.

"In 2019, however, Congress authorized $25 million in spending on gun violence research, to be split evenly between the CDC and the National Institutes of Health (NIH). Although the amount is nearly 10 times greater than the $2.6 million that the CDC was spending on gun violence prevention studies when the Dickey Amendment took effect, a leading expert said the field is still woefully underfunded.

The 1% Steps for Health Care Reform Project (including kidney exchange)

 The goal of the 1% Steps for Health Care Reform Project is to shift the way we think about health care spending in the US and offer a roadmap to policy makers of tangible steps we as a country can take to lower the cost of health care in the US. We want to leverage leading scholars’ work to identify discrete problems in the US health system and offer evidence-based steps for reform. We will continually update the project with new proposals that are based on the latest academic research.

Here is their full list of Policy Briefs.

Here's one on kidney exchange:

Expanding Kidney Exchange

Authors: Nikhil Agarwal, Massachusetts Institute of Technology; Itai Ashlagi, Stanford University; Michael Rees, The University of Toledo Medical Center; Alvin Roth, Stanford University

Here's one paragraph:

"Policy Proposal: This brief discusses three specific proposals for expanding kidney exchange. First, policy makers should eliminate financial disincentives for participating in kidney exchange platforms by including medical and administrative costs specific to kidney exchange in reimbursements from the Medicare program. Second, policy makers should direct the federal contractor UNOS (United Network for Organ Sharing) to allow kidney exchange chains to be initiated by deceased donors. Third, Medicare should pay for the costs of a global kidney exchange that allows exchanges involving patients in different nations."

And here's some discussion by Nikhil Agarwal with Zack Cooper:

Hypertension: the surgeon general calls for a New Year's resolution

 The U.S. Public Health Service has issued the following call to action on high blood pressure, which affects many Americans, differentially across race, ethnicity and socioeconomic status:

The Surgeon General’s Call to Action to Control Hypertension

"Hypertension, or high blood pressure, affects nearly one in two U.S. adults and is a major preventable risk factor for heart disease and stroke.1  Despite the common nature of this condition and a large amount of national attention,2,3  only about 24% (26 million) have their blood pressure controlled to ≤130/80 mmHg.1  Regardless of the threshold used to measure control, national rates have stagnated and disparities persist.3,4 The Surgeon General’s Call to Action to Control Hypertension seeks to avert the negative health effects of hypertension across the U.S. by identifying interventions that can be implemented, adapted, and expanded across diverse settings.

The Call to Action is divided into three sections. Section 1 summarizes the current state of  hypertension control, including the economic costs and disparities between different population groups. It notes that progress in hypertension control has been demonstrated in communities and health care systems across the country.5,6,7  In many areas, we know what works, but we need to replicate and expand these efforts and continue to explore new interventions to achieve control across all population groups.

Section 2 presents three overall goals to support improvements in hypertension control:

Goal 1. Make hypertension control a national priority.

Goal 2. Ensure that the places where people live, learn, work, and play support hypertension control.

Goal 3. Optimize patient care for hypertension control.

De-adopting zombie medical procedures

What happens to medical procedures that are found to be no more effective than placebos?  Some live on for quite a while. One thing that works is to stop paying for them.

Here's an article in JAMA:

De-adopting Low-Value Care--Evidence, Eminence, and Economics

Brian W. Powers, MD, MBA1; Sachin H. Jain, MD, MBA2,3; William H. Shrank, MD, MHSA1   JAMA. Published online October 2, 2020. doi:10.1001/jama.2020.17534 

"An often cited shortcoming of the US health care system is the slow pace with which new innovations are adopted into routine clinical practice.1 A parallel problem receives comparably less attention: the US and other countries are slow to abandon practices that provide little or no benefit to patients. Despite robust research cataloguing common practices that confer little or no value,2,3 these practices remain widespread, accounting for an estimated $67 billion in spending annually.4 For example, estimates suggest that the Centers for Medicare & Medicaid Services (CMS) spends more than $274 million annually on carotid artery disease screening for asymptomatic patients and more than $111 million annually on cervical cancer screening for women older than 65 years.2 The concept of de-adopting these and other low-value services is embedded in the Less Is More series in JAMA Internal Medicine5 and in the Choosing Wisely campaign from the American Board of Internal Medicine.6"

PNAS celebrates Janet Currie

 The National Academy of Sciences celebrates Janet Currie in the current issue of PNAS, with an interview and an inaugural article.

QnAs with Janet Currie, by Tinsley H. Davis, PNAS September 29, 2020 117 (39) 24008-24009; https://doi.org/10.1073/pnas.2017808117

"Many mental illnesses arise in adolescence, and a study of national insurance claims in the United States finds a large variance in how adolescent patients are treated even within the same zip code. The findings, reported in Janet Currie’s Inaugural Article (IA) (1), reveal that 45% of adolescents receive first-line treatments that are not approved by the US Food and Drug Administration (FDA) (1). Currie, elected to the National Academy of Sciences in 2019, has studied children’s health for three decades. A professor of economics and public affairs at Princeton University, Currie has undertaken pioneering economic analysis of child development, including analysis of the effects of the Head Start program on children (2, 3) and the effects of expansions of the Medicaid program for pregnant women and children (4, 5). In her IA (1), Currie analyzes a large national dataset to reveal disparities in treatment that cannot be attributed to supply-side factors, such as limited availability of treatment providers."

Here's the first question and answer:

"PNAS:What is the link between health and economics?

"Currie: Health can have an impact on how much human capital, like education, people are able to acquire. Moreover, healthcare is a business, and it accounts for almost 20% of US GDP [gross domestic product]. So there are two strands: One is thinking about health as a business, and another is thinking about health as a form of wealth. My work generally focuses more on that second aspect of health as a form of human capital. The Inaugural Article (1) brings those two strands together to a certain extent because mental health problems in children are one of the things that causes them to have less human capital than they might otherwise, and I’m looking at how those children with mental health problems end up getting treated by the healthcare system."

And here is her INAUGURAL ARTICLE

Treatment of mental illness in American adolescents varies widely within and across areas

Emily Cuddy and  Janet Currie, PNAS September 29, 2020 117 (39) 24039-24046; https://doi.org/10.1073/pnas.2007484117

"Abstract: Many mental health disorders first manifest in adolescence, and early treatment may affect the course of the disease. Using a large national database of insurance claims, this study focuses on variations in the type of care that adolescent patients receive when they are treated for an initial episode of mental illness. We found large variations in the probability that children receive follow-up care and in the type of follow-up care received across zip codes. We also found large variations in the probability that children receive drug treatments that raise a red flag when viewed through the lens of treatment guidelines: Overall, in the first 3 mo after their initial claim for mental illness, 44.85% of children who receive drug treatment receive benzodiazepines, tricyclic antidepressants, or a drug that is not Food and Drug Administration-approved for their age. On average, these children are 12 y old. While the supply of mental health professionals impacts treatment choices, little of the overall variation is explained by supply-side variables, and at least half of the variation in treatment outcomes occurs within zip codes. These results suggest that other factors, such as physician practice style, may play an important role in the types of treatment that children receive."