ACA – A Ticking Time Bomb For Republicans.
Posted on | October 20, 2020 | 2 Comments
Mike Magee
Watching the Amy Conan Barrett hearings last week, I couldn’t help but wonder who exactly was running the Republican Death Star at the moment.
Specifically the Supreme Court candidate’s vulnerability based on an outspoken disdain for the ACA seemed to release a quiet, below-the-surface, Democratic scream “Go ahead. Make our day!”
For nearly a decade the Republican party has done everything within its power to kill President Obama’s signature legislation, always promising but never delivering an alternative. And all along the way, they have succeeded in emphasizing the pieces of the bill that Americans in large majorities favor.
In the process, they’ve alienated not only those who believe health care is a right rather than a privilege, and those who support protections for pre-existing conditions, but also those against deceptive skimpy health insurance, those who believe transgender Americans deserve care guarantees, those who demand access to affordable drugs, those who have their adult children covered on their family plan, those opposed to cuts in coverage of contraceptives, and those in favor of federal funding of Planned Parenthood clinics.
No surprise then that Nancy Pelosi, on the first day of the Barrett hearings, went straight to the mic and said, “The president is rushing to make some kind of a decision because … Nov. 10 is when the arguments begin on the Affordable Care Act…He doesn’t want to crush the virus. He wants to crush the Affordable Care Act.”
What the House Speaker was referring to was California v. Texas. As Kaiser Health News Washington correspondent, Julie Rovner, recently wrote, “With the death of Ruth Bader Ginsburg, the ACA’s future is in doubt.”
That’s because California v. Texas, set for presentation to the Supreme Court in just a few weeks, is seeking clarity on a challenge by Texas led Republican attorneys general (AGs) to declare the ACA unconstitutional based on a weak technicality. The California refers to 21 Democratic (AGs) led by California, and Barrett when confirmed could be the deciding vote.
But charter members of the Medical-Industrial Complex (MIC) aren’t lining up with Mitch McConnell. America’s Health Insurance Plan (AHIP), the lobbying arm for the big insurance companies, says a Trump win here would cast “a long shadow of uncertainty over ACA-based investments and denies health insurance providers, states, individuals, and other stakeholders of much needed clarity.”
The AARP, with its own proprietary Part D pharmaceutical plan, says a bad decision here “plunges millions of Americans into an abyss of prolonged uncertainty because they do not know if they will lose access to life-sustaining health care coverage and consumer protections.”
The American Hospital Association, the Catholic Health Association of the United States, and the Association of American Medical Colleges issued a joint warning that a Trump/McConnell victory here could “have serious, perhaps irreparable, consequences for hospitals and the patients they serve.”
Why would charter members of the MIC be spurred to such progressive, public-spirited action against their very own free-market allies?
The answer lies in the “What if?” What if Republicans actions in the Supreme Court on November 10th succeed in throwing American health care into full-throttled chaos in the middle of a pandemic now slated to result in 400,000 plus American casualties as we enter 2021…and Joe Biden wins control of the executive and legislative branches of government?
One scenario: Inside the White House on January 21, 2021, Biden takes a good hard look at the ACA, and at a new batch of Republican-led “nickel and dime” legal challenges that proceed unabated (with tacit support from the health care lobby status quo), and says, “Screw it. I’m going Medicare for All.”
Tags: amy conan barrett > Code Blue > health reform > medical-industrial complex > MIC > texas v. california
Nature Magazine: Trump has taken an axe to our Democracy.
Posted on | October 15, 2020 | Comments Off on Nature Magazine: Trump has taken an axe to our Democracy.
Mike Magee
A month ago, I catalogued the actions of the editorial boards of Scientific American and Science in their historic endorsements of Joe Biden for President.
This week Nature magazine goes one step further in expressing regret for their statement of tolerance in 2016 when they wrote, “US democracy was designed with safeguards intended to protect against excesses.” Four years later? This mea culpa: “How wrong we turned out to be.”
Their opening paragraph sets the record straight:
“No US president in recent history has so relentlessly attacked and undermined so many valuable institutions, from science agencies to the media, the courts, the Department of Justice — and even the electoral system. Trump claims to put ‘America First’. But in his response to the pandemic, Trump has put himself first, not America.”
