Blasey Ford, Kavanaugh, bias and arrogance: present in medicine, not just politics

Mostly it is pretty easy for me to think of things I want to write about in the area of medicine and social justice; there is so much awful stuff going on there. But today it was harder; I want to write about the bravery of Christine Blasey Ford, and how powerful the calm, collected testimony that she gave was, especially given the fact that she had nothing to gain except harassment for herself and her family, and even death threats that required her to go into hiding.

I want to write about the atrocious behavior of Brett Kavanaugh, who has a lot to gain -- a lifetime appointment to the Supreme Court of the United States – but chose to take the low road, not just denying the charges but displaying aggrieved entitlement, snarling and attacking and refusing to give straight answers to straight questions. Right out of the Donald Trump playbook. And absolutely not the behavior we want on the Supreme Court, or even that we heard about his control in his current Appeals Court job. Much more, in fact, like the 17-year old Kavanaugh that Dr. Blasey Ford described.

I want to write about the tone-deaf but mission-focused hubris of the 11 white men who formed the majority on the Judiciary Committee. Ten of them having made up their minds in advance, they were not going to be derailed by anything, certainly not the testimony of the witnesses. Led by their chair, Sen. Grassley, who never made eye contact with Dr. Blasey Ford but kept his eyes on the paper he was reading from, and their attack dogs (Lindsey Graham, harsh, and John Cornyn, snide) they had a woman prosecutor question the female witness so as not to look like they were who, in fact, they were. That the format never allowed Rachel Mitchell to pursue a line of questioning was irrelevant, since it was all a charade for them. It is a shame that they made old men look so dumb and evil; remember that Grassley (85) and Hatch (84) were arrogant misogynists when they were younger, and that those (like Crapo and Cruz and Sasse) still in the 40s already are the same.

But this is a blog about medicine and social justice, and while there are certainly social justice lessons to be learned (in the negative) from the disingenuous cavorting of racist, sexist, we’ll-do-this-because-we-can behavior of white men in the hearing room, it has little to do with medicine or public health. Except, of course, to the extent that this entitled behavior is so frequently seen in those fields.

I recently wrote about an example of entitled corruption in José Balsega, the former Chief Medical Officer of Memorial Sloan-Kettering Medical Center (“Baselga, graft and corruption in medical research: why should we tolerate it?”, September 16, 2018), and we just learned that their vice president in charge of corporate relations has been required to pay them back the $1.4M he made from, essentially, insider trading.

I have also written about other corrupt executives, mainly in the pharmaceutical industry (e.g., “Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?”, September 3, 2016). These “Masters of the Universe” (h/t Tom Robbins) think they deserve everything they can get, and the rest of us be damned. Thanks to women like Heather Bresch of Mylan (Epi-Pen®) and criminal mastermind Elizabeth Holmes of Theranos, they are not all men. But mostly they are, and even these women had the protection of old men; Bresch’s father is Sen. Joe Manchin (D-WV) and Holmes attracted rich old white guys like Riley Bechtel of Bechtel, George Schultz, former Secretary of State and Bechtel CEO, and William Foege, former head of the CDC and hero of the anti-smallpox crusade, in a real-life parody of a bad thriller femme fatale.

Bad behavior is rife in the medical and public health communities, motivated, like that in the pharmaceutical sector and politics, by self-interest, a desire for money and power. Aaron Carroll, in “The Upshot” in the New York Times on September 24, 2018, writes about the many forms of bias in scientific and medical publication. He takes off from an article in Psychological Medicine, “The cumulative effect of reporting and citation biases on the apparent efficacy of treatments: the case of depression”, but he points out the many forms of bias affect research and research papers in general. These include publication bias, which means journals are more likely to publish papers with positive results (our study showed this new treatment worked!) rather than negative (well, we thought this would work but it didn’t, 😞); outcome reporting bias where only the positive outcomes are published and the negatives are left out; spin where, when unable to avoid reporting results that are negative, you use language to make them seem more positive; and citation bias, whereby other authors are much more like to refer to (“cite”) papers with positive results than those with negative, thus increasing their visibility. He does not specifically discuss confirmation bias, in which researchers are much more likely to notice and report on findings that confirm their prior ideas and dismiss those that contradict them, but this is also very insidious.

Sometimes the stakes, seen by the really rich and powerful, are minor – status and reputation in the academic scientific community (recalling the old adage “competition in academics is so vicious because the stakes are so low”). However, it is not just the researchers who are at fault. Journal editors and publishers are motivated by their own metrics of success, such as the “impact factor” based upon how often articles in their journals are cited by others. And, of course, our old “friends”, the pharmaceutical companies, are behind much of this bias, suppressing negative results for the drugs they make and emphasizing secondary outcomes (unethical!). For them, the stakes are financial and very high.

