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03/26/2020

Daniel Dawes Discusses His Just-Published, "The Political Determinants of Health" (March 25th)

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It is altogether appropriate to discuss the political determinants of health since this past Monday we marked the ten year anniversary of the Affordable Care Act (ACA).   The law was intended, in part, to reduce health inequities.  Research published earlier this month in Health Affairs concluded, “the ACA produced broad gains in insurance coverage,” and “that coverage increased most among groups whose members were mostly likely uninsured before the reforms,” i.e., racial and ethnic minority groups.   We would do well to remember the 19th century German physician Rudolph Virchow whom argued, we should think of medicine as a social science - meaning medical care requires collective action to address social inequality’s contribution to ill health.  (Concerning social inequities, I encourage listeners will to listen to my March 10th conversation with the Center for Budget and Policy Priorities' Mr. Joseph Llobrera regarding the administration's treatment of SNAP.)

During this 33 minute conversation, Daniel Dawes begins by providing historical context, i.e., early efforts in our nation's history to address population health and health inequities, e.g., creation of the (short lived) Freeman's Bureau in 1864.  He identifies and discusses three over-arching political determinants of health, possible reasons why the ACA (and again its health inequity provisions) have been so polarizing and current progress in political determinants addressing inequities, e.g., as related to the climate crisis.      

Mr. Daniel Dawes is the Director of the Morehouse School of Medicine’s Satcher Health Leadership Institute and Associate Lead for Government Relations.   Among previous Danieldawes-685x1024positions he founded and chaired the advocacy group, the National Working Group on Health Disparities and Health Reform and was the co-founder of the Health Equity Leadership and Exchange Network (HELEN).  He has worked to shape federal health equity policies including the Mental Health Parity Act, the Americans with Disabilities Act Amendments Act, the Genetic Information Nondiscrimination Act and the Affordable Care Act.  He is the author of the 2017 work, 150 Years of Obamacare.  He is an elected fellow of the New York Academy of Medicine and has served on several boards, commissions, and councils focused on improving health outcomes and elevating health equity in the United States.  He is an adviser to international, national, regional, state, and municipal policymakers, as well as think tanks, associations, foundations, corporations, and nonprofit organizations.  Mr. Dawes obtained his Juris Doctorate from the University of Nebraska. 

For more information on The Political Determinants of Health go to: https://jhupbooks.press.jhu.edu/title/political-determinants-health

03/25/2020

Dr. Dan Blazer Discusses the National Academy of Sciences Just-Published, "Social Isolation and Loneliness in Adults: Opportunities for the Health Care System (March 24th)

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Increasing social isolation and loneliness have been recognized for several decades.  The issues was the topic of Harvard’s Robert Putnam’s much publicized research three decades ago, i.e., his 2000 publication "Bowling Alone."   More recently, the Pope has observed “radical loneliness,” caused by a consumer culture is subverting social relationships.  In Japan, loneliness deaths among the elderly have become so common the Japanese have named the phenomenon, kodokushi (lonely death).  In the UK, former Prime Minister Theresa May in 2018 created the new cabinet position, Minister of Loneliness.   In the US, former US Surgeon General Vivek Murthy called loneliness a “growing health epidemic.”  

During this 32-minute conversation, Dr. Blazer begins by defining social isolation and loneliness or collectively social connections.  He then discusses the numerous associated adverse health effects including cardiovascular disease and dementia.  He discusses the current state of play regarding the extent to which the health care sector is addressing, social isolation in context of the ongoing COVID-19 pandemic, he notes several recommendations the report makes, discusses programming, and the scientific evidence for, that attempt to address these issues and potential problems associated with some of these interventions moreover use of technology.        

Dan G. Blazer II, M.D., M.P.H., Ph.D., is the J. P. Gibbons Professor of Psychiatry Emeritus and a professor of community and family medicine at Duke University as well as D014dac2e1-image_0770942adjunct professor in the Department of Epidemiology, School of Public Health, University of North Carolina.  He is the author or co-author of more than 180 books chapters, more than 220 published abstracts, and nearly 500 peer-reviewed articles.  He is also the editor or author of 40 books.  Many of the book chapters and scientific articles are on the topics of late life depression, epidemiology, consultation liaison psychiatry, the interface between religion and psychiatry, and the epidemiology of substance use disorders.  Most of his research projects have focused on the prevalence of physical and mental illness in the elderly.  He has served as the principal investigator (PI) of the Duke University Established Populations for Epidemiologic Studies of the Elderly, the Piedmont Health Survey of the Elderly, and the MacArthur Field Studies of Successful Aging.  He also was the original PI of the Duke Clinical Research Center for the Study of Depression in Late Life.  Dr. Blazer is an elected member of the National Academy of Medicine from which he received the Walsh McDermott Award for Distinguished Lifetime Service to the Academy.

