Oliver’s Twist

African Americans are dying at a higher rate than whites from cardiovascular disease. One contributing factor may be vitamin D deficiency in this population.

In a study to be published in the Annals of Family Medicine on January 11, 2010, Kevin Fiscella, M.D., and colleagues report the results of their investigation of the role of vitamin D deficiency in cardiovascular death. Fiscella, a nationally known researcher in health disparities, lead a team of researchers in this NIH-funded project. They evaluated 15,000 adults, collecting data on vitamin D levels, body mass index, smoking history, and levels of C-reactive protein, among other measurements.

They found that vitamin D deficiency was associated with a 40 percent higher risk of death from cardiovascular disease for all study subjects. However, African Americans’ risk of cardiovascular death was 38 percent higher than whites. Fiscella et al also found that increased levels of poverty also were associated with increased risk of cardiovascular death.

Vitamin D deficiency is widespread around the world. Among otherwise healthy young adults in the United States, it’s estimated that 36 percent have low vitamin D levels. Some 57 percent of hospitalized adults are vitamin D deficient.

Vitamin D deficiency has been associated in epidemiological studies with diabetes, hypertension, some cancers, and with kidney and heart disease. As vitamin D is obtained from exposure to sunlight and through the diet, it may be a modifiable risk factor. Interventions with supplements or public campaigns to help increase sun exposure could help decrease death attributable to vitamin D deficiency.

Fiscella cautions against any rush to judgment on this matter. Previous observational studies indicating the health benefits of macronutrients — for example, vitamin E and beta-carotenes — have not panned out to be true when tested in clinical trials.

In addition to this caution, we need to keep in mind that the cause of the health inequities suffered by African Americans is not inherent biological differences. Even in this study, poverty was an independent risk factor — and poverty disproportionately affects the African-American. As long as these social inequities exist, racial health disparities will continue — no matter how much vitamin D we put in peoples’ diet.

Sen. Nelson and President Obama agree on health plan that denies coverage to millions and increases restrictions on abortions.

Just a few moments ago, the U.S. Senate wrapped up its Christmas present for working people. After months of debate, the Senate passed a health care “reform” bill Christmas Eve. The gift is worse than a lump of coal; it’s a stab in the back!

Among the vacuous campaign promises made by President Obama was the pledge to reform the health care system to provide “high-quality health care for all Americans.” President Obama’s health care plan, which the U.S. Senate approved at 7:15 a.m. this morning, actually is a blueprint for enriching the insurance and pharmaceutical industries and further restricting women’s right to abortion services.

The Senate bill, like the companion bill already passed by the U.S. House of Representatives on November 7, mandates individuals to purchase insurance through a “health insurance exchange.” The Senate plan will force 30 million uninsured people to purchase private insurance — leaving nearly 20 million other uninsured people still without health care coverage. The increase in insurance premiums is welcomed by the insurance industry, and the pharmaceutical firms look forward to the increased revenue from new drug sales.

Individuals may qualify for a government subsidy to help pay their insurance premiums, which means that billions of dollars of public money will be funneled into the coffers of the insurance companies and drug manufacturers. This increased revenue for the insurance and pharmaceutical industries will come from huge cuts in Medicare and increased taxes. Medicaid will be expanded to cover more people.

The mandate requiring individuals to purchase health insurance will squeeze working people hard. In the House bill, the government subsidies will be adjusted so that individuals will pay anywhere from 1.5% to 12% of their income as health insurance premiums. The penalty for not purchasing health insurance is that you must then pay 2.5% of your income into the plan. The Senate bill stipulates a penalty of 2% of one’s annual income. (For a side-by-side comparison of the House and Senate bills, see this site provided by the Kaiser Family Foundation.)