They catalog a list of grievances. First at home:
“On the domestic front, one of this administration’s most dangerous legacies will be its shameful record of interference in health and science agencies — thus undermining public trust in the very institutions that are essential to keeping people safe.”
And around the world:
“Challenges such as ending the COVID-19 pandemic, tackling global warming and halting the proliferation and threat of nuclear weapons are global, and urgent. They will not be overcome without the collective efforts of the nation states and international institutions that the Trump administration has sought to undermine.”
On the pandemic:
“Trump has lied about the dangers posed by the virus and has encouraged people to protest against policies intended to slow its transmission. The result, if not the goal, has been to downplay the greatest crisis the country — and the world — has faced in at least half a century…These actions have had devastating consequences.”
On the environment:
“…under the Trump administration, the EPA has withered as its scientists have been ignored by the senior leadership. Those at the top of the agency have worked to roll back or weaken more than 80 rules and regulations controlling a spectrum of pollutants, from greenhouse gases to mercury and sulfur dioxide.
On discrimination and hatred:
“Trump has also promoted nationalism, isolationism and xenophobia — including tacitly supporting white-supremacist groups. The administration has rewritten immigration policies, beginning in 2017 with a controversial travel ban on people from seven countries, including five Muslim-majority states.
On destruction of our Democracy:
“Donald Trump has taken an axe to a system that was intended to safeguard and protect citizens when leaders go astray. He has become an icon for those who seek to sow hatred and division, not only in the United States, but in other countries, too.”
The cure:
“Joe Biden must be given an opportunity to restore trust in truth, in evidence, in science and in other institutions of democracy, heal a divided nation, and begin the urgent task of rebuilding the United States’ reputation in the world.”
I agree.
Tags: 2020 election > nature magazine > trump > trust in science > truth and integrity
“The Magnitude of this Failure is Astonishing.” – The NEJM Cluster.
Posted on | October 8, 2020 | 6 Comments
Mike Magee
“Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy.” …and that’s just the first paragraph.
From the last paragraph: “Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for their actions…When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.”
Who is speaking here? The New York Times, the Washington Post, The Atlantic?
None of the above. This editorial, signed by 34 high-profile physicians and scientists, states “The magnitude of this failure is astonishing.” Individually they are science luminaries. But what is more consequential is the platform they inhabit. They are the editors of the world renowned New England Journal of Medicine.
Here are their names and titles:
Editor-in-Chief
Eric J. Rubin, M.D., Ph.D.
Executive Editor
Mary Beth Hamel, M.D., M.P.H.
Deputy Editor
Lindsey R. Baden, M.D.
Deputy Editor
Julie R. Ingelfinger, M.D.
Deputy Editor
John A. Jarcho, M.D.
Deputy Editor
Dan L. Longo, M.D.
Deputy Editor
Elizabeth G. Phimister, Ph.D.
Deputy Editor
Allan H. Ropper, M.D.
Deputy Editor
Caren G. Solomon, M.D., M.P.H.
Deputy Editor
Darren B. Taichman, M.D., Ph.D.
Associate Editor
Arnold M. Epstein, M.D., M.A.
Associate Editor
Guadalupe Garcia-Tsao, M.D.
Associate Editor
Ellen M. Gravallese, M.D.
Associate Editor
Michael F. Greene, M.D.
Associate Editor
John F. Keaney, Jr., M.D.
Associate Editor
Clifford J. Rosen, M.D.
Associate Editor
Gary Wong, M.D., F.R.C.P.C.
Associate Editor
Rui‑Ping Xiao, M.D., Ph.D.
Executive Managing Editor
Stephen Morrissey, Ph.D.
Statistical Consultants
Ralph B. D’Agostino, Sr., Ph.D., Constantine Gatsonis, Ph.D., David Harrington, Ph.D., Joseph W. Hogan, Sc.D., David J. Hunter, M.B., B.S., M.P.H., Sc.D., Sharon‑Lise T. Normand, Ph.D.