The NAS report is at: https://www.nationalacademies.org/our-work/the-health-and-medical-dimensions-of-social-isolation-and-loneliness-in-older-adults.

03/11/2020

CBPP's Dr. Joseph Llobrera Discusses the Administration's Proposed Cuts to the Supplemental Nutrition Assistance Program (SNAP) (March 10th)

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Despite the fact the US is a net food exporter, the country suffers a significant food security problem (defined as uncertain of having or unable to acquire enough food).  Per the USDA, over 11% of Americans, or over 37 million(including 12 million children), are food insecure or worse.   In addition, the US ranks first among OECD countries in obesity, a primary indicator of a poor or low nutritional diet.  (Many Americans also suffer from "hidden hunger" or micro-nutrient deficiency.)  What explains this includes the fact 42% of American workers are paid $15 an hour or less – causing the US to have one of the highest poverty rates among developed/wealthy countries.   The US, unlike 158 other countries, is not a signatory to the 1966 International Covenant on Economic, Social and Cultural Rights which recognizes “the fundamental right of everyone to be free from hunger.”  In addition, health care ironically contributes to hunger in America.  If health care cost what it does, for example in Switzerland or 30% less per capita, median income growth over the past 30 years would have grown to twice what it is.  Phrased another way, medical expenses push millions of Americans below the poverty line, including 7 million who earn 150% of the poverty level.  (Devoted listeners may vaguely recall I interviewed the CBPP's Dr. Paul Van de Water in January 2013 regarding Medicare and Social Security reform.) 

During this 32-minute conversation Dr. Llobrera begins by providing an overview of the SNAP program and its benefits.  He then explains the Trump administration's proposed FY 2021 SNAP budget that would, like the administration's previously proposed budgets, cut SNAP spending by $182 billion over ten years, or by over 25%, he discusses administration regulatory reforms currently being implemented that will cut SNAP by $50 billion and remove approximately 4 million from the program, how or what rationale the administration uses to explain these budget cuts/program changes, the Congress's response to these policies and what the health care industry/health care providers are doing programmatically to address the reality that food is medicine.     

Dr. Joseph Llobrera is the Director of Research for the Food Assistance team at the Center on Budget and Policy Priorities (CBPP).   Previously, Dr. Llobrera served as Research Associate at Joseph-llobrera-500x500the Center between 2002 and 2007.   Before returning to the Center, he served as an Associate Director of Learning and Improvement at Insight Policy Research, providing technical assistance and training to federal, state, and local human service agencies that administer the Supplemental Nutrition Assistance Program and the Temporary Assistance for Needy Families program.  He also also employed as a researcher at IMPAQ International and the Urban Institute, focusing on food assistance policy, workforce development, and health policy.  Dr. Llobrera received his Ph.D. in Nutrition from the Friedman School of Nutrition Science and Policy at Tufts University, his master’s degree from the University of Washington (Seattle), and a bachelor’s degree in Mathematics and Urban Studies from Brown University.

The CBPP's February 18 memo providing an overview of the president's proposed 2021 SNAP budget is at: https://www.cbpp.org/research/food-assistance/presidents-2021-budget-would-cut-food-assistance-for-millions-and-radically

CBPP's November 2019 SNAP Chartbook is at: https://www.cbpp.org/research/food-assistance/chart-book-snap-helps-struggling-families-put-food-on-the-table

 

02/20/2020

Archway Health's Keely Macmillan Discusses Medicare Bundled Payment Performance (February 19th)

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CMS' efforts, via the Centers for Medicare and Medicaid Innovation (CMMI),  to develop episode-based bundled payment models in Medicare is now it its eight year.  This work is currently being pursued under the 2018-initiated Bundled Payments for Care Improvement (BPCI) Advanced (that succeeded the BPCI demo, begun in 2013, now concluded) and the Comprehensive Care for Joint Replacement (CJR) and the Oncology Care Model demonstrations, both began in 2016.   These models are designed to pay a specified or target price for a discrete episode of care, in CJR for a hip or knee replacement.   Assuming quality performance is met, if spending is below the target price the provider recoups the savings, if above the target they owe the difference.   Recent evaluations, discussed here, show these programs are on balance demonstrating savings, though modest, to the Medicare program.  Listeners may recall I interviewed Archway's Founder and CEO, Dave Terry two years ago this  month.     

