Oliver’s Twist

Hurricane's victims seek shelter in Superdome

This Saturday marks the fourth anniversary of the day Hurricane Katrina slammed into the Gulf Coast. The people of New Orleans, particularly the poor and African-American communities, suffered disproportionately from the hurricane’s effects, living in the least-protected areas and lacking the resources to flee the storm’s onslaught. The lackadaisical response of the federal, state, and local governments to the necessity of robust rescue efforts compounded the hurricane’s damage.

The health status of people in Louisiana — one of the least healthy states in the country prior to Hurricane Katrina — has deteriorated even more over the last 4 years. Pre-Katrina, approximately 21% (900,000 individuals) of Louisiana residents were without health coverage. In New Orleans, individuals without health coverage typically received care at either Charity Hospital or University Hospital, which are a part of the Louisiana State University health system.

In 2004, approximately 75% of patients treated at Charity Hospital were African American and approximately 85% had an annual income of less than $20,000. (The federal poverty rate is $22,000 a year for a family of four.) Charity Hospital also was the area’s primary provider of substance abuse treatment, psychiatric care, and HIV/AIDS treatment. Pre-Katrina, Charity Hospital was faced with limited financial capacity, due in part to budget cutbacks by local governments and a high percentage of uncompensated care.

The weakened Charity Hospital was finished off by Katrina. Its doors remain closed today, and a hospital that was once a safety net for Blacks, poor, and uninsured patients is now an empty building surrounded by wire fence.

Not that health problems in New Orleans have abated. According to The Economist of May 16, 2009, some two-thirds of New Orleans residents report having a chronic health problem, which is a 46% rise since 2006. Mental health issues are a particular problem. The percentage of people with depression has tripled since 2006, and the suicide rate has doubled since 2005.

While the federal government has poured more than a trillion dollars into the coffers of the banks, insurance companies like AIG, and the auto industry, only about $400 million federal dollars have been directed specifically towards restoring health services, including mental health initiatives, in New Orleans. The most commonly noted barrier to providing mental health services is a lack of mental health providers, and the most commonly cited barriers to receiving mental health care for children include a lack of transportation and competing family priorities (including housing, employment, and other financial concerns).

Almost a fifth of New Orleans households live below the federal poverty line. Less than half of New Orleans’s public transport facilities have been restored. Some 12,000 people are still homeless.

What New Orleans, and the other communities hit by Hurricane Katrina, needs is a massive public works program to rebuild transportation, housing, schools, and the health care system. The paltry effort being mounted by the federal government and a few foundations is a band-aid on a festering wound that needs radical treatment. The lives of tens of thousands depend upon such action. We need to demand that the federal government provide massive relief. The poor and minority communities of the Gulf Coast deserve it far more than the Wall Street financiers.

Health inequities abound in this country. I’ve used this site to speak out against the health inequities inflicted upon African Americans, Latinos, and other people of color; however, I’ve tried to make it clear here (and in other writing) that it’s not only victims of racial discrimination who suffer from health disparities but working people in general who bear an unequal burden of sickness and death.

Nowhere is this fact more clear than among workers and working farmers in rural America. Take the coalfields of far southwestern Virginia, for example. Whereas the death rate in the state is 780/100,000, the rate in southwestern Virginia is more than 1,200/100,000. About 203/100,000 Virginians die of heart disease each year compared with about 340/100,000 in the Virginia coalfields. It’s the same with cancer deaths: statewide, 185/100,000 people die from solid tumor cancers; whereas in the state’s southwestern coalfields, some 260/100,000 die from those cancers.

The psychological distress and dis-ease of this population is also high. Virginia’s overall suicide rate is 11/100,000, whereas in the coalfields it’s double at 22/100,000. Substance abuse, particularly prescription drug addiction, is rampant in southwestern Virginia, which takes its toll in human suffering and death. Fatal drug overdoses in the state occur at a rate of 8/100,000; however, in far southwestern Virginia, the rate is 40/100,000.

As noted in earlier posts, social inequities underlie these health inequities. Nearly 10% of Virginians live below the federal poverty line; 20% of people in Virginia’s coalfields live below this poverty line. The per capita income of people in far southwestern Virginia is about 58% of the per capita income of the state’s population.