Carroll does a masterful job, supported by research published in a number of journals. He ends by discussing the ways in which these practices hurt we, the people, by getting false or misleading information out to other physicians and scientists. This can lead to us receiving treatments that don’t actually work, or work as well as they are portrayed as doing, or may even be more likely to harm us than help us. He emphasizes the important fact that not all, or even most, published scientific research is not to be trusted, but that these scurrilous articles are out there, and depend upon not only reporters and the public, but doctors not reading them carefully. Sadly, many medical (and other) professionals often hear only the reports of research in the popular press or, if they read the study, read only the Summary, or the Discussion section (most easy to “spin”) instead of carefully looking at the reported Methods and Results and drawing their own conclusions. Carroll makes a series of suggestions as to how the discipline might change this culture of bias; they are good and should be pursued.

I am not sure where the blame originates, whether from our leaders like our politicians and businessmen who see truth as an option which can be disregarded in the pursuit of money and power, or our scientists who take these illegitimate roads to further their own careers, or the public which has become agnostic about truth and searches only for confirmation of their own preconceived notions (or biases). But I am sure that, at all these levels, it is a bad thing and corrosive of the progress that should come from new knowledge.

Most of us will never get the chance to publicly put ourselves out there on the line like Dr. Blasey Ford, and very likely wouldn’t if we could. We can, however, stand for the idea that truth is not “revealed” but emerges from continuing work, from confirmation by replication of studies, from more work that further elucidates the truth. And that the enemy of truth is the kinds of biases that Dr. Carroll discusses.

In talking about his suggestions for correcting them, Carroll writes “These actions might make for more boring news and more tempered enthusiasm. But they might also lead to more accurate science.” And that would be good for us all.

The Supremes and ACA: Is opposing coverage for the poor really just mean?

In the context of the historic and momentous Supreme Court decision legalizing gay marriage across the US, and its affirmation of the Fair Housing Act, the third of the “trifecta” of progressive decisions announced this week, the ruling against those who argued that the ACA forbid federal financial support of federally-sponsored rather than state-sponsored insurance exchanges, seems rather pedestrian. After all, it just decided that the intent of the ACA was to achieve what its intent was – greater insurance coverage for the American people – and this would not be invalidated by 4 poorly-chosen words in a 1,000 page bill. What is more worthy of note is that there were three Supreme Court Justices who voted against it, when it was clearly not a real issue of law but an end-run to get it invalidated on a technicality. The low point of the dissent was Justice Scalia’s juvenile characterization of the majority decision as “jiggery-pokery”, an archaic expression most recently used in the public domain in a Harry Potter movie. Of course, Scalia could make a fair Harry Potter villain; not the potent evil of Lord Voldemort, but more of a scowling, snarling Severus Snape.

But the decision has real meaning. It means that millions of Americans in the 34 states that elected to not establish state-based exchanges and thus depend upon federal ones will not lose their health insurance. That is a good thing for those people, and it is a good thing for America. It does nothing for those people who were excluded by the SCOTUS decision 3 years ago (also written by Chief Justice Roberts) that, while validating ACA, precluded requiring states to expand Medicaid. This left millions more in the states that have not done so (like mine, Kansas) without insurance.  It certainly does nothing for the millions of those without legal documentation who live here, or the many others who fall between the cracks of the law. It still leaves us without the moral, medical, social, and economic advantages that come from a truly universal health system such as any of those adopted by every other wealthy nation, which achieve better health for less cost (see graphic). But it does make us seem slightly less cruel and benighted.

Not that this will end the discussion. A small article in the New York Times of June 27, 2015 notes that “Legal challenges remain for health law”.  These include a lawsuit by House Republicans led by Speaker John Boehner maintaining ACA is invalid because it spends money not appropriated by Congress, and a series of suits by religious organizations about the law’s requirement that they cover contraception. Indeed, the whole opposition to the law has becoming akin to a religion itself; according to its opponents (obviously also including all the Republican candidates for President) it is bad as a matter of faith, even though it does so much good. Yes, it does good in costly ways, ensuring that insurance companies make their profit; it does it in arcane ways; it does it in ways which in fact cost some people more than they might have otherwise paid. But it provides several million people the opportunity to not be the Donna Atkins or Tommy Davis of the future (see Dead Man Walking: People still die from lack of health insurance, November 17, 2013).

