Category: Health

The “Affordable” Care Act Gives Huge Drug Subsidies to Rich, Urban “Nonprofit” Hospitals

(p. A1) A decades-old federal program that offered big drug discounts to a small number of hospitals to help low-income patients now benefits some of the most successful nonprofit health systems in the U.S.

Under the program, hospitals buy drugs at reduced prices and sell them to patients and their insurers for much more, often at facilities in affluent communities.

One participant is the Cleveland Clinic’s flagship hospital, which reported $1.35 billion in net income last year. The hospital doesn’t admit enough Medicaid and low-income Medicare patients to qualify for low-cost drugs under the program’s original requirements. But a quirk in federal law allowed the hospital to qualify as a “rural referral center,” despite its location near the center of Cleveland.

Despite the benefits, the program hasn’t resulted in new drug discounts for low-income Cleveland Clinic patients, nor has it caused the hospital to increase the financial assistance it offers to those who can’t afford care. (p. A10) The charity care the main hospital writes off represents less than 2% of its patient revenue, according to a Wall Street Journal analysis of hospital Medicare filings.

. . .

The hospital’s $1.35 billion net income figure for 2021, she said, includes investment returns.

Cleveland Clinic’s adoption of the drug-discount program at its main hospital in April 2020 produced about $136 million in savings on drugs that year, the spokeswoman said.

The federal drug-discount program, known as 340B after the statutory provision that created it, requires pharmaceutical companies to sell drugs to participating hospitals at reduced prices. The program has grown rapidly in recent years. It now includes about 2,600 nonprofit and government hospitals, which spent at least $38 billion on discounted drugs last year, according to the Health Resources and Services Administration, the federal agency known as HRSA that oversees the program.

What the hospitals do with their valuable discounts isn’t always clear.

The program doesn’t require participating hospitals to pass on drug discounts to patients, insurers or Medicare. There is no rule limiting how much they can charge for the drugs. They don’t have to report how much they make from such sales, nor do they have to spend any profits to benefit low-income patients.

. . .

The 2010 Affordable Care Act brought a big expansion of 340B, adding new categories including critical access hospitals, which are small, typically rural facilities, and rural referral centers, which are supposed to be rural hospitals that treat a large volume of patients, including many complicated cases.

Under the federal definition of rural referral centers, hospitals that aren’t in rural locations could still qualify if they meet other criteria—minimally, having at least 275 beds. There is no requirement to serve rural patients.

. . .

“We were trying to help rural hospitals,” said Robert Kocher, an Obama White House health adviser involved in crafting the ACA who is now at venture-capital firm Venrock. “It would not be our intention to have a medical center in Cleveland, Boston or Chicago be included.”

For the full story, see:

Anna Wilde Mathews, Paul Overberg, Joseph Walker and Tom McGinty. “Drug Discounts Aimed at Needy Boost Hospitals.” The Wall Street Journal (Wednesday, Dec. 21, 2022): A1 & A10.

(Note: ellipses added.)

(Note: the online version of the story has the date December 20, 2022, and has the title “Many Hospitals Get Big Drug Discounts. That Doesn’t Mean Markdowns for Patients.”)

Government Contractor UNOS Is 15 Times More Likely to Lose or Damage Transplant Organs as Private Airlines Are to Lose or Damage Luggage

(p. A24) Where Tonya lives in California, the wait for a kidney from a deceased donor is up to 10 years. Tonya, like many on dialysis to treat kidney failure, knows the odds of her surviving the wait are slim; the median survival time for patients on dialysis is five years.

. . .

Everyday Americans are doing their part, signing up to be organ donors, but the organizations in charge of organ recovery (known as organ procurement organizations, or O.P.O.s) have been plagued with inefficiencies and abuses, and the contractor that runs the national system — the United Network for Organ Sharing (UNOS) — has been failing to oversee them.

The organ procurement system is made up of 56 organizations, each with a monopoly in its jurisdiction. When someone dies and can donate an organ, O.P.O.s are supposed to go to the hospital, talk to the person’s family and manage the process of transporting donated organs to those in need, but all too often they have failed to show up — literally.

. . .

Tonya asked the government to hold these organizations accountable, and naïvely, we thought it would be that simple. Our efforts would surely get Tonya a kidney.

She did everything she could to push for change, everything that our government asks of concerned citizens: She wrote an opinion essay; appeared in a government video; wrote letters to members of the Biden administration, including the Centers for Medicare and Medicaid Services (C.M.S.) administrator Chiquita Brooks-LaSure and the head of the Health Resources and Services Administration, Carole Johnson; worked with members of Congress, including Representative Katie Porter; and even testified before the House Oversight Subcommittee on Economic and Consumer Policy in May 2021.

There she told the committee she would die without the federal government’s urgent action. A year and a half later, on Dec. 30, 2022, Tonya died of complications from kidney failure.

. . .

After the video Tonya and I made, in 2020 the Trump administration finalized a rule bringing accountability to the forefront, and the Biden administration has inherited it. This is a good start: The new rule changes the metrics by which O.P.O.s are evaluated and requires that they face decertification for failure to perform. But the rule would not replace a single failing organ contractor until 2026, which is not acceptable.

. . .

To make matters worse, in the Biden administration’s 2023 budget, the C.M.S. requested flexibility to recertify failing O.P.O.s so they can keep their contracts even after 2026. If we allow failing O.P.O.s to keep operating, then we essentially nullify the reform we’ve worked so hard for and ensure further delays and more deaths.

. . .

When the Senate Finance Committee finally began investigating, it found that UNOS has systematically failed to provide oversight. At the committee hearing, doctors and transplant professionals testified that they have been afraid to criticize UNOS publicly, for fear it will retaliate against their patients. Also at the hearing, Senators Elizabeth Warren, Charles Grassley and Rob Portman called out another mind-boggling fact: From 2014 to 2019, UNOS was 15 times as likely to lose or damage an organ in transit as an airline is a passenger’s luggage.

For the full commentary, see:

Kendall Ciesemier. “She Feared the Organ Donation System Would Kill Her. It Did..” The New York Times (Wednesday, February 1, 2023): A24.

(Note: ellipses added.)

(Note: the online version of the commentary has the date Jan. 28, 2023, and has the title “Tonya Ingram Feared the Organ Donation System Would Kill Her. It Did.”)

Mary Grimaldi Died of Measles a Few Days Before the Government Approved the Vaccine That Would Have Saved Her

(p. A15) Members of my own family have . . . chosen not to vaccinate their children against measles, even as my mother laments that the measles vaccine didn’t arrive in time for Sissy, as Maura was known in our family. She recently told me that she wishes she had found a way to enroll Sissy in the measles-vaccine trial, which involved 50,000 children over several years in the early 1960s.

. . .

Until the vaccine, the only way to gain immunity to measles was to contract the disease. Sissy was exposed as an infant when my brothers caught it, but the case wasn’t severe enough to give her immunity. “She’ll have to get the shot when it’s available,” the family pediatrician, Dr. George Herman, told my mother.

Why did it take so long for that to happen? Culturing the virus from the blood serum of young David Edmondston, and then weakening or “attenuating” it enough for a vaccine, was no easy feat. “The hardest vaccine to make is a live, attenuated vaccine,” said Dr. Offit. He would know: It took him and fellow virologists 26 years to develop a safe and effective vaccine against rotavirus, which can cause potentially fatal diarrhea in infants. “It is all trial and error. Nine years is fast,” Dr. Offit said.

It wasn’t fast enough for Sissy.

. . .

The Kansas City Times ran a short obituary. The paper asked my parents if they wanted to report the cause of death, and my mother said yes, “so that other parents would know to get the vaccine when it was available.”

A few pages away was an article headlined “O.K. on Measles Vaccine; Two Forms Released by Government and Surgeon General Predicts a Sharp Drop in the Disease Next Season.” “This is one of our most significant advances toward decreasing or eliminating one of our most serious childhood diseases,” said U.S. Surgeon General Luther Terry. An editorial in the paper on the vaccine news concluded, “The disease and its sometimes tragic consequences are on the way out with other ancient plagues.”

For the full essay, see:

James V. Grimaldi. “My Family and the Measles Vaccine.” The Wall Street Journals (Saturday, March 25, 2023): A15.

(Note: ellipses added.)

(Note: the online version of the essay has the March 23, 2023, and has the same title as the print version.)

Allow Entrepreneurial Competition in Medicine by Ending Obamacare’s Ban on Physician-Owned Hospitals

(p. A17) A tiny paragraph in the enormous Affordable Care Act prohibits physicians from building or owning hospitals. Any existing physician-owned hospital built before 2010 is prohibited from growing beyond the size it was when the bill passed. This law limits competition, defies common sense and is likely contributing to higher prices for Medicare and reduced access to treatment for millions of Americans.

. . .

. . . recent research affirms the power of American entrepreneurship to lower costs and improve quality. Doctors, whether at the bedside or the forefront of scientific innovation, are well-suited to reimagine healthcare operations, lower costs and improve the quality of care.

Specialty physician-owned hospitals focused on cardiology and cardiac surgery were found to deliver higher-quality care than nonprofit hospitals, with lower rates of hospital readmission or mortality for high-risk surgery. Physician-owned specialty hospitals for orthopedic procedures, such as hip and knee replacements, offered lower costs and higher quality than nonprofit counterparts.

. . .

Healthy competition drives job creation, innovation and long-term economic growth. The federal government doesn’t prohibit plumbers from owning plumbing companies, radio hosts from owning radio stations or farmers from owning farmers markets. It’s time to reopen the free market in healthcare and let the power of competition do its work.

For the full commentary, see:

James Lankford and Brian J. Miller. “End ObamaCare’s Ban on Physician-Owned Hospitals.” The Wall Street Journal (Tuesday, Feb. 21, 2023): A17.

(Note: ellipses added.)

(Note: the online version of the commentary has the date February 20, 2023, and has the same title as the print version.)

State Bureaucracies Did Not Nimbly and Effectively Spend Massive Pandemic Crisis Funds

(p. A1) . . . when the Biden administration gave Mississippi $18.4 million in mid-2021 to hire public health workers — part of $2 billion in grants to bolster the Covid work force at state and local health agencies nationwide — it appeared that help had, at long last, arrived.

But as of January [2023], 18 months later, Mississippi had spent just $3.6 (p. A14) million of its grant — less than a fifth. Its attempts to hire epidemiologists, nurses and other soldiers in the war against Covid had largely fallen flat. The state has lost one in 224 residents to Covid-19, one of the nation’s worst death rates, including 122 people in tiny Scott County alone.

Mississippi’s woes are an acute example of a larger public health failure that is reprised nearly every time a major health threat grabs headlines. The problem, experts say, is that Congress starves state and local health agencies of cash for even basic needs in quiet times. Then, when a crisis hits, it floods them with millions or even billions of dollars earmarked to battle the disease of the moment. And the sluggish machinery of Capitol Hill often ensures that most of the aid arrives only after the worst of the crisis has passed.

The $2 billion in Covid hiring grants is the latest example. Nationwide, states and localities had spent only $371 million of the money by December, or about 19 percent, according to the Centers for Disease Control and Prevention, the conduit for the funds.

. . .

The record is replete with other such fumbles.

Six months after the World Health Organization declared the H1N1 influenza pandemic over in mid-2010, states and localities had used just a third of the $1.4 billion in federal funds they had received to combat it. The outbreaks of the Ebola virus in 2014 and the Zika virus in 2016 also led to funding windfalls, but health experts say most of the money arrived late.

For the full story, see:

Sharon LaFraniere. “In Mississippi, Covid Millions Left Unspent.” The New York Times (Monday, Feb. 13, 2023): A1 & A14.

(Note: ellipses, and bracketed year, added.)

(Note: the online version of the story has the same date as the print version, and has the title “Why Mississippi, a Covid Hot Spot, Left Millions in Pandemic Aid Unspent.”)

Regulations, Trade Barriers, and “Restrictive Government Contracts” Caused Infant-Formula Crisis

(p. A15) The pandemic era has seen its share of supply-chain problems, but the infant-formula crisis—which began a year ago—stands out for its depth, duration and danger.

. . .

Politicians responded to the crisis with their standard pandemic playbook. They claimed decades of laissez-faire economics—free trade, deregulation, etc.—had left the U.S. formula market vulnerable to a major shock. Thus, the politicians argued, new government industrial policies and more regulatory enforcement were needed to resolve the current crisis and protect against future ones.

These refrains ignored the reality of the U.S. formula market and related federal policies, . . .

. . .

First, high and complicated “tariff rate quotas” dating back decades subjected most infant-formula imports to an effective tax of more than 25%; . . .

. . .

Two aspects of U.S. domestic policy added insult to this injury by effectively ensuring that a handful of large formula producers continue to dominate the market.

First, the U.S. regulates formula more strictly than any other food and more strictly than most other countries. Heavy regulatory burdens can discourage new market entrants, . . .

. . .

Second, the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children, or WIC, which has grown to cover almost half of U.S. infant-formula sales each year, demands steep discounts from participating formula producers in exchange for sole access to a state’s WIC market and prime shelf space at participating retailers.

. . .

The combination of high trade barriers, onerous domestic regulations and restrictive government contracts has created a concentrated and sclerotic U.S. formula market that collapsed when a single factory shut down and still hasn’t fully recovered. Tellingly, the federal government’s emergency actions to alleviate the formula crisis targeted these very policies. Congress suspended baby-formula tariffs through the end of 2022. The FDA exercised its “enforcement discretion” to approve eight new foreign manufacturers to sell formula until 2025 without meeting all U.S. regulations. The Agriculture Department allowed WIC recipients to use their benefits to buy noncontract formula brands, including imports, until mid-2023. And President Biden’s Operation Fly Formula commissioned military aircraft to deliver formula from abroad.

In all cases, the federal government implicitly recognized how freer markets can boost economic resilience and how protectionism and excessive regulation undermine it. Yet Congress and the executive branch haven’t made these reforms permanent. Tariffs are now back in force, even as discrete shortages persist.

For the full commentary, see:

Scott Lincicome and Gabriella Beaumont-Smith. “The Infant-Formula Market Is Still Bottled Up.” The Wall Street Journal (Friday, Feb. 17, 2023): A15.

(Note: ellipses added.)

(Note: the online version of the commentary has the date February 16, 2023, and has the same title as the print version.)

Let “People Express Concerns in a Therapeutic Environment Before You and I Decide the Policy”

(p. A4) Britain’s top civil servant warned in October 2020 that Prime Minister Boris Johnson was a “nationally distrusted” figure who should not announce new social-distancing rules in the depths of the coronavirus pandemic.

The health secretary at the time, Matt Hancock, disparaged an eminent medical researcher who had publicly criticized Britain’s handling of Covid as a “complete loudmouth.” Mr. Hancock also mocked “Eat Out to Help Out,” a program to lure people back to restaurants sponsored by Rishi Sunak, referring to it as “eat out to help the virus get about.”

Those and many other unfiltered remarks are in more than 100,000 WhatsApp messages exchanged among Mr. Hancock, other ministers and aides as they tried to control the coronavirus outbreak in 2020 and 2021. They were handed to The Daily Telegraph, a British newspaper, by Isabel Oakeshott, a journalist who obtained them while helping Mr. Hancock write a book, “Pandemic Diaries,” about those desperate days.

. . .

“What I found shocking was the callous nature of the messages — the banter, the humor, and how casual they were about making decisions that affected people and their lives,” said Prof. Devi Sridhar, head of the global public health program at the University of Edinburgh.

. . .

Amid the pervasive sense of dread in the texts, there were also moments of gallows humor. Mr. Hancock once asked Michael Gove, a fellow minister, to explain the goals of a coming government meeting on the pandemic.

“Letting people express concerns in a therapeutic environment before you and I decide the policy,” Mr. Gove wrote.

“You are glorious,” Mr. Hancock replied.

For the full story, see:

Mark Landler. “Juicy Nuggets, but No Surprises About U.K. Covid Policy.” The New York Times (Monday, March 8, 2023): A4.

(Note: ellipses added.)

(Note: the online version of the story has the date March 7, 2023, and has the title “Ex-Minister’s Texts Lift the Veil on U.K. Covid Policy. It Isn’t Pretty.”)

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Elon Musk Got Rich the Old-Fashioned Way, He EARNED It

(p. B4) Elon Musk is tired, his back hurts and his mom wants him to get some sleep.

. . .

A self-described nanomanager, Mr. Musk has long waded deeply into the weeds of the companies he runs, including SpaceX and Tesla Inc., green up pointing triangle routinely working late into the night and sleeping little. His tenacity has led to superhuman-like accomplishments, such as landing space rockets and making electric cars sexy.

. . .

Since taking ownership of Twitter Inc. in late October [2022], Mr. Musk’s workload has exploded to more than 120 hours a week from as much as 80 hours before, he told investor Ron Baron in November at a conference.

“I go to sleep, I wake up, I work, go to sleep, wake up, work—do that seven days a week,” Mr. Musk said.

. . .

Even before buying Twitter, Mr. Musk wasn’t a “chill, normal dude,” as he once joked on “Saturday Night Live.” Mr. Musk has said he usually goes to sleep around 3 a.m. and typically gets six hours of shut-eye before waking and immediately checking his phone for any new emergencies.

These days, Mr. Musk has said he is sleeping at Twitter headquarters in San Francisco. He has even provided beds for employees.

. . .

Concerns about Mr. Musk’s health had circulated a few years ago, ignited by photos of him that appeared to show a new scar on his neck. In 2020, he confirmed he had two surgeries, the first a failure, to address neck pain.

His pain, Mr. Musk has said, traces to a birthday party thrown years ago by his second wife that was attended by a sumo wrestler.

Mr. Musk took to the ring and—according to him—managed to throw the 350-pound opponent, resulting in an injury to his spine. “It cost me smashing my c5-c6 disc & 8 years of mega back pain!” Mr. Musk said on Twitter last year.

. . .

Entrepreneur Arianna Huffington at one point in 2018 pleaded with Mr. Musk to take better care of himself.

. . .

He responded with a tweet sent at 2:32 a.m.: “Ford & Tesla are the only 2 American car companies to avoid bankruptcy. I just got home from the factory. You think this is an option. It is not.”

For the full story, see:

Tim Higgins. “Musk’s Frantic Schedule Comes at a Personal Cost.” The Wall Street Journal (Monday, Feb. 6, 2023): B4.

(Note: ellipses, and bracketed year, added.)

(Note: the online version of the story was updated February 5, 2023, and has the title “When Does Musk Sleep? He Speaks of Limits to Fixing Twitter, Back Pain.”)

Lives Lost to Covid-19 Due to Slow Regulatory Recommendations

(p. B1) In the early days of the COVID-19 pandemic, the Nebraska Medical Center was at the forefront of an international clinical trial of the drug remdesivir, . . .

. . .

By April 2020, the early trial showed that remdesivir shortened the time it took for all patients hospitalized for COVID-19 to recover by five days overall, compared with those who received a placebo.

. . .

A study published last week in the British medical journal The Lancet Respiratory Medicine confirmed findings of the initial NIH trial.

Dr. Andre Kalil, who led the Omaha-based arm of the trial, said it’s always important to see studies replicated by other (p. B2) researchers.

But Kalil, in an invited commentary on the Lancet study, noted that a number of public health and medical bodies delayed acting on the early beneficial results and recommending the drug in guidelines for clinicians.

The National Institutes of Health and the Infectious Diseases Society of America guidelines for nearly two years recommended remdesivir only for hospitalized patients who received supplemental oxygen. Only after that time did the groups recommend it for patients who were hospitalized but did not need supplemental oxygen.

The World Health Organization didn’t recommend remdesivir for patients hospitalized with COVID-19 until late 2022.

“Regrettably, the delays in recommendation of remdesivir for patients — even after the initial remdesivir shortage was resolved — adversely shaped antimicrobial policy in hospitals around the world, preventing patients from receiving timely remdesivir,” wrote Kalil, a University of Nebraska Medical Center professor and an infectious diseases physician with Nebraska Medicine, the health system that includes the Nebraska Medical Center.

In an interview, Kalil said he believes more lives could have been saved if the guideline panels had been more timely in making their recommendations. All three now recommend remdesivir for hospitalized patients.

For the full story, see:

Julie Anderson. “Delays on Remdesivir May Have Cost Lives.” Omaha World-Herald (Sunday, March 5, 2023): B1-B2.

(Note: ellipses added.)

(Note: the online version of the story has the same date as the print version, and has the title “Could earlier adoption of remdesivir have saved lives during the COVID pandemic?”)

Janega Claims That Europeans in Middle Ages Washed Themselves Daily

If the claims in the book quoted below turn out to be well-documented, then I may need to modify a few sentences in my Openness book, if a new edition ever appears.

(p. A15) A longstanding myth holds that people in medieval Christian Europe didn’t bathe. In fact, the Middle Ages subscribed heartily to the adage “cleanliness is next to godliness.” Thinkers of the period considered physical beauty to represent spiritual purity, and they looked at hygiene in the same way: If one’s body was impure, it would by definition be unattractive and out of harmony. If it had any imperfections, one would best address them through cleansing. For women, in particular, cleanliness was one of the very highest virtues.

The daily wash usually involved collecting water in a ewer, heating it, then pouring it into a large basin to be used for scrubbing. Baths in a wooden tub would happen less often, given it was a world without plumbing. Water is heavy, and collecting it, heating it, and then getting it from the kettle into the bathtub was difficult. Baths also required space, which was at a premium in most households.

Luckily, there were a few ways to bathe outside the home. In warmer months, you could simply find a pond or a lake, and you were good to go. But in January this could be a problem, and that was where bathhouses came in. Bathhouses took the laborious and difficult work of drawing and heating water and monetized it. Most towns boasted at least one professional bathhouse, while cities played host to a number of competing establishments.

For the full essay, see:

Eleanor Janega. “The Middle Ages Were Cleaner Than We Think.” The Wall Street Journal (Saturday, Jan. 14, 2023): A15.

(Note: the online version of the essay has the date January 12, 2023, and has the same title as the print version.)

The essay quoted above is based on the author’s book:

Janega, Eleanor. The Once and Future Sex: Going Medieval on Women’s Roles in Society. New York: W.W. Norton, 2023.

610,000 Cancer Deaths Predicted in U.S. in 2023

(p. A3) The cancer mortality rate in the U.S. has dropped by a third in the past three decades, a report showed, but an increase in advanced prostate cancer diagnoses threatens to reverse some hard-won gains.

The American Cancer Society said Thursday [Jan. 12, 2023] that changes in preventive measures and screening in the past decade drove important trends in U.S. cancer incidence and outcomes.

. . .

The report was published in the journal CA: A Cancer Journal for Clinicians. The authors at ACS analyzed federal and state cancer registries for data on cancer rates through 2019 and federal mortality data through 2020, the report said.

Cancer is the second-leading cause of death in the U.S., behind heart disease, with nearly 2 million cases and some 610,000 deaths estimated to occur in 2023, the ACS said. The decline in smoking rates in the U.S., better early detection and innovative treatments including immunotherapy drugs have driven a drop in death rates since 1991, the report said, averting an estimated 3.8 million cancer deaths in that time.

. . .

For prostate cancer, the second leading cause of cancer death among men after lung cancer, rates of advanced diagnoses have risen about 4.5% annually since 2011, the report found. The proportion of men diagnosed with later-stage disease has doubled. Declines in mortality rates have leveled off.

For the full story, see:

Brianna Abbott. “Cancer Death Rate Has Dropped By a Third.” The Wall Street Journal (Friday, Jan. 13, 2023): A3.

(Note: ellipses, and bracketed date, added.)

(Note: the online version of the story has the date January 12, 2023, and has the title “U.S. Cancer Death Rate Has Dropped by a Third Since 1991.”)

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