Perspective Editor
Debra Malina, Ph.D.
National Correspondent
Lisa S. Rosenbaum, M.D.
International Correspondent
Charlotte J. Haug, M.D., Ph.D.
CME Editor
Carla S. Rothaus, M.D.
Images Editor
Chana A. Sacks, M.D.
Editors-at-Large
Joseph Loscalzo, M.D., Ph.D., Richard P. Wenzel, M.D., M.Sc.
Editorial Fellows
Jehan F. Chowdhury, D.O., Siri R. Kadire, M.D
In taking this action, they join others in declaring outright independence from Trump and his Republican enablers. They are preceded by the leadership of two other prominent science publications. In its 175-year history, Scientific American had never endorsed a US presidential candidate – until last month when they chose Joe Biden. One week earlier, H. Holden Thorp, the spicy new editor of Science, penned an editorial titled “Trump Lied About Science.”
Actions like these are not taken lightly. They can undermine well-established and hard-earned reputations for independence. They can create enemies in high places. They can have financial consequences.
This NEJM cluster, in its own way, is as significant as the Rose Garden/Covid cluster that Trump personally ignited. Both actions have captured our attention. Both actions united individuals of like mind. And both have real-life consequences that no longer can be ignored.
Tags: COVID-19 > Joe Biden > NEJM > Pandemic > Presidential election 2020 > trump
The History of Presidential Health, Succession, and the 25th Amendment in 15 slides.
Posted on | October 5, 2020 | Comments Off on The History of Presidential Health, Succession, and the 25th Amendment in 15 slides.
Mike Magee
In 2019 I taught a course at the President’s College at the University of Hartford titled “The President’s Health and the 25th Amendment.” The questions raised then are now prescient and include:
1. What is the 25th Amendment?
2. How do you define “inability” and who defines it?
3. Has Presidential “inability” been a problem in the past?
4. What is the role of the White House physician?
5. What is his/her responsibility to the nation?
6. Is a Presidential candidate required to release medical records?
7. Have White House doctors lied to the public in the past?
8. Have Presidents lied about their health?
In this abbreviated format, here are 15 selected slides from that course with brief commentary.
Slide 1. The first commentary in our Constitution did not appear until 1787. This was not simply an oversight on the part of our Founding Fathers. Rather it reflected that the issue would be thorny and complicated – as it has remained to this day. In the statement, the position of Vice President is established, and (in the case of inability of the President) his duties “devolve on the Vice President” until the Congress identifies who should take the President’s place.
Slide 2. Over the next roughly half century, the issue of succession surfaces twice. In 1792, five years after the Constitutional Convention, Congress establishes that the line of succession after the Vice-President will be first to the leader of the Senate and then to the leader of the House of Representatives. When President William Henry Harrison dies in office from Typhus 49 years later, his Vice President, John Tyler”, has a local judge swear him in as “President.” John Quincy Adams is outraged by this precedent setting move since most believed he was only entitled to serve for an interim period as “Acting President.”
Slide 3. Historically, turnover in the Executive Office has been relatively common in our history requiring frequent succession. Violence and disease have been the common instigators of these crises.
Slide 4. Formal discussions regarding how best to legislatively manage succession have often followed these acute crises. On July 2, 1881, James Garfield was shot. Though incapacitated, he (and his supporters) refused to relinquish control of the government for the next 80 days until he died. When Chester Arthur, his VP assumed the Presidency, he directed the Legislature to reconsider the issue of succession. In 1886, they passed the Succession Act. It created a line of successors in the Cabinet should a President and Vice President become disabled. The successor would be titled “Acting President.” The issue of defining “inability” and who could determine “inability” was left unaddressed.
Slide 5. President Woodrow Wilson is often cited as the prime example of Presidential abuse when faced with incapacity. During his second term, exhausted from campaign efforts in support of passage of the League of Nations, Wilson suffered a stroke on October 2, 1919. For the next 15 months, Wilson’s 2nd wife, Edith Wilson, his long time Chief of Staff, Joe Tumulty, and White House Dr. Gary Grayson entered into a conspiracy to run the government and cover up his incapacity. The VP would not confront the issue fearing he’d be accused of opportunism. When the Secretary of State, Robert Lansing, finally surfaced the problem, he was fired. Wilson had to be convinced not to run for a 3rd term. He died on March 4, 1921.