Also, the House bill stipulates that those under age 65 with annual incomes below $18,700 for a couple or $9,350 for an individual will be exempted from the mandate. The Senate bill says that those whose incomes are less than 100% of the poverty level (annual income of $11,201 for an individual or $21,834 for a family of four) will be exempted from the mandate. These provisions, in today’s economy, mean that millions will be uncovered by this insurance plan. As the lowest-paid workers, African Americans and Latinos will be the hardest hit by these provisions. (Nearly half of Detroit workers, for example, are unemployed.) Undocumented workers, who disproportionately lack health insurance, would be ineligible for subsidies to pay for private health insurance; thus, they continue to be denied access to decent health care.

The supposed benefits of the new health care legislation are meager at best. Millions of people will remain uninsured. The touted reform to eliminate pre-existing health conditions as an excuse to deny health insurance coverage does, in fact, provide insurance for these people. However, the Senate bill allows insurers in the exchanges to charge three times as much for the elderly and others with chronic medical conditions than they charge younger and healthier customers. So, the so-called health care reform bill is really a boondoggle for the insurance and pharmaceutical industries.

The Senate bill is also an attack on women’s right to abortion. The proposed legislation allows states to prohibit the coverage of abortions by insurers in their exchanges. The bill is a pro-insurance, pro-pharmaceutical industry and anti-abortion bill; it has nothing to do with providing “high-quality health care to all Americans.”

Part of the deal brokered by Senate Majority Leader Harry Reid to win the support of the bill from Nebraska Senator Ben Nelson is an agreement that no major changes will be made to the Senate bill in conference. Therefore, the major provisions of the Senate bill are likely to become law. As a result, millions of people will be denied health coverage, millions more will be forced to reduce their incomes by buying private health insurance, billions of public dollars will be channeled into the hands of private owners of insurance and pharmaceutical companies, and abortion rights will be further restricted. A Christmas present working people will want to return for sure.

African-American patient on dialysis

Grady Memorial Hospital in Atlanta recently closed the doors to its outpatient kidney clinic. The clinic provided life-sustaining dialysis treatment, and the hospital provided charity care to patients regardless of their immigration status. However, the hospital closed the clinic in October for “fiscal reasons.” A group of some 50 immigrant patients sued Grady, pointing out that the public hospital was abandoning them. Today’s New York Times reports that Fulton County Superior Court Judge Ural D. Glanville ruled that Grady acted legally.

Medicare pays for the expensive dialysis treatments for U.S. citizens and documented immigrants. Grady provided dialysis treatment to a significant number of undocumented immigrants, who are ineligible for Medicare. The first priority of Grady, like the entire U.S. health care system, is to make a buck. The so-called health care industry is not interested in providing health care; rather, its interested in turning a profit.

Grady has provided the immigrants denied dialysis treatment through the closure of the hospital’s clinic with bridge coverage at a private dialysis center for 3 months. However, the undocumented workers are on their own after that time. Without dialysis treatment, they will die — but Grady will have saved some money.

(See a couple of prior posts on immigrant health care and denial of insurance to undocumented workers.)

According to reports last month, 49 million people in the United States live in hunger. The U.S. Department of Agriculture tracks “food insecurity,” and this number of people falling into this category is the highest since the feds starting keeping tabs on it in 1995. With the unemployment rate rising above 10%, millions of workers have been laid off or let go. Unemployed workers, African Americans, Latinos, and women are the hardest hit by hunger and its consequences.

Skipping meals, cutting back on portion sizes, and otherwise finding ways to decrease food intake is a daily ritual for millions in the United States. The report estimated that nearly a third of the 49 million people suffering from hunger are in this category. The other two-thirds finds food through visiting food pantries, soup kitchens, or using food stamps.

The health consequences of poor nutrition are myriad. The more immediate sequelae result from vitamin and mineral deficiencies: hyponatremia (pathologically low sodium), anemia, thyroid goiters and hypothyroidism, night blindness, Beri-Beri, pellagra, scurvy, ricketts, and a number of more long-term ailments such as  osteoporosis, hypertension, and nervous disorders.

In the long-term, chronic malnutrition leads to lower energy and fatigue, preventing affected people from acting effectively on their behalf. Chronic malnutrition weakens the body’s immune system, leading to increase infectious disease among the malnourished.