Working people in the coalfields of Virginia lack access to health care — both because of a scarcity of available physicians and health care facilities and owing to the high number of people lacking health insurance. Some 20% of people in southwestern Virginia are uninsured compared with about 13% statewide.

Until these social inequities are resolved, health inequities will continue to plague the coalfields of southwestern Virginia and the rest of rural America. A national, single-payer health plan would go a long way toward decreasing the disparities.

(Statistics on southwestern Virginia obtained from the Healthy Appalachia Institute. www.healthyappalachia.org)

Percent of people uninsured (Family Core, NHIS 2008)

The health care reform package being crafted by the U.S. Congress and President Obama will deny insurance coverage for millions of immigrant workers. The August 11th Chicago Tribune reports that House Speaker Nancy Pelosi “emphasized that illegal immigrants would not be covered under the current proposals.” Workers, including those without legal documentation, have no voice in the U.S. Congress. The same Tribune article notes that the Congressional Hispanic Caucus has called for insurance coverage “only for ‘legal, law-abiding’ immigrants who pay their ‘fair share’ for health care.”

One in three Latinos and one in five African Americans lack insurance, compared with one in eight whites. (See graph.) This situation is getting worse in the current economic crisis. Blacks and Latinos are the last to be hired and the first to be fired. As unemployment among African Americans and Latinos increases, so too will the number of uninsured or underinsured in those populations.

Health care is a human right. Undocumented workers deserve health care. This is not just a moral issue; it’s a matter of life and death. Those who lack health insurance lack access to health care. As a result they are sicker, die younger, and die in disproportionately higher numbers than those who do have insurance. This health inequity falls upon working-class and minority populations.

President Obama and the Congress are cobbling together a health care plan that will kill hundreds of thousands of Latino workers. It’s a crime, and we need to speak out against it.

Are white physicians racist? The vast majority of them are not. Do white physicians hold unconscious biases against African Americans and Latinos? The overwhelming majority of them do. When less than 6% of physicians are African American or Latino, this fact has a big impact. Unconscious racial stereotyping and bias contributes to the health inequities suffered by African-American and Latino populations. A recent CNN story brought this issue into the public light again.

Physicians racial biases affect their clinical decision-making. In a landmark study by Schulman et al, African-American patients were less likely than whites to receive life-saving therapy for a heart attack — although everything about the patients’ presentation was the same except for the color of their skin. Schulman argued that racial bias against African Americans must be the reason for the disparity in the proposed therapy. Schulman’s finding has been replicated numerous times in the last 10 years. Each time, the researchers find that presumed racial bias affects the physicians’ clinic decisions, resulting in poorer quality care for African Americans. Each time, however, the researchers make no objective measurement of the racial bias.

In 2007, this changed. A study conducted by Green et al replicated the Schulman findings, showing that a group of emergency medicine and internal medicine physicians were more likely to recommend life-saving medical therapy for heart attack patients if they were white. However, Green et al used a psychometric instrument called the implicit association test (IAT) to measure unconscious racial bias in their study subjects. They objectively demonstrated that racial bias was associated with the preferential treatment of the white patients.

The Web-based IAT is a well validated tool that has been used in more than 400 studies and in more than 10 million subjects. Go to the Project Implicit website and check it out yourself.

Brian Nosek, PhD, an Associate Professor in the Department of Psychology at the University of Virginia and the Director of Project Implicit, and colleagues have a paper in the upcoming August 2009 issue of the Journal of Health Care for the Poor and Underserved that evaluates the unconscious racial biases of physicians.

When I asked Dr. Nosek about physicians’ racial biases, he noted that “Implicit biases are pervasive and have been linked to important behaviors, including treatment decisions by health care providers.” In discussing his recent study in the Journal of Health Care for the Poor and Underserved, Nosek said “we found that – in terms of implicit racial biases – medical doctors are much like the rest of us.  We measured more than 2,500 MDs and their implicit preference for White people over Black people was similar in magnitude to JDs, PhDs, and people without advanced degrees.”