During this 37 minute interview (lengthy but worth it), Ms. Macmillan begins by providing an overview of Archway Health.  She then discusses Archway's results to date regarding participation in BPCI Advanced relative to financial performance, quality and utilization - that she unpacks by discussing what accounts for savings, what quality is being measured and how measuring quality can be improved and steps CMS is taking to more accurately target price episode payments via peer groupings.  We discuss CMS' latest evaluation of the agency's CJR demonstration and other evaluation findings, participation by MA and commercial plans in episode based bundled payment arrangements, how best these demonstrations or models can be evolved, i.e., how better episode and population-based models can be better integrated, the inclusion of Part D spending, whether bundled payments should be made mandatory and what explains Archway's success in participating in these payment  models.      

Ms. Keely Macmillan is currently Senior Vice President of Policy and Solutions management at Archway Health where she oversees all aspects of Archway’s involvement CMS' Keely+MacmillanBundled Payments for Care Improvement (BPCI) Advanced demonstration.   She is an expert in alternative payment models including bundled payments and ACOs, value-based purchasing, and MACRA’s Quality Payment Program.  Previously, Ms. Macmillan was manager of government payment policy at Partners HealthCare, the largest health system in Massachusetts, where she managed public payer financial forecasting and led the government payment policy team in the analysis of performance-based reimbursement models.   Ms. Macmillan earned her master’s degree in Health Policy and Management from the Harvard T.H. Chan School of Public Health and a Bachelor of Science from Yale University.

Information on Archway Health is at: https://www.archwayhealth.com/.

Mentioned during this discussion:

CMS' January 2020 8-page overview of episode based bundled payment results to date is at: https://innovation.cms.gov/Files/reports/episode-payment-models-wp.pdf

The Lewin Group's second CJR evaluation published last June is at: https://innovation.cms.gov/Files/reports/cjr-secondannrpt.pdf.

Evaluations of BPCI published in the January issue of Health Affairs are by Amol Navathe, et al. and Rajender Agarwal, et al., are at: https://www.healthaffairs.org/toc/hlthaff/39/1 (subscription is required).

02/11/2020

Andrea Rodgers Discusses the Recent 9th Circuit Court Decision in Juliana v the US (February 10th)

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This past January 17 the 9th Circuit Court of Appeals ruled in Juliana v the US.   Filed in 2015 by 21 children and others, the plaintiffs argued health harm caused by the federal government’s long support or promotion of the fossil fuel industry violates their Constitutional right to life and liberty, i.e., their right to a survivable climate.  The plaintiffs argued further the court should redress this harm by issuing an injunction requiring the federal government  to prepare a plan for judicial review and approval that would draw down green house gas emissions.  In its defense the federal government argued there is no fundamental constitutional right to a stable climate system, or that the state of the climate has no connection to personal life and liberty.  The court ruled 2-1 in favor of the US government, arguing the plaintiffs complaint was not redressable or was nonjusticiable, despite admitting "climate change was occurring at an increasingly rapid pace," "will wreak havoc on the Earth if left unchecked" and "may hasten an environmental apocalypse."  The dissent argued the Constitution's perpetuity principle, that life and liberty is secured for both ourselves and posterity, does not "condone the Nation's willful destruction."  

During this 30 minute discussion, Ms. Rodgers begins by describing the physical and mental health harm experienced by the Juliana plaintiffs.  She notes organizations that contributed amicus briefs.  She explains the majority opinion's reasoning (authored by Justice Andrew Hurwitz) that ruled in favor of the defense and the minority opinion authored by Justice Josephine Staton.  She discusses media coverage of the case, related cases, moreover the December Urgenda decision by the Supreme Court of the Netherlands that ruled in favor of the plaintiffs, and the Juliana plaintiffs intent to appeal the January decision or petition the 9th Circuit Court for a rehearing en banc.   

Ms. Andrea Rodgers is Senior Litigator Attorney at Our Children’s Trust, an Oregon-based public interest law firm, that represents the Juliana plaintiffs.  In her role at Our Children's Trust she also is lead counsel on the constitutional youth climate lawsuits against the state of Washington, Aji v. State of Washington, and the state of Florida, Reynolds v. State of AndreaFlorida.  Previously, Ms. Rodgers served as an Honors Attorney for the U.S. Department of Transportation, In-House Legal Counsel for the Snoqualmie Indian Tribe, and Staff Attorney for the Western Environmental Law Center.  After graduation from the University of California, Santa Barbara in 1998 and the Arizona State University School of Law in 2001, where she served as co-executive editor of Jurimetrics: The Journal of Law, Science and Technology, she clerked for the Hon. John C. Gemmill on the Arizona Court of Appeals.  In 2016, Seattle Met Magazine recognized her legal work representing youth in the Washington climate change case in King County Superior Court against the Washington Department of Ecology (Foster v. Ecology).  

The 9th Circuit Court's January decision is at: http://cdn.ca9.uscourts.gov/datastore/opinions/2020/01/17/18-36082.pdf

For complete information on the Juliana case go to: https://www.ourchildrenstrust.org/juliana-v-us

Information on the Urgenda case decided this past December in the Netherlands is at: https://www.urgenda.nl/en/themas/climate-case/

01/22/2020

Am Entertaining Listeners' Questions (January 22nd)

Over the seven plus years I have produced this podcast, I've been asked numerous questions by listeners.  As a result, it has been suggested that I, more formally, solicit listeners' questions and program a podcast in which I attempt to answer them.  Okay, let's give this try.  If you have a question concerning any of the 190-plus podcasts to date or have a related or other health care policy question (the questions are, at least in theory, endless) , I will attempt to answer.  Please send your questions to me via: dmintr@gmail.com.  Assuming there are a sufficient number, I will organize and schedule a podcast in the near future to discuss.  In answering, I'll not note any names.  Thank you.       

01/20/2020

The US Court of Appeals Rules the Judiciary Cannot Prevent Irreparable Devastation to the Nation Posed by the Climate Crisis (January 20th)

Podcast listeners are likely aware I've conducted several, if not numerous, interviews over the past few years regarding the climate crisis or catastrophe, or as Astra Taylor terms it, our carboniferous capitalist economy.   

Late last week the US Court of Appeals, 9th Circuit, ruled 2-1 in dismissing the Juliana v. the US case.  (Re: background, there is a related Wiki page.)

I strongly encourage listeners to read the court's 32 page decision by Judge Hurwitz - and the equally long dissent by Justice Staton.  They are both at: http://cdn.ca9.uscourts.gov/datastore/opinions/2020/01/17/18-36082.pdf

Though the majority recognizes the existential threat the climate crisis poses, e.g., they open with "the record left little basis for denying that climate change was occurring . . . an will wreak havoc on the Earth's climate if unchecked" and that "the record conclusively established that the federal government has long understood the risk of fossil fuel use and increasing carbon dioxide emissions," the majority ostensibly argued the court cannot readdress the problem because the plaintiffs claim that the Constitution protects their right to a "climate system capable of sustaining human  life" is "non-justiciable," i.e., the court found the guarantee clause of the Constitution (that protects "life, liberty and the pursuit of happiness") "does not provide the basis for a justiciable claim."    Justice Staton argued, in part, "the Constitution does not condone the Nation's willful destruction."     

Plaintiffs' attorneys stated they will appeal. 

Listeners should also be aware last month the Supreme Court of the Netherlands, in a case similar to Juliana with 900 co-plaintiffs, ruled/ordered their government to cut the nation's carbon emissions by 25% from 1990 levels over five years.  The court based its Urgenda decision in part on human rights.  The decision is at: https://uitspraken.rechtspraak.nl/inziendocument?id=ECLI:NL:HR:2019:2006 (hit your "translate" button at the top right to read in English).  

There are currently an estimated 1,400 plus related climate lawsuits pending worldwide.  

01/14/2020

Dr. Peter Cram Discusses Health Care Delivery In Canada (January 13th)

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Considering the frequent favorable assessment of Canadian health care of late, by, for example, several presidential candidates and (surprisingly) the Trump administration via its recent decision to propose a regulatory pathway for US entities to import drugs from Canada, the question is begged how or how well do the Canadians deliver universal health care and at what expense.

During this 30-minute interview Dr. Cram begins by providing a general overview of population health in Canada.  He goes on to discuss moreover how care is organized and budgeted (or how spending is managed) in Canada, how care is designed (via an emphasis on primary care), the extent to which providers enjoy autonomy and patients suffer lengthy appointment/referral wait times and the prospects of Americans importing drugs from Canada.  

Dr. Peter Cram, an American citizen (a Connecticut native), is currently the Director Image of General Internal Medicine and Geriatrics at Sinai Health System and the University Health Network and Professor of Internal Medicine at the University of Toronto.  Previously, he was on faculty at the University of Iowa from 2002 to 2013.  Dr. Cram has published more than 180 research papers and is the co-founder of the International Health System Research Collaborative (IHSRC).  He earned his medical degree at the Wake Forest School of Medicine and completed his medical training at the University of Michigan.  

During this interview mention was made of Cram, et al., "Trade-Offs: Pros and Cons of Being a Doctor and Patient in Canada," it is at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400751/

01/10/2020

Andrea Freeman Discusses Her Just-Published Book, "Skimmed: Breastfeeding, Race and Injustice" (January 9th)

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Professor Andrea Freeman's recently published, Skimmed: Breastfeeding, Race and Injustice, explains how and why Non-Hispanic Black women are significantly less likely to breastfeed their newborn than White, Non-Hispanics and Hispanics.  Black, Non Hispanics are, instead, significantly more likely to feed their newborns formula milk.  That formula, manufactured by Pet, Mead Johnson, Abbott Labs, Nestle and others and consisting of corn syrup and among other ingredients enzymatically dydrolyzed soy protein isolate (Freeman terms junk food for babies) does not compare to breast milk (that consists of living human cells, active hormones, antibodies and hundreds of other unique components ideal for infant health) helps explains why Black infant (and maternal) mortality remains twice that of White, Non-Hispanics.  Why Black women use formula, Professor Freeman explains, is due to a myriad of reasons that include targeted Black marketing, Professor Freeman details Pet's use of the Fultz quadruplets (born in North Carolina in 1946), federal policies that support and endorse formula use by Black women and a web of other laws, polices and practices that obstruct the ability of Black women to initiate or sustain breastfeeding. 

During this 30 minute interview, Professor Freeman discusses Dr. Fred Klenner's contract with Pet to market the Fultz children and numerous other variables that explain why Black women are less likely to breastfeed.  Among others, she discusses the effect 350 years of slavery has played, stereotypes of Black women, formula milk industry motivations, federal policies that reinforce/subsidize these motivations, limited legislative and regulatory oversight and limited efforts by the medical profession to contain or prohibit marketing formula milk and encourage breastfeeding.

Andrea Freeman is an Associate Professor at the University of Hawaii's William Richardson School of Law.  She has also taught as a visiting professor at the University of California, Berkeley, School of Law, at the University of Denver Strum College of Law and has a Distinguished Scholar of Sustainable Agriculture and Food Systems at Vermont Law School. Freeman_AndreaBefore joining the faculty at the University of Hawaii, she taught at Santa Clara University School of Law, University of San Francisco School of Law, and California Western School of Law.  Professor Freeman is an active community member serving on the Litigation Committee of the ACLU Hawaii chapter.  She volunteers with the Kokua Hawaii Foundation, makes legal presentations to the Hawaii Judiciary History Center and Hawaii State Judiciary, and writes op eds on topics including Hawaiian sovereignty and race and health.  In 2015, Professor Freeman received the Community Faculty of the Year award from Richardson's Advocates for Public Interest Law.  Professor Freeman is the Chair of the AALS Section on Agriculture and Food Law and Treasurer of the AALS Section on Constitutional Law.  She is co-chair of the Law and Society Collaborative Research Network for Critical Race and the Law and a Founding Member of the Academy of Food Law and Policy.  After graduating from UC Berkeley School of Law, she clerked for Judge Jon O. Newman of the U.S. Court of Appeals for the Second Circuit and former chief Judge José A. Fusté of the U.S. District Court for the District of Puerto Rico.  Prior to attending law school, she worked in Toronto as a counselor for women and children who experienced domestic violence and in New York as a production manager in the independent film industry.   

Information on Skimmed is at: https://www.sup.org/books/title/?id=28151

The related CDC August 2019 Morbidity and Mortality Weekly Report (MMWR) report noted during this interview is at: https://www.cdc.gov/mmwr/volumes/68/wr/mm6834a3.htm

01/02/2020

Essay: MedPAC and MACPAC Have Never Discussed the Health Effects of the Climate Crisis (December 30th)

On December 30th, The Hill published my essay titled, "Agencies Need to Discuss Health Effects Caused by the Climate Crisis."  At: https://thehill.com/opinion/healthcare/476217-agencies-need-to-discuss-health-effects-caused-by-the-climate-crisis.  (I had titled the piece, "MedPAC and MACPAC's Historic Failure.")   As the essay or opinion piece notes neither commission has ever discussed, much less mentioned, the climate crisis despite the fact the health effects thereof will disproportionately affect the frail elderly and poor children, i.e., Medicare and Medicaid beneficiaries, or those whose health these agencies are suppose to protect.