Those hardest hit by hunger are unemployed workers, women and their families, and racial and ethnic minorities. The report found that problems gaining access to food were highest in households with children headed by single mothers, with nearly three times as many such households reporting some food “insecurity” than married households. In both African-American and Latino households, hunger was more than twice as prevalent as in white households.

What this recent report makes clear is that these health inequities, which affects billions of people around the world, also affect millions in the United States. And, once again, African-Americans, Latinos, and working people suffer the most.

We’re currently in a heated debate about the pros and cons of conducting breast cancer screening with mammography in women aged 40 to 49. This debate is raging in the wake of the United States Preventive Services Task Force (USPSTF) announcement of new guidelines on mammography. The USPSTF does not recommend such screening in women less than 50 years old without their informed consent with respect to the potential harm of such screening.

Some African-American organizations, such as the National Medical Association, have come out in favor of continuing to recommend mammography for African-American women 40-49 years old. They argue that because African-American women are at higher risk of dying from the disease, it’s appropriate to do massive screening of the population.

This past spring, I wrote a blog post on the detrimental effects of prostate cancer screening, and what I said then is relevant to the current debate on breast cancer screening. After discussing recent studies that show the harm caused by broad prostate cancer screening, I took up the argument that — because African Americans suffer more disproportionately from the disease — screening is appropriate in that population. “However,” I said, “some would argue that the situation is different for African-American men. The burden of this disease does not fall evenly across the population. African Americans get it more often. African Americans get it at a younger age. African Americans die from the disease in disproportionately high numbers. The problem for African-American men, this argument goes, is not overdiagnosis and overtreatment of prostate cancer, but rather its underdiagnosis and undertreatment.”

“That’s a straw-dog argument. It really highlights the fact that African Americans have poor access to health care; however, it doesn’t assess the effect of screening on African-American men. If you look at the United States, out of 100 men, 20 will develop prostate cancer in their lifetime. Of that 20, three will die from their prostate cancer. Among African-American men, five of 20 will die from their prostate cancer. Although we can’t tell our patient with prostate cancer sitting in the exam room in front of us whether he will die from the disease, it’s clear that most men with prostate cancer won’t die from it. PSA testing, therefore, leads to finding and treating clinically insignificant cancers — for both whites and African Americans.”

Overdiagnosis is not just limited to prostate cancer in men. Mammography detects breast cancer in women who would otherwise have lived their lives never knowing that they had breast cancer.

Overdiagnosis is a different problem than getting falsely positive results. As noted by the USPSTF, nearly 2,000 women need to be regularly screened over the course of 10 years to prevent one woman from dying from breast cancer. However, during that same period, 10 healthy women will be falsely identified as breast cancer patients and treated unnecessarily. These women are harmed by a false-positive mammography.

With overdiagnosis, patients are correctly told they have breast cancer and are subsequently treated; however, if they hadn’t had the mammography, they would have lived the rest of their lives unaware that they ever had breast cancer. One third of women between the ages of 40 years and 54 years who die from other causes have breast cancer found on autopsy. In countries with massive breast cancer screening programs, approximately 1 in 3 women will be diagnosed with breast cancer that, had they not been screened, would not have affected them.1

What does it mean to say that overdiagnosis of breast cancer occurs 1 in 3 women? For every 1000 women over 50 screened for breast cancer with annual mammograms for 10 years: 1 woman will avoid dying from breast cancer; 2 to 10 women will be overdiagnosed and unnecessarily treated; 10 to 15 women will find out they have breast cancer but it won’t affect their disease course; and 100 to 500 women will have at least one false-positive finding, with about half of these women receiving biopsies.

As with prostate cancer screening in men, the most prudent thing for clinicians to do is to help our female patients make an informed medical choice regarding breast cancer screening. We should give them the facts regarding the modest benefit of breast cancer screening today versus the harm of overdiagnosis and overtreatment of this disease and let our patients make the choice to be screened or not. This approach is as true for African-American women as it is for others.