Yesterday, President Barack Obama announced his nomination of Regina Benjamin, M.D., as U.S. Surgeon General. Benjamin founded a rural health clinic in Bayou La Batre, AL, a Gulf coast town of 2,500 people where, according to the Washington Post, 40 percent of the population has no health insurance. “Stories abound,” report Post writers Alexi Mostrous and Michael D. Shear, “of Benjamin making house calls in a muddy Toyota pickup, and accepting buckets of shrimp from patients too poor to pay cash.”

Benjamin said “My father died with diabetes and hypertension. My older brother died at age 44 of HIV-related illness. My mother died of lung cancer because as a young girl she wanted to smoke, just like her twin brother could. My family’s not here with me today, at least not in person, because of preventable diseases. While I can’t change my family’s past, I can be a voice in the movement to improve our nation’s health care and our nation’s health for the future.”

The Surgeon General’s position is a bully pulpit for issuing crucial public health messages. Let’s hope that Dr. Benjamin uses the post to campaign for providing comprehensive health care for rural and minority populations, who lack access to decent health care today. Dr. Benjamin’s appointment, if confirmed by the U.S. Senate, could highlight the issue of health care inequities, which is sorely missing from the current debate on health care reform. What we need is an advocate for minorities and rural folk, not another defender of privatized health care — albeit one who has a moral center. My fear, however, is that President Obama plans are limited only to using her as an “anti-lobby” against those opposed to his so-called health care reforms.

The Wall Street Journal, New York Times, and Washington Post all report today that negotiators for the hospital industry struck a deal with the White House, agreeing to some $155 billion dollars in cuts over the next 10 years. The cuts will come mostly through decreased Medicare and Medicaid payments to hospitals.  The Journal article also reports on a deal in the making with health insurance companies in which that industry agrees to at least $100 billion in cuts over 10 years.

These deals come in the wake of a similar pact between the pharmaceutical industry and the White House for $80 billion in cuts over that same 10-year time period. These supposed savings total to the more than $300 billion in “savings” that President Obama claims will pay for the proposed health care reform package.

These deals are shams. They are supposed acts of “good faith” on the part of the entities that reap profits from health care delivery, demonstrating their acceptance of “shared responsibility” in paying for whatever health care reform package gets cooked up by Obama and the Congress.

I say it’s a sham because they don’t wind up giving up anything! Only individual patients wind up paying. Here’s how this shell game works: Hospitals, drug companies, and the insurance industry agree to $300 billion in “cuts” over 10 years. However, they make it all back through the addition of 40 million newly insured patients. (One of the reasons for the phased-in cuts over 10 years is so that the addition of newly insured patients outstrips the “losses” in Medicare and Medicaid dollars.) The federal government agrees to help subsidize any individual who can’t afford to buy private insurance, and, for those who still can’t afford it, the government-sponsored insurance plan agrees to pay out at a higher rate than Medicare and Medicaid. Hospitals, pharmaceutical companies, and insurance firms make out like bandits.

Patients…well, they don’t do so well. They wind up paying out of their own pockets directly to health care profiteers or indirectly, through taxation, their dollars end up in the coffers of the hospitals, pharmaceuticals, and insurers. The “shared responsibility” isn’t shared at all. The profit-makers in health care are guaranteed a profit, and patients are guaranteed to pay.

This burden will fall heaviest upon those who can least afford it — working people, racial and ethnic minorities, the unemployed, rural populations, and other disadvantaged communities. All the talk about how everyone is pitching in and making a sacrifice is a bunch of hooey aimed at keeping patients quiet when the government and the health care industry puts the screws to them.

The health insurance industry, pharmaceutical companies, and physician job-trusts are spending millions to influence the health care reform package being cobbled together in Washington, D.C. The July 6 Washington Post reports that these groups have hired more than 350 former government staff members and retired members of Congress to lobby key congressional committees and legislators. The Post estimates that the health care industry is spending $1.4 million a day to lobby Congress on the health care reform package. The paper reports that “the Pharmaceutical Research and Manufacturers of America (PhRMA) doubled its spending to nearly $7 million in the first quarter of 2009, followed by Pfizer, with more than $6 million.”