Slide 6. White House doctors through history have routinely lied about the President’s health. Wilson’s doctor was not an outlier. FDR’s doctor, Admiral Ross McIntire, actively hid FDR’s progressive and eventually fatal Congestive Heart Failure for over a year before he died in office. This included penning a rosy portrayal of the President’s health in Collier’s magazine, titled, “Unconquerable Spirit” 2 months before he died.
Slide 7. In the middle of the Cold War, on September 24, 1955, President Eisenhower suffered a massive heart attack that confined him for months out West until he could be transported back to his home in Gettysburg, PA. He reportedly insisted on waiting until he was capable of walking unaided up the airplane stairs for a photo op. The Democratic Congress at the time asked for hearings to clarify succession issues. In 1958, rather than submit to legislative changes, Eisenhower penned a letter to Nixon, authorizing a temporary and reversible transfer of power were he to declare “inability” to govern.
Slide 8. At the time, Congress raised, and Eisenhower partly addressed the issue in his letter to Nixon.
Slide 9. Senator Frederick Payne (R, ME) had this response in 1958. The key issue he said was “Who will determine ‘inability’?”
Slide 10. Attorney General Robert F. Kennedy commented directly on the role of the Vice-President in declaring “inability” if a President is unable to do so himself. After JFK is assassinated, LBJ seeks clarity on the issue of succession. A junior senator from Indiana agrees to head up a Congressional committee to explore the need for a Constitutional Amendment. Few believe it will amount to much.
Slide 11. Since 1788, there have been 11,000 proposed Amendments to the Constitution. Only 27 to date have succeeded and 10 of these were contained in the original Bill of Rights. Ratification of an Amendment requires support from 2/3 of both Houses of Congress, and approval by ¾’s of the states. On January 23, 1967, the 25th Amendment was ratified.
Slide 12. During Nixon’s second term, the 25th Amendment gets a work out. VP Spiro Agnew resigns in disgrace. Gerald Ford is appointed by President Nixon. Nixon resigns and Ford assumes the Presidency. Ford appoints Rockefeller as his VP.
Slide 13. During his Presidency, Ronald Reagan ignores the 25th Amendment after an assassination attempt. His PR people create an inaccurate and deceptive heroic narrative for public consumption to cover-up the seriousness of his condition. Returning a “hero” to address both Houses of Congress helps Reagan pass his “trickle down” tax cut which is partially reversed one year later.
Slide 14. When Reagan undergoes general surgery for colon cancer, he transfers power temporarily to George H. W. Bush, but specifically notes that he is not invoking the 25th Amendment. Late in his second term, the First Lady, and White House staff (including the White House doctors) cover-up Reagan’s declining mental status. George H. Bush is the first to formally invoke the 25th Amendment when under anaesthesia to Dick Cheney.
Slide 15. In 1992, twenty-five years after its passage, Birch Bayh and Fordham University Dean of the Law School, John D. Feerick (both of whom were involved in creating the original language for the 25th Amendment in 1967), co-chair a committee to re-examine the Amendment, and recommend any necessary changes. They conclude it should be left as is, deciding that the issue of both “inability” and “transfer of power” is primarily a political decision, and that transferring the power to override the result’s of the body politics vote to a medical committee, the Supreme Court, or other expert body, would create more problems than it would solve. They also reinforced their faith in Section 4 of the 25th Amendment – a succession scheme empowering the Cabinet and the Vice-President to appeal to Congress to remove an “inable” President who refuses to leave.
Pfizer CEO Should Distance Himself From Trump.
Posted on | October 1, 2020 | 2 Comments
Mike Magee
The executive team on the 18th floor at 42nd and 2nd Avenue had to be shifting in their seats a bit on Tuesday night as they heard the President of the United States assure the American public that Pfizer will very soon (maybe even in October) come to the rescue with a miraculous Covid-19 vaccine.