1. Welch HG. Overdiagnosis and mammography screening. BMJ 2009;339:b1425)

In a study reported earlier this fall,(1) Ian Gregory examined the geographical relation between mortality and deprivation in England and Wales at the start of the 20th and 21st centuries. He used census data from 1900 and 2001 to compare mortality rates while evaluating the association of those deaths with deprivation. This researcher was investigating whether the well-known relation between economic deprivation and death showed any significant changes over an entire century. It didn’t — a damning expose of the myth of medical triumphalism.

Gregory calculated standardized mortality ratios for all census districts for both periods. He used the Carstairs Index, a measure of deprivation, to compare deprivation in these districts in the early 1900s and 2001. He had data on 614 districts and was able to calculate correlation statistics between the deprivation scores and SMRs in the 1900s and 2001.

What did he find? No significant difference in the relationship between deprivation and death between the start and the finish of the 20th Century. At the start of the 21st Century, populations with the highest deprivation scores — working people and oppressed minorities — have the highest death rates. It’s the same pattern that obtained at the beginning of the 20th Century.

Western medicine and health care delivery has changed dramatically over the course of the last century. Huge social, economic, and political changes also have taken place. Yet, one essential fact remains: social inequity continues to exist, and this social inequity is the root cause of health inequities like the increased death rates among working people and racial and ethnic minorities.

(1) Ian N Gregory
Comparisons between geographies of mortality and deprivation from the 1900s and 2001: spatial analysis of census and mortality statistics
BMJ 2009;339:b3454, doi: 10.1136/bmj.b3454 (Published 10 September 2009)

Nancy Pelosi and other Democratic leaders announce their health legislation this past summer.

This morning, the pundits are hailing last night’s passage of the “Affordable Health Care for America Act” (see http://tinyurl.com/qyajn9 for summary) by the U.S. House of Representatives. However, the House health care bill marks no great advance toward providing quality health care services to working people in this country.

The legislation, if enacted, mandates individuals to purchase insurance. This provision will create millions of new customers for the insurance industry and generate billions of dollars in profits. (http://tinyurl.com/lyrj3q) Individuals and small employers will purchase insurance through a “health insurance exchange,” in which some insurance companies will participate and the government will provide a public insurance option. Individuals may qualify for a government subsidy to help pay their insurance premiums, and Medicaid will be expanded to cover more people. Some small employers will be allowed to opt out of providing health insurance plans to their employees, and others will be eligible for a government subsidy.

The mandate requiring individuals to purchase health insurance will be a hardship for many. The government subsidies will be adjusted so that individuals will pay anywhere from 1.5% to 12% of their income as health insurance premiums. The penalty for not purchasing health insurance is that you must then pay 2.5% of your income into the plan. Those under age 65 with annual incomes below $18,700 for a couple or $9,350 for an individual will be exempted from the mandate, which means (in today’s economy) millions will be uncovered by this insurance plan. As the lowest-paid workers, African Americans and Latinos will be the hardest hit by these provisions. Undocumented workers, who disproportionately lack health insurance, would be denied access to the so-called public option in this plan, and they would be ineligible for subsidies to pay for private health insurance.

The supposed benefits of the legislation are meager at best. Millions of people will remain uninsured. The touted reform to eliminate pre-existing health conditions as an excuse to deny health insurance coverage provides insurance for these people; however, it requires those with chronic health problems to pay higher premiums. The bill calls for developing a “high-risk” pool of those with pre-existing medical conditions, whose premiums will be set at 125% of the prevailing rate. The so-called public option calls for a government insurance plan that would compete with all private insurance companies in the exchange. The public plan will pay providers at least the Medicare rates; however, providers may opt out of the plan.

So, this health insurance reform bill will leave millions still uninsured, exact huge cuts on individual workers’ incomes through mandatory insurance premiums, generate huge profits for the insurance industry through enrollment of millions of new customers and higher premiums for “high-risk” clients, deny coverage to undocumented workers, and continue to deny federal money to women seeking to exercise their legal right to an abortion.