The lobbying effort has had its effect. Clearly the owners of these industries want to minimize their costs in any reform of the health care system while maximizing their access to some 46 million uninsured potentially new customers. The two main health care reform bills being discussed in the Senate’s Finance Committee and the Health, Education, Labor and Pensions Committee both ensure increased access to the uninsured while limiting the costs to the insurance industry — for example, by providing government subsidies to individuals to pay for private insurance.

Minority communities have no real voice in this discussion. The needs of African Americans, Latinos, and other racial and ethnic minorities will be ignored as Congress forges its health care package.

Today’s New York Times reports on a poll it conducted with CBS News on support for government-run health insurance plan — something akin to Medicare for those aged 65 years or younger. The national telephone survey found that 72% of those polled support such a plan. The survey revealed that the majority of people would be willing to pay higher taxes in order to provide health insurance for everyone.

Although the poll did not ask whether people support a single-payer health care system (in which only a government-run health insurance plan would be in effect), it clearly shows widespread support to the idea that the federal government would do a better job running the health care system than private industry. As one poll respondent said in a follow-up interview, “Even though [clinical services] might not be quite as good as what we get now,” he said, “I think the government should run health care. Far too many people are being denied now, and costs would be lower.”

African Americans and Latinos are disproportionately represented in the ranks of the underinsured and uninsured. This fact leads to huge barriers blocking access to needed health care and the resulting health inequities that plague these communities.  A national health insurance plan administered by the federal government, therefore, would help reduce racial and ethnic health disparities.

Atul Gawande, MD

I’m often at odds with Atul Gawande’s views on health care reform in the United States. I’m a staunch supporter of a single-payer, government-run, national health care plan; he supports a market-based system. However, of late, Dr. Gawande has been speaking out in support of the accountable care organization concept pushed by the Dartmouth Institute for Health Policy and Clinical Practice. To the extent that such organizations strive to deliver low-cost, high-quality health care to the communities they serve, Gawande, the Dartmouth Institute, and I are all on the same page. (I go further and say that we need such organization on a national scale. All health care providers would be organized into such teams in a national health care plan, rather than voluntarily doing it as smaller, market-based units.)

In his recent New Yorker magazine article, Dr. Gawande tells a vivid and moving story about the reasons for the high cost of medical care by focusing on McAllen, Texas, which is a border town with one of the most expensive health care markets in United States. It’s a must-read article.

I also think you should read Maggie Mahar’s June 12th post in her blog, Health Beat. In this posting, she prints excerpts from Dr. Gawande’s address to the graduating class at the University of Chicago’s Pritzker School of Medicine. Evidence-based practice, which we emphasize in the training of our family medicine residents here at UVa, results in high-quality, low-cost care. I also believe it leads to more equal care because it mitigates the influence of implicit racial bias and stereotyping.

AP Photo/Mary Ann Chastain

President Obama told the delegates and other attendees today at the annual meeting of the American Medical Association that he supports a market-based national health plan in which the federal government offers an insurance plan that competes with private insurers. As he said earlier in the week in a speech in Green Bay, Wisconsin, Obama feels a government-run insurance option is necessary “because if the private insurance companies have to compete with a public option, it will keep them honest and help keep prices down.”

Such a plan — predicated on defending the profits of the insurance industry — will fail to provide high-quality health care to all, and it will do little to reduce or eliminate racial and ethnic health disparities. The profit interests of the insurance industry will continue to drive what services are provided and to whom, rather than the health needs of the insured. At best, a government insurance plan that is just one among many insurers in an insurance-exchange market will act only to force a de facto cap on profits.

Instead, we need a government-run, single-payer health plan that distributes funding based on the health needs of the population. Because the funding would derive from a single source, administrative costs would be vastly reduced. A single-payer could demand medications at cost and enforce provision of proven therapies and interventions, thus helping to ensure provision of high-quality care to all. In such a manner, racial and ethnic health inequities would be reduced.

Health care is a public good, a human right to be shared by all — not a commodity to be sold at a profit.

That’s my two cents on President Obama’s AMA speech. What do you think?