It’s been a heady two months for Pfizer’s new CEO, Albert Bourla. A veterinarian from Greece who spent 27 years working his way up the corporate ladder, he’s in the middle of a barnyard mess that is not of his making.
Two months ago, he teamed up with Germany-based BioNTech and landed a $1.95 billion deal with the US government. That contract is contingent on him finding a safe and effective vaccine and can deliver 100 million doses as promised (with 500 million more to follow).
With such happy news, why is Mr. Bourla increasingly sweating under the Primetime spotlight?
It’s likely because of the company he’s been forced to keep. As Trump former henchman Michael Cohen warned Congress on February 27, 2019. “I did the same thing that you’re doing now” and you will eventually “suffer the same consequences that I’m suffering.”
Increasingly Bourla finds himself out on the limb – a situation that became more tenuous during this week’s debate. First, Pfizer is some distance (months not days) away from completing phase three studies which have at least as good a chance of failing as succeeding. Second, if the vaccine is submitted for approval, it will have to survive a fully transparent and very public FDA review. Third, since Trump is a chronic liar who has displaced real science experts, it’s unlikely that the public will respond with open-armed trust even with an approval.
Bourla and the other PhRMA execs signaled as much when they sent out a joint release in September pledging not to cut corners on safety. Why did Bourla feel this was necessary? He told the Washington Post, “People are confused. Right now, they don’t know who to believe and what to believe. And we felt that, as this debate was peaking, we had to go out and say that we are going to stand with science. And we had to make it clear that if there are pressures, we are going to honor our legacy, and we are going to do whatever it takes to deliver a product that is safe and effective.”
He may not want to hit that “Pfizer’s legacy” too hard. As recounted in “Code Blue: Inside the Medical Industrial Complex”, the Pfizer “rap sheet” over six decades, from controversial experiments on children with meningitis in Nigeria to a $2.3 billion fine for massive over-marketing, is not exactly the kind of “legacy” worth defending in public.
The point being for Bourla, you’ve been warned. Aggressively maintain your distance from Trump, and listen to the advice of your fellow Greek, Aristotle, who said, “Moral excellence comes about as a result of habit. We become just by doing just acts, temperate by doing temperate acts, brave by doing brave acts.”
Sam Rayburn on Trump’s Disruptive Debate.
Posted on | September 30, 2020 | 4 Comments
Mike Magee
When it comes to policy and politics, it can be a struggle to maintain perspective and provide context. And as Trump’s performance in last night’s presidential debate well illustrated, Sam Rayburn was right when he said, “Any jackass can kick down a barn, but it takes a good carpenter to build one.”
In 1987, I published the “Positive Medicine Credo” – five principles to guide health professionals committed to caring for others. Underpinning all of these was health, further complicated by Covid-19.
A decade ago, I laid out seven principles that attempted to respond to the question, “How do we make America healthy again?”
The seven visions were:
5. Integrating health databases.
6. Techmanity: Humanizing technology.
7. Caring for the “planetary patient.”
In the lead up to the 2018 Mid-Term election, The New Yorker’s David Remnick mirrored these same values and visions in a piece titled “Trump’s illiberalism.” He also suggested that Trump and his followers were testing the resilience of “sturdy-seeming American values” and the endurance of “institutions that the President has scorned and threatened.”
He saw active turnout in the 2018 midterm elections as part of the test, but also suggested that any victory here would require more to follow.
Last night’s assault by the president on American standards and values should motivate, activate, and accelerate healthy Americans committed to embracing diversity, leading in the public sphere, exposing and addressing prejudice wherever and whenever it occurs, limiting guns and violence, encouraging respectful communications, and rising to the environmental challenges that threaten our planet’s health.
A healthy America requires healthy Americans. We need to get on with it. The message on November 3rd needs to be strong, clear and resounding in its rejection of Trump and his legislative enablers. Enough time has passed for us to rise to this challenge. #2020 Election.
The Future of the ACA Four Years Later – and The Perils of Being A Futurist.
Posted on | September 29, 2020 | 2 Comments
Mike Magee
Tonight we witness the first Presidential debate of 2020, and the future of the ACA (in the middle of a pandemic) is once again on the line. If past is prologue, make predictions of the outcome at your own risk.
Four years ago, 1 month before the election, the New England Journal of Medicine served as a platform for dueling visions of the outcome. UNC’s Jonathan Oberlander penned the fallout of a Democratic win, while Gail Wilensky presented the Republican version. Both landed far afield of what has happened since.
October, 2016
A Democratic Victory: by Jonathan Oberlander
1. While the ACA has resulted in a decline in the nation’s uninsured rate from 48 million to 27 million, the rising cost of insurance, especially for those at the upper levels of poverty (200% of the Federal Poverty Limit), where a family plan on average now costs more than $20,000 a year, is untenable. Translation: some changes will be required to address their needs.
2. There is also a problem with rising deductibles. This averaged $303 in 2006, but hit $1,077 in 2015. Hillary Clinton’s plan is to provide a refundable tax credit for citizens with high out-of-pocket deductibles.
3. Three major insurers (UnitedHealthcare, Humana, and Aetna) are planning to curtail their involvement with the ACA exchanges. They complain that the pricing differential they are allowed between the healthiest and sickest enrollees (3 to 1) is not adequate to cover their financial risk. In their view, we should go back to 5 to 1. It is unlikely they will force the government hand on this, any more than reversing the provisions that prevent exclusion based on prior conditions. Instead their stance will likely move both the federal government and state governments toward “public options”, whether through downward extension of age eligibility for Medicare, or expansion Massachusetts-like universal coverage plans to other states.
4. A Democratic victory would likely cause most Republican led states that have resisted Medicaid expansion under ACA to give up their resistance. Their abandonment of a stance that has been financially self-destructive to their states could be hastened by changes that assure permanent, near 100% federal funding of Medicaid into the future. This would come with greater standardization of rules nationwide governing the coverage package. Any move toward nationalization would carry with it more focus on cost and efficiency, with data transparency leading the charge to address price gougers, research result hiders, sloppy prescribers, and outcome outliers.
A Republican Victory: by Gail Wilensky
1. Gail Wilensky predicts the likely outcome of the presidential race to be a Democratic victory, with the House remaining under Republican control, but the Senate majority potentially shifting to the Democrats. In this light, she outlines the current Paul Ryan’ health care plan versus Donald Trump’s which bundles an outright repeal of the ACA with allowance of drug reimportation and negotiation of Medicare Part D drug prices.
2. Were the Ryan plan to be implemented, unchanged by a Democratic controlled Senate or presidential veto, we could expect:
a) Medicare age eligibility would gradually increase to age 67, and Medicare would become a “premium support” , partially privatized program.
b) High deductible plans, which deliberately increase consumer focus on cost, would be promoted through government supported Tax Savings Accounts, housing tax-exempt funds to cover excess medical costs.
c) The current prohibitions on exclusion for prior conditions or excessive cost profiles would remain in force. But insurers would be allowed a 5 to 1 cost ratio spread based on age.
d). Medicaid would be funded by a federal grant at “X” dollars per person, and states would have substantial leeway on how to prioritize spending as well as the ability to require “able bodied adult recipients to work”.
September 29, 2020
Our current ACA reality:
- Trump is trying for a second term.
- The ACA is still alive, though Trump and Republicans are still trying to kill it. The latest gambit – stack the Supreme Court with a conservative majority. His alternative? Still not clear.
- Large majorities of Americans now support universal health coverage, protection for pre-existing conditions, and a comprehensive basic benefit package.
- Only 12 deep red states continue to pass on the extended Medicaid offering built into the ACA.
- Medicare eligibility remains at age 65, and there is active debate whether the country should move to a “Medicare-for-all” plan.
- Cost of health care annually now approaches $4 Trillion, with approximately 25% (in multiple studies) wasted, and qualities outcomes far short of other developed nations.
- There are 16 health care workers for every one physician in America – and at least half of these have absolutely now clinical “hands-on” care role.
What will happen next?
Predict at your own risk.
Tags: 2016 election > 2020 election > gail wilensky > health futurists > health reform > jonathan oberlander > trump pandemic
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