What’s to celebrate? As I see it, it’s no exaggeration to say that this bill condemns tens of thousands of people — disproportionately Black and Latino — to death. Rather than a sweeping reform of the U.S. health care system, it’s a reform of health insurance that funnels billions of dollars into that industry while leaving millions of working people with inadequate or no insurance.

What would happen if African Americans, Latinos, and Asian Americans had the same health outcomes as whites? Not only would we be spared the pain and suffering of the unequal burden of disease we bear, but we’d save billions of dollars each year.

In a recent study published by the Joint Center for Political and Economic Studies, Thomas LaVeist et al estimate that the combined costs of health inequalities and premature death in the United States between 2003 and 2006 were $1.24 trillion. Direct medical care expenditures during this 4-year period could have been reduced by $229.4 billion if racial and ethnic health inequities had been eliminated.

LaVeist and his colleagues used data from the Medical Expenditure Panel Survey (MEPS)[1] for the years 2002-2006 to develop a model to estimate health care costs for African Americans, Latinos, Asian Americans, and whites. They then re-estimated the model, assuming that each racial and ethnic category had the same health status — and, therefore, the same health care expenditures as that of the group with the best health status (usually the whites). The difference in two models represents the potential direct medical savings if all racial and ethnic groups had equal health status and outcomes. The savings in direct medical care costs totaled $229.4 billion.

To estimate the savings in indirect costs, these researchers used the MEPS data to estimate the days of work lost by adults owing to disability or illness. Then, they re-estimated the days of work lost with the racial and ethnic health inequities eliminated. The total savings came to $50.3 billion.

The researchers also estimated the costs secondary to premature death. Using data from the National Vital Statistics Reports,[2] they estimated the number of deaths by racial and ethnic category. Then, they estimated the number of deaths by racial and ethnic category if each category had the same health status as whites. This calculation gave them the number of excess deaths owing to racial health disparities. They used a very conservative estimate of $50,000 for each year of life lost to estimate the costs of premature death secondary to racial and ethnic health inequities, which was $957.5 billion.

You’d think that saving $1.24 trillion in health care costs would be important; however, no serious moves are being made to eliminate the health inequities responsible for these costs. Why don’t these excess costs motivate those who run the U.S. health care to do something to eliminate racial and ethnic health inequities?

Well, who bears these costs? Direct medical expenditures come out of the pockets of the patients, third-party payers, and some employers. LaVeist et al estimate that African Americans, Latinos, and Asian Americans paid nearly 31% of the excess direct medical costs out of our own pockets. While we consider that a loss, the barons of the health care industry consider that revenue. Excess costs for us equal profits for them.

What about the indirect costs of health inequities? Surely, they care about lost days of work? Employers tend to be very provincial in their thinking. They care about their employees’ missed days of work; however, if a worker at another shop misses work, that’s his or her employers’ problem.

Besides, 95% of the indirect costs of health inequities ($957.5 billion) were owing to the costs of premature deaths. From the perspective of employers as a class, African-American, Latino, and Asian-American workers are expendable. They can be easily replaced with others.

Those of us concerned with the premature loss of life, increased burden of disease, and increased health care costs endured by African Americans, Latinos, Asian Americans, and working people in general need to stand up and demand social justice. It’s the necessary precondition for eliminating racial and ethnic health inequity.

[1] Cohen JW, Monheit AC, Beauregard KM, et al. 1996/1997. “The Medical Expenditure Panel Survey: A National Health Information Resource.” Inquiry 33:373-389

[2] Heron MP, Hoyert DL, Murphy SL, et al. 2009. “Deaths: Final Data for 2006.” National Vital Statistics Reports 57(14). Hyattsville, MD: National Center for Health Statistics.

My son, 19, has “pre-existing health conditions” that will make it difficult for him to get health insurance when he’s forced to get it on his own at age 24. If the proposed changes in insurance regulations goes into effect, he’ll be able to get coverage. That’s great for him, and his parents are relieved. However, for millions of others in this country, the proposed changes in health insurance guarantees that they will live sicker and die younger than they should.

Last night, President Obama spoke for 45-minutes before the entire Congress and the country, cajoling us to support his proposed health insurance plan. Claiming to give us the details regarding his insurance plan, President Obama outlined points already known about his proposal. In a surprise to some, he continued to voice support for a so-called public option.

The President proposes an insurance exchange or pool to which employers and other payers would go and shop among competing health insurance providers. Insurance companies would have new restrictions placed upon them. They would not be allowed to deny coverage to people with “pre-existing health conditions,” nor would they be allowed to drop anyone’s coverage once they get sick. In some of the health insurance plans being discussed on Capitol Hill, there would be a cap placed on customers’ out-of-pocket medical costs.

I’m all for being treated more favorably by the insurance companies. However, being treated more favorably doesn’t mean that one is being treated fairly or equally.

The insurance industry has agreed to the proposed new restrictions on them not out of the goodness of their hearts. Rather, they do so because they will make billions of dollars in new profits. The proposed health insurance plans being discussed in Congress and pushed by the White House would be a boondoggle for the insurance industry. They would get millions of new customers because of the proposal to force people to buy health insurance. The federal government will provide subsidies to help people buy this insurance, thus transferring billions of dollars from the federal government into the coffers of the private insurers.

For those people who can’t get or can’t afford health insurance through an employer, President Obama proposes a public insurance option. Most people wouldn’t have access to this public health insurance. As President Obama noted in his speech, “I have no interest in putting the insurance companies out of business.” Too bad.

Instead, President Obama’s plan calls for  “making a not-for-profit public option available in the insurance exchange.” He was quick to add, ” Let me be clear – it would only be an option for those who don’t have insurance.” At most, it would be available for only about 5% of the country’s population.

The result will be that millions of people will remain uninsured. Undocumented workers are expressly excluded from coverage under the public option. “There are also those who claim that our reform effort will insure illegal immigrants,” said Obama. “This, too, is false – the reforms I’m proposing would not apply to those who are here illegally.” Millions of workers will suffer as a result of this refusal to provide health care. Thousands will die.

The so-called health care reform being bandied about in Congress amounts to some tweaking of health care insurance and is designed to ensure the continued profits of the insurance, pharmaceutical, and health care industries. The health care industry is all about making profit, not providing health care. Let’s take the profit out of it. Let’s revolutionize health care by providing it to everyone through a nationalized, government-run health care system.

Tomorrow, September 2nd, the American Medical Association’s Commission to End Health Care Disparities will meet in El Paso, Texas. Both Dr. Willarda Edwards, President of the National Medical Association, and Dr. Elena Rios, President of the National Hispanic Medical Association, will address the meeting. Having the conference take place in a U.S.-Mexico border town will highlight the health inequities suffered by the majority Latino population living in the border area.

According to the United States-Mexico Border Health Commission, there are some 12 million people living in the 32 border counties on the U.S.-Mexico border, running from San Diego County, California to Cameron County, Texas. Latinos comprise a little more than 52% of the population in this region. Three of the ten poorest counties in the United States are located in the border area, and twenty-one of these counties have been designated as economically distressed areas. Meanwhile, two of the ten fastest-growing metropolitan areas in the country — Laredo and McAllen — are located on the Texas-Mexico border. (McAllen recently made headlines when a study found it to be the most expensive health care market in the United States.)

High rates of unemployment and under-employment, high poverty rates, and lack of health care insurance underlie the huge disparities in the health status of this population. Will the AMA commission step up to the plate and demand health insurance coverage for everyone in the border counties? I doubt it. They likely will rail against the deplorable health conditions along the border; yet, speak out against providing health insurance for undocumented workers — so-called illegal immigrants.

Health care is a human right, and all people — documented and undocumented — deserve it. We can’t begin to seriously address health disparities along the border without providing access to health care to undocumented workers.