In response to a blog in which I posted a map that shows that the vast majority of those remaining uninsured are in the states of the former Confederacy and suggested that while Southern people might not be meaner than others, the impact of their policies was (Medicaid expansion and uncovered lives: are people meaner in the South?, February 8, 2015), Bobby Cohen wrote in a comment “If meanness doesn't explain the rejection of Medicaid expansion by Southern states, what does?” Well, for many people, I suppose, it is ignorance, of the sort demonstrated by “Keep the government’s hands off my Medicare!” or what I have called the “Craig T. Nelson fallacy” (“I've been on food stamps and welfare. Anybody help me out? No. No.”!!). Or the beliefs of some of the people in southeast Kansas interviewed for Kai Wright’s excellent article “Life and Death in Brownback’s Kansas”, published in the June 22/29 issue of The Nation where it seems that “Everyone is convinced that someone else is getting a better deal, that somewhere a horde of Kansans are gaming the system and preventing the truly needy from getting help.” In a true “What’s the Matter with Kansas”[1]illustration, even the doctor at the community health clinic who is fighting hard to get care for her impoverished patients who would have otherwise had Medicaid is conflicted; Brownback, after all, is a strong anti-abortion advocate, as is she.

All of these may explain some of the position of the leaders of this movement, but a better explanation can be found in the answer to one of the questions in “Steven Pinker’s Mind Games”, a psychology quiz on the NY Times website: “the best liar is the one who believes his own lies”. But it is hard to look at, not to mention listen to or read, the hard-core right-wing justices on the Supreme Court (who, unlike the GOP’s many presidential candidates are not even running for office) without thinking that they are, essentially, mean. They are not only against helping people when it will cost them, not altruists (another Pinker question), but even when it will save them money (again, see graphic).

I do not claim to be a legal scholar of the status of any of the Supreme Court Justices, or indeed the President. I gained some understanding from “The elusive right to health care under US law”, by Prah Ruger, Ruger, and Annas in the June 25, 2015 issue of the New England Journal of Medicine, published before any of these SCOTUS decisions were announced.[2]It’s a good and readable article which helps medical people like me understand some of the logic of court decisions. One line I found of particular interest was “American constitutionalism has championed negative liberties more than positive rights.” The idea is that the Constitution says government should not be allowed to take away our individual liberties (e.g., our guns) but not so much that we have a right to things (e.g., health care).

And yet, as pointed out by Gail Collins in “Supremes hit a high note”, this Court has “…destroyed the nation’s campaign finance laws, limited workers’ rights to challenge wage discrimination and women’s rights to control their bodies. And basically disemboweled a 50-year-old Voting Rights Act that Congress had renewed by increasingly large margins on four different occasions.” These decisions, almost all of which came out differently from those of the last 2 days only by the “swing vote” of Justice Kennedy (Chief Justice Roberts did join the majority in the decision on ACA), do not always follow this logic. It is quite an extension of the idea of liberty to say that corporations are people (the founders certainly didn’t think so) or money is speech. It is quite opposite protecting individual liberty to have laws limiting the ability of women to obtain contraception or abortion (although they can sure have guns!). Whether put forward by ignorant bigots, self-serving politicians, or sanctimonious Supreme Court Justices, the concept is most consistently “people should be allowed to do whatever they want, as long as they want the same things I do, but not what I disapprove of”. Sometimes, particularly when describing the actions of the powerful, this is described as political. But I think Dr. Cohen is right; it is essentially mean.

A phrase we commonly hear is that “mean people suck”. They do, but more important, when they have positions of power, they can do a lot of damage to others.

  

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[1]Thomas Frank. “What’s the matter with Kansas?”. Henry Holt. 2004 [interestingly, published in the UK and Australia under the title “What’s the matter with America?”!] ISBN 0-8050-7339-6.

[2] Jennifer Prah Ruger, Ph.D., M.S.L., Theodore W. Ruger, J.D., and George J. Annas, J.D., M.P.H., The Elusive Right to Health Care under U.S. Law, N Engl J Med 2015; 372:2558-2563June 25, 2015DOI: 10.1056/NEJMhle1412262

ACA: Where are we? And where should we go?

I am finished writing the book, as yet untitled, that I have been working on during my sabbatical, which accounts for the sparse number of blog posts. This is not to say that the book is anywhere near ready to be published; I am sure it will need more revisions.

However, it does mean that I am likely to be posting to the blog more frequently, as I find things that inspire me to write.

Thanks for your patience!
Josh

The Affordable Care Act (ACA) has been law since 2010, and was supposed to have been fully implemented this year in 2014, although as is clear many of its provisions have not yet been. The most important has been the failure of about half our states to implement the expansion of Medicaid, which was the mechanism through which the law intended to cover all those poor (incomes under 133% of the federal poverty level) who are currently ineligible for Medicaid (most of those now receiving it are poor children and their mothers, although the majority of dollars are spent on nursing home care). This is legal as a result of the Supreme Court decision that was important because it made the rest of the law legal; this is, I think, of faint solace to those poor people who live in my state of Kansas and the others who have failed to expand Medicaid despite the fact that the federal government would have paid 100% of the cost for 4 years, then 90%.

The newest court actions that affect ACA are two Court of Appeals decisions which say, basically, opposite things about the subsidies that support the premiums of people making above 133% of poverty but less than allows them to pay the full amount.[1]One court decided that people living in states that ran their own exchanges were eligible for the subsidies, but that those who were in federally-administered exchanges were not. The other appeals court decided that both were. Of course, those states that have federally-administered exchanges are those with governors and legislatures who oppose ACA completely; they include all those who did not expand Medicaid plus many more (about 36 altogether). This suggests some political agenda; the interpretation of Congressional intent rather than parsing the words, has historically been the basis for such court decisions. It also will mean that the cases will go to the Supreme Court, sometimes known as SCOTUS, but now appropriately called COCUHL (Court of Citizens United and Hobby Lobby), where it will be amazing if a conscious, careful, legal approach supersedes politics. The decision to basically gut the Hobby Lobby decisions one remaining protection only a day after it was announced bodes ill. The Republicans in Congress have decided to sue President Obama for not implementing portions of the ACA, which, as Timothy Egan of the NY Times points out, “…they have tried to repeal more than 50 times.”[2]

What has the Republicans so flustered that they have taken to self-contradictory actions is, in fact, the success of the ACA at achieving many of its goals. These are summarized in another NY Times op-ed, by Paul Krugman, titled “Obamacare fails to fail”.[3]There has been a huge surge in enrollment, and while indeed some people are paying more (largely healthy young people who are low risk for high-cost illness, thus previously had lower premiums), most people (including 74% of Republicans) are happy with their current premiums. In addition to the early wins (preventing insurance companies from not covering those with pre-existing conditions, allowing young people to stay on their parents’ insurance until they are 26), we now add over 6 million people who are newly covered, and can access health care. Despite decisions such as Hobby Lobby, most women will now get contraceptive coverage without a copayment. It is a good thing. This is why opponents (mainly ideological) are trying any trick that they can to limit its effectiveness, including the two biggest addressed above—not expanding Medicare and trying to block subsidies for those on the federal exchanges. That is to say, trying to limit health insurance coverage to our less-affluent citizens.

But ACA, even if it came through all the court decisions unscathed, is not a solution. It doesn’t cover those who are not citizens, even though they live here. It is a gift to insurance companies, who still get to charge high rates and make enormous profits, but now have the federal government paying the premiums. Therefore, it will not really save cost. Don’t get me wrong – I am not advocating that we provide less of the health care people need to save money (although I do advocating not providing “health care” that will not help or even harm people just because someone can make money on it). I am saying that the huge profits guaranteed for insurers, and other components of our system who make profit, make it excessively costly. It costs us way more per capita, for poorer health outcomes, than do the healthcare systems of other developed countries. The latest edition of “Mirror, Mirror on the Wall”, published in 2014 by the Commonwealth Fund demonstrates this clearly; in comparing 11 wealthy countries the US ranks #11 overall, and #11 in 3 of the 5 areas examined (Efficiency, Equity), and Healthy Lives), #5 in Quality, and #9 in Access. It achieves this less-than-mediocre performance by spending (2011) $8508 per capita, while the other 10 countries spent from $3182 (New Zealand) to $5669 (Norway).[4]

The problem is not that our system is not working, but that it is. Paul Batalden is famous for saying “every system is perfectly designed to get the results that it gets”, and ours is. The results that we get are relatively poor health outcomes on a population basis, large numbers of people excluded from health care coverage (even after ACA), many people getting unnecessary care because someone can make a profit on it, and the bizarre concept that there are not only people who are preferable to provide care for (because of their wealth or insurance status) but even diseases that it is preferable to provide care for (because the profit margin is better). Our system is not designed for people’s health; it is designed so that some (providers, insurers, drug companies, etc.) can make profit. It gets the results it is designed to get.

But that is unacceptable. We need a health system designed to maximize the health of our people. All our people. And we need it yesterday.

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[1]Goodnough A, Ruling on Health Care Subsidies Puts Coverage at Risk, NY Times 7/23/14, http://www.nytimes.com/2014/07/24/us/politics/court-ruling-on-health-care-subsidies-risks-loss-of-coverage.html

[2]Egan, T, “Ambulance Chaser in the House”, NY Times, 7/26/14, http://www.nytimes.com/2014/07/26/opinion/timothy-egan-Congresss-Next-Big-Idea-Sue-Obama.html

[3][3]Krugman P, “Obamacare fails to fail”, NY Times, 7/13/14. http://www.nytimes.com/2014/07/14/opinion/paul-krugman-obamacare-fails-to-fail.html

[4] Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2014 Update, The Commonwealth Fund, June 2014. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror