CBO: Obamacare 20% cheaper than they projected; *net* +24M people will have health insurance before Obama leaves office.
— Steven Dennis (@StevenTDennis) January 26, 2015
Cheaper, better, faster — not bad at all.
CBO: Obamacare 20% cheaper than they projected; *net* +24M people will have health insurance before Obama leaves office.
— Steven Dennis (@StevenTDennis) January 26, 2015
Cheaper, better, faster — not bad at all.
My in-laws are looking to buy a new car soon as Rambling Red just ticked over at 250,000 miles and they aren’t sure if she’ll make it to 300,000. Their plan is simple. They have a list of requirements (multi-axle drive, big enough to put the grandkids in back, decent mileage, comfortable, good USB connection for Pandora and a better CD player as my father in law has way more indie cred with his music collection than I could ever wish for), and then they have a list of nice to have features that aren’t critical for the purchasing decision but would be nice to have. Heated seats are on the nice to have list. If they find a vehicle that meets their budget with their have to haves, and it has heated seats, that vehicle is preferable to a near identical vehicle without heated seats.
So why can’t we sell health insurance like that where breast cancer coverage is an option? This is a “conservative” idea on how to reduce costs by letting people buy the insurance to cover only what they think they need.
Breast cancer is expensive to treat. A simple case of breast cancer from diagnosis to remission will cost $20,000 or more, while a more complicated case requiring surgery and chemotherapy could cost $100,000 or more. Breast cancer is also very common:
About 1 in 8 U.S. women (about 12%) will develop invasive breast cancer over the course of her lifetime.
In 2014, an estimated 232,670 new cases of invasive breast cancer were expected to be diagnosed in women in the U.S., along with 62,570 new cases of non-invasive (in situ) breast cancer.
About 2,360 new cases of invasive breast cancer were expected to be diagnosed in men in 2014. A man’s lifetime risk of breast cancer is about 1 in 1,000.
There are roughly 140,000,000 women under age 70, and 108 million women between 18-70. Prime breast cancer age is narrower than that band. In any given year, about 1 in 375 women between 18 and 70 will have a breast cancer diagnosis. Roughly one in 45,000 men will have a breast cancer diagnosis in the same year. Breast cancer payments work out to be about $3.15 per person in the country per month. We also know that there is a significant genetic component of breast cancer risk. So what would happen if breast cancer was only covered a la carte like heated seats?
If people had to buy a breast cancer rider, men would not buy coverage. The one guy in 45,000 is simply screwed. Men not paying for breast cancer treatment roughly doubles the acturially fair pricing of breast cancer coverage to $6.30 per person per month. Women under the age of 18 would not buy coverage either. That is roughly 23% of the population pool, so pricing goes up to $8.07 per woman ages 18-70 per month. Now since we know there is a genetic component, we know the risk pool knows that. Women with no relatives with breast cancer and who don’t have a bad copy of the BRCA-1/2 genes are reasonably unlikely to be diagnosised with breast cancer in any given year. Quite a few of these women will look at the list price and opt-out of buying breast cancer coverage until they get new information such as an older sister receiving a breast cancer diagnosis.
Now pricing for breast cancer coverage is $10.00 or more per potential buyer per month. The women who will buy breast cancer coverage are far more likely to have had a relative with a breast cancer diagnosis and far more likely to have a bad copy of the BRCA-1/2 genes than the general female population. The risk pool is extremely sick from an acturial point of view. Some of these women who could have afforded $3.15 per month in breast cancer coverage now can’t afford the $10.00/month in breast cancer coverage, so they’ll opt-out and we’ll have a social choice of treating these women at the public cost or telling them to shut up and die quietly in the corner as an illustration of responsibility in a liberterian paradise.
The same logic will apply to prostate cancer riders, the men who buy prostate cancer coverage riders will be far more likely to get a prostate cancer diagnosis than the general adult male population. The same applies to an even more extreme degree to pregnancy riders. All men will opt out, all pre-pubescent females will opt out, all post-menopausal women will opt-out, women who have long term birth control will opt-out, so the cost of pregnancy risk would fall on a very narrow, and comparatively poor population, so there will be quite a few uninsured babies being born or more likely massive cost shifting from private insurance to Medicaid.
Adverse selection is a bitch from purely a pricing point of view. Creating a menu of 2,000 disease clusters where people have to opt-in and opt-out of coverage riders is also a bitch that is designed to cause choice overload and piss-poor outcomes for the people who made an individually rational decision to not buy hit by a meteorite coverage but who got hit by a medical meteorite.
I’ll admit, I’m a sucker for medical dramas (all 15 seasons of ER, House M.D., Mercy, Trauma, even early Gray’s Anatomy). But I can’t bear to watch “docudrama” medical shows, for fear of just such a story as this one from the NYTimes:
Anita Chanko could not sleep. At 4 a.m., on an August night in 2012, she settled onto the couch in her Yorkville living room with her dog, Daisy, and her parrot, Elliott, and flipped on the DVR. On came the prior night’s episode of “NY Med,” the popular real-life medical series set at NewYork-Presbyterian Hospital, starring Dr. Mehmet Oz. Mrs. Chanko, 75, was a fan of the show and others like it.
“It starts off, there’s a woman with stomach cancer and her family, and then there’s somebody with a problem with their baby, I think it was a heart,” she remembered. “And then I see the doctor that treated my husband.”
Mark Chanko, her husband, died 16 months earlier, in April 2011, after being struck by a sanitation truck while crossing a street near his home. The doctors and nurses at NewYork-Presbyterian Hospital/Weill Cornell Medical Center tried in vain to save his life.
On the TV screen, she saw the chief surgery resident Sebastian Schubl, responding to an emergency in which a man is hit by a vehicle. “And then I see, even with the blurred picture, you could tell it was him,” she said. “You could hear his speech pattern. I hear my husband say, ‘Does my wife know I’m here?’ ”…
Maryn McKenna, at “Superbug”, her Wired blog: “To Slow Down Drug Resistance in Health Care, Buy an Antibiotic-Free Turkey for Thanksgiving“:
… How can healthcare workers contribute to slowing down antibiotic resistance? A healthcare nonprofit suggests they commit to buying an antibiotic-free turkey for Thanksgiving…
Here’s the backdrop to the campaign, created by Health Care Without Harm,the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) collaborative, and the Pediatric Infectious Disease Society (PIDS):
Health Care Without Harm takes seriously the injunction in the Hippocratic Oath — “first, do no harm” — and works to improve the industry’s impact on patients, workers and the environment. Among other things, the group has encouraged large healthcare organizations to use their institutional food-purchasing power to support production of sustainable meat and produce. Recently, they have been encouraging hospitals to commit to buying meat from animals raised without the routine use of antibiotics, and a lot of hospital systems have signed on.
Their new pledge asks health care workers to make the problem personal, by choosing an antibiotic-free turkey for Thanksgiving — arguably the meat-animal purchase that gets the most attention out of all the holiday meals in the year…
More details at the link.
"We finally conquered Ebola" — Feeble attempt at irony? Or is Howie Kurtz really this fucking stupid –> https://t.co/QJK8lyEAmq
— Billmon (@billmon1) November 11, 2014
NYC Dr. Craig Spencer has gone home, virus-free, even if the media didn’t pay as much attention to his recovery as it did to his diagnosis. Thomas Duncan’s family has reached a settlement with Texas Health Presbyterian Hospital — “Terms of settlement were not disclosed, but the family’s lawyer said it would be enough to care for Duncan’s parents and his four children, NBC News reported. The attorney also said the hospital wouldn’t charge the family for Duncan’s treatment…” Some of his family members still sound a little bitter. So does this guy..
Three weeks ago, it was a media and political frenzy. Today, not one person in U.S. is being treated for Ebola. #panicpeddling
— David Axelrod (@davidaxelrod) November 11, 2014
But the epidemic has not yet been smothered in Africa. From the Washington Post, “Governments, groups striving to become as agile as the Ebola virus“:
The news out of West Africa in recent days — good and bad — has demonstrated a fundamental challenge in the fight against Ebola: The virus is more nimble than the human response to it. The landscape of infection and disease has changed dramatically in recent weeks, even as institutions have largely stuck to blueprints drafted months ago…
The first Ebola treatment unit built in Liberia by the U.S. military is expected to open in the coming days, about two months after President Obama announced that he would send troops to supplement the civilian effort against the disease. But even before that first ETU has become operational, Liberia has seen a sharp drop in new infections and has empty beds in Ebola wards. The new ETUs, temporary structures that can’t easily be used for anything else, may not treat many patients.
Up the coast of West Africa, Sierra Leone has made far less progress in the fight against Ebola. The country had three times as many new infections as Liberia in the most recent three-week monitoring period, according to the World Health Organization. The United States has sent troops to Liberia but not to Sierra Leone.
Guinea, the third West African country hit hard by the virus, is another landscape entirely. It is bigger than Liberia and Sierra Leone combined. There was a drop in cases in the capital, Conakry, over the summer, but the virus recently surfaced again in some neighborhoods. In addition, hot spots continue to pop up in remote places, and health workers still encounter community resistance.
As the epidemic enters this new phase, officials say the strategy must be more aggressive: looking for Ebola “brush fires” and recognizing that “sparks are igniting all over,” as Thomas Frieden, director of the Centers for Disease Control and Prevention, said in an interview last week. The contagion has to be tracked to the last patient and obliterated lest it flare anew…
The Guardian reports on the “sharp rise” of new cases in Sierra Leone:
Official figures released by the minister of health and sanitation show there were 111 new cases registered on Sunday, the highest daily rate since the ministry started publishing figures in August.
There were 45 new cases the day before, including 24 in the capital, Freetown. Laboratory results for patients in Freetown, which include the new British army-built Ebola hospital, showed 40 new cases on Sunday.
There was also a spike in the number of cases in Port Loko, a district north of Freetown where there is still no treatment centre and where, until recently, corpses were left lying on verandahs, in hospitals and in houses for days before collection.
The figures come days after warnings by the UN that Ebola cases in Sierra Leone are being underreported by up to 50%. It is thought that some patients are still not turning up to hospital over fears that they will be turned away because there are no beds or that they will die isolated from their families…
With 596 confirmed cases and still no treatment centre, the rise in the number of cases in Port Loko will cause deep concern among medical aid agencies such as Médecins sans Frontières, International Medical Corps and the Red Cross, who have been pleading for more beds and resources since the beginning of August. The latest figures make Port Loko the third most affected of the 14 districts in the country…
Sarah Stillman, in the New Yorker, reports on “Ebola and the Culture Makers“:
Facely Camara, a young radio journalist, was eager to fight Ebola in his native Guinea. In mid-September, Camara joined a convoy of health workers and government officials heading to Womé, a village in Guinea’s densely forested southeast, where he intended to cover an Ebola-centered education and disinfection campaign for Zaly FM, a popular station. Before he left, his friends and relatives applauded him on Facebook: “A super Mr. Journalist,” they called him. “The future of the family.”
By the time the group returned, many of its original participants, including Camara and two other radio reporters, were corpses in the back of a rescue truck. They were killed not by Ebola but by a hostile mob reportedly suspicious of the government’s public-health interventions in Womé, and of its actions in the region generally. All three murdered journalists were trainees at Search for Common Ground, a conflict-resolution nonprofit that has worked in Guinea, Sierra Leone, and Liberia for more than fifteen years…
The mass killing in Womé presaged a concern that the Ebola outbreak is evolving from a public-health crisis into “a crisis for international peace and security,” as the World Health Organization’s director general, Margaret Chan, called it last month, from Geneva. This past spring, as Ebola spread across the region, S.C.G., which operates on four continents, began generating its own inventive community-by-community responses to the virus, to better tailor communications to local fears, strengths, and histories. The core of their approach has been to recruit not only standard public-health actors but also small-town preachers and soap-opera stars, taxi-drivers and town criers, local reporters and cameramen. What would it look like, they’ve asked, to fight Ebola with culture makers?…
S.C.G. is working closely with regional governments and global groups, but much of its staff is comprised of men and women in affected communities. The organization convenes groups in towns and neighborhoods for sessions structured like the conflict-resolution talks they’ve hosted for years. They start with questions, Jobbins said: “What are the top four or five reasons people here aren’t taking certain steps? What are the barriers? What are the blockages?” From there, a second round of work—what might be called Ebola-prevention craftsmanship—begins…
Given the varied challenges facing the region affected by the Ebola outbreak, community groups, artists, and social-media users across West Africa have also tried their best to experiment. In Freetown, Sierra Leone, groups are circulating informational YouTube videos via cell phones. In Lagos, Nigeria—a notable success story, as Michael Specter writes—Nollywood Workshops has recruited celebrities to make short video dramas about the virus. The episodes suggest how a new language of intimacy between romantic partners might help thwart the virus, and end with simple advice: “Stay calm, stay healthy.” S.C.G. is also recruiting motorcycle-taxi-drivers to distribute health information in hard-to-reach towns. Many of these men are ex-combatants. Jobbins said, “Nobody pays attention to them, nobody listens to them, but they have deep access to all these different communities,” including towns where government officials are too distrusted to enter safely or be heard…
And there are indeed success stories, as per the NYTimes:
Using old-fashioned detective work, public health workers in Mali, one of the world’s poorest nations, working with the Centers for Disease Control and Prevention and the World Health Organization, tracked and quarantined 108 people in two cities and a few roadside towns who may have had contact with a 2-year-old girl from Guinea who died of Ebola on Oct. 24…
A 21-day quarantine since the little girl’s death on Oct. 24 is almost over, and 41 of the 108 Malians in quarantine are due to be released Tuesday, and the remainder by Friday. Since none are showing symptoms, health officials are allowing themselves to hope that their quick response has kept Mali’s first outbreak to a single case.
If so, Mali will join Senegal and Nigeria in having proved yet again that rapid reactions can stop Ebola. In contrast, the initial outbreak in Guinea festered unaddressed for months before it exploded…
The case also illustrates how even people in close contact with victims do not necessarily get the disease, which spreads when infectious fluids get into an open cut, or a nose, eye or mouth.
Remarkably, no one in Mali who touched the girl, Fanta Condé, is yet sick. Not the woman she called her grandmother, her 5-year-old sister or her uncle, who all spent three days traveling with her from Beyla, Guinea. Not Dr. Abdouramane Koungoulba, the pediatrician who first examined her on Oct. 21, nor two traditional healers who saw her earlier, nor any of a dozen other doctors or nurses who gave her a transfusion and intravenous hydration and cleaned up her vomit and diarrhea in the 48 hours before she died.
Nor, apparently, are any of the dozens of bus passengers, taxi drivers, family friends or other contacts she had while traveling…
Trigger warning: Probably NSFW, especially for those of us whose family members have “unresponsive to treatment” mental illness, because here are all of your worst fears and shameful secrets spelled out. But it’s a powerful, and important, story.
Stephanie McCrummen, in the Washington Post:
HE WAKES UP, and even before he opens his eyes, he can see his beautiful, delusional son.
Gus, Creigh Deeds thinks.
He lies in bed a few minutes more, trying to conjure specific images. Gus dancing. Gus playing the banjo. Gus with the puppies. Any images of Gus other than the final ones he has of his 24-year-old, mentally ill son attacking him and then walking away to kill himself, images that intrude on his days and nights along with the questions that he will begin asking himself soon, but not yet. A few minutes more. Gus fishing. Gus looking at him. Gus smiling at him. Time to start the day.
He gets out of bed, where a piece of the shotgun he had taken apart in those last days of his son’s life is still hidden under the mattress. He goes outside to feed the animals, first the chickens in the yard and then the horses in the red-sided barn. He leads the blind thoroughbred outside with a bucket of feed, the same bucket he was holding when he saw Gus walking toward him — “Morning, Bud,” he said; “Morning,” Gus said, and began stabbing him — and then he goes back inside…
… Gus’s mother had him evaluated. Gus was given a diagnosis of bipolar disorder, and at some point that Deeds cannot remember, he was told about it. His son had a mental illness.
“I never wanted to believe that about my son,” Deeds says. “I just wanted to get him back.”
He kept trying to get him back. He helped Gus get a job washing dishes at the Homestead, a sprawling mountain resort in Hot Springs, because surely the structure of a job would help, but then Gus got fired after some sort of fight Gus never explained, and in June of 2011 he moved in with his father, the two of them together in the old white wooden house in Millboro…
“He was having delusions, and I was under the illusion that things would work out. I’m optimistic. Sometimes I’d say to Gus, ‘Come on, pull yourself up.’ For a period of months, he had this book, ‘Confederacy of Dunces,’ and I said, ‘You’re like the hero in the book,’ ” he says, referring to the brilliant, eccentric, philosophical but also slothful main character. “I said, ‘Come on, Bud, you’ve got to do better than this.’ I said, ‘Gus, what’s the plan?’ ”
He shakes his head at how he reacted.
“I just didn’t know what to do,” he says.
He had no information. Gus was an adult, and so his medical records were private…
HE DRIVES TO RICHMOND. He walks into Senate Room B, Siobhan holding his hand. He sits at a long dais and bangs a gavel, facing a room full of mental-health workers, state officials and families assembled for the first meeting of the Joint Subcommittee to Study Mental Health Services in the 21st Century.
“I’m Creigh Deeds,” he says after the other legislators introduce themselves. “I represent the 25th District. You know who I am.”
Before everything happened, his legislative work revolved around economic development, cleaning up a Superfund site, transportation, electoral law and public safety. He supported changes to the mental-health-care system after the 2007 Virginia Tech massacre, but it wasn’t until the day before Gus attacked him that Deeds fully grasped how dysfunctional the mental-health system could be.
That was the day he obtained an emergency custody order for Gus once again. But at the hospital, the legal time limit to find a psychiatric bed for someone deemed to be in need of commitment — at the time, six hours in Virginia —was reached before a bed could be found, at which point Gus was sent home with his worried father.
Then came January, two months after the attack, when Deeds returned to the state legislature, his scars still raw, his eyes red from crying, knowing, he says, that “it would be damn difficult” for legislators to say no to his requests, which they didn’t. Now, because of Deeds, the legal time limit to find a bed is up to 12 hours, and if no bed can be found, the state psychiatric hospital must provide one.
There were other changes, too, but not enough, Deeds says, and so now he is chairing the subcommittee to study Virginia’s mental-health system….
Props to the New Yorkers who understand how epidemic illness works:
Flu vaccinations are up 50 percent in New York City, according to the Health Department — though the city’s flu chief said it’s too soon to know whether the surge is the result of the vaccine being more widely available than ever before, or because of Ebola fears.
Mayor Bill de Blasio and other authorities have been saying a the flu shot is one of the best things people can do to fight Ebola — albeit indirectly. The vaccine does nothing to protect people from the deadly virus. But Dr. Jane Zucker, the city Health Department’s flu chief, said more people getting flu shots and nasal mist means fewer sick people diverting the esources of hospital emergency rooms…
Not so much for Bobby Jindal’s suffering state:
Louisiana has a message for many of the scientists and medical experts studying Ebola and aiding efforts to fight the deadly virus in West Africa — stay away.
The state sent a letter to members of the American Society of Tropical Medicine and Hygiene, which is holding its annual conference in New Orleans next week. If they’ve recently been to any of the West African countries where the virus has infected more than 13,000 people, they shouldn’t attend the meeting…
Louisiana’s decision was made to “address concerns regarding the possible importation of Ebola virus,” the state officials said in the letter. The state has instituted a policy that prohibits people who have traveled to West Africa or cared for people with virus in the past 21 days from using public transportation or joining large groups.
The state said it can’t effectively assess the risk of people who’ve been in the countries. “We see no utility in you traveling to New Orleans to simply be confined to your room,” the officials said in the letter…
Meanwhile, per NYMag, nurse Kaci Hickox defies the alarmists:
Quarantine-defying Ebola nurse Kaci Hickox, now home in Maine after escaping Chris Christie’s bluster in New Jersey, flaunted her freedom in the most Maine way possible this morning: by going on a bike ride. While health officials in the state are insisting she stay inside until November 10, when her 21-day incubation period ends, Hickox, who served with Doctors Without Borders in Sierra Leone but has twice tested negative for the virus and shown no symptoms, keeps pushing the boundaries.
Last night, “Hickox made her point when she stepped outside the home,” the Associated Press reports. “After speaking to reporters, she shook a hand offered by one of the reporters.”…
Per CNN [warning: autoplay video], there’s at least one sensible judge in Maine:
A Maine judge on Friday ruled in favor of a nurse who defied a quarantine in a tense standoff with state authorities, saying local health officials failed to prove the need for a stricter order enforcing an Ebola quarantine.
District Court Chief Judge Charles LaVerdiere ordered nurse Kaci Hickox, who recently returned to the United States after treating Ebola patients in Sierra Leone, to submit to “direct active monitoring,” coordinate travel with public health officials and immediately notify health authorities should symptoms appear…
I’m hoping Governors Christie (NJ) and LePage (Maine) get into a public shoving match at the next big GOP conclave. Preferably with Gov. Jindal trapped between them, for the lulz.
This is just a drive-by sidelight on Richard’s brief — but its worth taking a look at this explainer from the Upshot.
The good news: Obamacare is doing what it set out to do. Kevin Quealy and Margot Sanger-Katz write that
The biggest winners from the law include people between the ages of 18 and 34; blacks; Hispanics; and people who live in rural areas. The areas with the largest increases in the health insurance rate, for example, include rural Arkansas and Nevada; southern Texas; large swaths of New Mexico, Kentucky and West Virginia; and much of inland California and Oregon.
Each of these trends is going in the opposite direction of larger economic patterns. Young people have fared substantially worse in the job market than older people in recent years. Blacks and Hispanics have fared worse than whites and Asians. Rural areas have fallen further behind larger metropolitan areas.
Women are the one modest exception. They have benefited more from Obamacare than men, and they have received larger raises in recent years. But of course women still make considerably less money than men, so an economic benefit for women still pushes against inequality in many ways. [all links in the original]
The bad news: it sucks to be ruled by the Republican cabal. Or rather, it’s great if your state government actually managed to get used to the idea of Free Money! (h/t the indispensable Charles Pierce):
Despite many Republican voters’ disdain for the Affordable Care Act, parts of the country that lean the most heavily Republican (according to 2012 presidential election results) showed significantly more insurance gains than places where voters lean strongly Democratic. That partly reflects underlying rates of insurance. In liberal places, like Massachusetts and Hawaii, previous state policies had made insurance coverage much more widespread, leaving less room for improvement. But the correlation also reflects trends in wealth and poverty. Many of the poorest and most rural states in the country tend to favor Republican politicians. Of course, the fact that Republican areas showed disproportionate insurance gains does not mean that only Republicans signed up; there are many Democrats living in even the most strongly Republican regions of the country.
But for the rest…
There are still a lot of uninsured people remaining, many in the places that had high uninsured rates last year.
Where would those folk live? Check out the last map in the piece. No one here will be surprised.
Image: Rembrandt van Rijn, Christ Preaching (Christ Healing the Sick — the hundred guilder print), 1646-50.
We’ve talked about the Copper plans being proposed by Senator Begich (D-Alaska) and others earlier this year. The basic thrust of the policy is the following:
Right now, minimal essential coverage for people over the age of 29 and those not facing a hardship is a Bronze plan. That plan covers 60% of the average expected acturial cost. All Bronze, Silver, Gold and Platinum policyholders from a single company in a single state make up a unified risk pool. The metallic band plans are subsidized by tax credits. Minimal essential coverage for people 29 and younger is catastrophic coverage which covers less than 50% of the expected acturial cost. Catastrophic coverage has its own seperate risk pool and is non-subsidized.
The copper plan would be a redefinition of essential minimum coverage for most people from 60% actuarial value to 50%. This is a 16% decrease in expected coverage value, and it is getting insurance to the point where it is truly hit by the bus coverage. The 16% decrease in coverage will probably lead to an 18% to 20% decrease in premium pricing if the pricing differentials between the same insurer/same plan design Bronze-Silver-Gold-Platinum hold up. To get that decrease in actuarial value, the maximum out of pocket levels will increase from the current $6,350 to between $8,000 and $10,000. It is a trade-off between lower guaranteed monthly payments and the possibility of much higher oh-shit payments. That is a legitimate trade-off for insurance.
Erik Loomis, at Lawyers Guns and Money, in service of making the larger and correct point that there was never 51 votes in the 2009-2010 Senate as it was for high acturial coverage, low monthly premium insurance for all or at least all citizens and permanent aliens, points out the Copper plan as evidence that there is a significant caucus for making insurance worse. However he makes a point that I think needs significant modification.
“a significant percentage of the Democratic caucus is looking to fix the ACA by making it a lot worse for poor people. “
We need to divide the analytical universe into three segments. I think only one segment would be significantly worse off, one would be in a series of trade-offs in a larger option space, and the third would be untouched.
Let’s get to the easy one first.
People who are buying their insurance on the Exchanges and are receiving federal subsidies won’t change their decisions all that much as long as the subsidy anchor point is the second cheapest Silver AND the expected personal contribution for a given income level stays constant. If we define poor or working poor as people making under 200% of the Federal Poverty Line, the subsidies are rich enough on the premium side of the equation to make Silver very affordable AND Silver has the cost sharing assistance subsidies that makes a 70% actuarialvalue plan jump to either an 87% actuarial value plan or 94% actuarial value plan. The working poor who get their insurance on Exchange can save $30 or $40 a month in premiums but see their deductible go from $500 to $9,000. I don’t think this makes people want to choose Copper as they did not choose Bronze last time around.
The segment where Copper is a toss up are the people who bought their insurance on the Exchange with minimal to no subsidy. The May 2014 data says that 17% or 18% of people bought on the Exchange without subsidy. 5% of the Exchange policies were no-subsidy Bronzes and another 2% were Catastrophic which can not receive subsidy. This is the market for Copper. People buying no-subsidy Bronze and Catastrophic plans were buying minimal coverage. Cheaper but skimpier minimal coverage could be appealing. People on Catastrophic might see a better deal with subsidized Copper for slightly higher deductibles.
I am not a big fan of high or very high deductible plans for most people. The one situation where they are appropriate is when the buyer has no pre-exisiting conditions, fairly young and can quickly access the entire deductible for the year without destroying their future. When we looked at why the Americans for Prosperity (AFP) anti-Obamacare ads sucked so much last winter, we identifed two groups of clear losers. One of them would benefit directly from Copper:
Young single males with absolutely no health problems, no relatives with health problems and incomes over 250% Federal Poverty Line that previously had a $42 a month, $25,000 deductible plans that did not cover maternity or mental health needs. Those policies got cancelled and they actually have to buy good insurance. Young guys making under $25,000 a year usually will get decent subsidies, past that, it is hard to be sympathetic to someone bitching that they (a member of a high accident group) have to buy decent insurance.
Copper does not quite get the 24 year old guy with a $50,000 a year job and no employer provider health insurance back to where he was pre-PPACA, but it would improve his lot. And as long as Copper pays into the general risk pool, this could be okay from a system’s perspective. That is a small group. I would guess 1% to 3% of the Exchange population would take a serious look at a Copper plan as we know the rest of the non-subsidized population valued high actuarialvalue coverage over low premiums, so some of the Bronze buyers would stay at Bronze as that would be the best they could afford.
Now the last segment is one that was not really in play in 2014. This is the segment of employees who work at large companies which want to offer the skimpiest plan that they can get away with to dodge the employer mandate penalties in 2015. These people, especially the working poor who have minimal leverage, would be getting screwed.
Right now the employer mandate is going into effect 1/1/15 for companies that employ more than 100 FTEs. Anyone who works, on average 30 hours or more per week, must be offered a qualifying health plan that costs, for single employee coverage no more than 9.5% of annual wages. If a person is offered that coverage but declines it, they can buy coverage on the Exchange without subsidy. If affordable and adequate coverage is not offered, the employer is fined in the following manner:
The annual fee is $2,000 per employee if insurance isn’t offered (the first 30 full-time employees are exempt).
• If at least one full-time employee receives a premium tax credit because coverage is either unaffordable or does not cover 60 percent of total costs, the employer must pay the lesser of $3,000 for each of those employees receiving a credit or $750 for each of their full-time employees total.
The most common route that I’ve been seeing for large employers to expand coverage has been to set up a seperate Bronze plan for their non-full timers where the payroll deduction is 9.5% of the check. The company then pays the remaining premium. This coverage has a$6,300 out of pocket limit and the narrowest HMO network out there. It is hit by a bus coverage. Someone in an Expansion state making under 138% of FPL is better off on Medicaid, and anyone making between 100% or 138% FPL to 250% FPL is better off on a cost-sharing Silver plan, but the subsidy lock was designed to keep the employer sponsored coverage market from unravelling at an unseemly pace.
If Copper qualified as minimal essential coverage for the Employer Mandate, what I think would happen is that the seperate Bronze plan would be downgraded to a seperate Copper plan with no other changes. The payroll deduction would still be the lesser of 9.5% of salary or total premium, with the company kicking in even less money to cover the rest of the premium. The coverage would have a $9,000 out of pocket limit, the narrowest HMO network available and be even more unusable. It would be more expensive and less useful for the working poor as it is hit by the bus and then run over by the ambulance coverage.
I could see Copper being a useful policy on the individual market if it was solely aimed at the current non-subsidized Bronze/Catastrophic buyers who are in good health and decent financial shape. If Copper meets the minimal essential health benefit for Employer Mandate purposes without a significant drop in the total employee contribution limit, it would be a disaester for the working poor, and should be opposed.
Last week, a major specialty practice in the east suburbs of my central city announced that they had agreed to be bought out by Big City Medical Group. BCMG will now control 85% of the orthopedists, 100% of the dermatologists, 90% of the nephrologists, 75% of the oral surgeons and 50% of the cardiologists who practice in three well populated counties east of the Big City. The press releases claim that BCMG will realize significant efficiencies and cost savings. The buy-out price only makes sense if BCMG either sees 30% efficiencies or 25% above trend reimbursement increases. The latter is far more likely than the former.
Aaron Carroll at the Incidental Economist passes along some further confirmatory research on the effects of provider consolidation on pricing in healthcare. As expected, consolidated providers get paid more:
The authors looked at more than 1050 counties in the US to see if changes in physician competition were associated with prices between 2003 and 2010. They used the HHI …
Variation existed in competition by counties. The 90th percentile HHIs were 3-4 times higher than in the 10th percentile. They also found that prices were $5.85 – $11.67 higher in the counties with the highest decile of HHI versus the lowest decile. Price indexes in the same deciles were 8%-16% higher as well. Over seven years of the study, prices went up more in areas of less competition than in areas of more competition.
One of the great weaknesses of PPACA is that it encouraged provider consolidation while fragmenting the insurance market. The power imbalance which had already led to very high pricing compared to other industrial countries was not corrected, nor improved upon but it was exacerbated. Provider consolidation has been encouraged by the significant push towards adapting electronic medical records which is a massive capital investment for two and three doc practices and the move towards population health management in the ACO model. ACOs require big populations and significant back-end administrative support to target the right patients with the right care. Small practices can’t do that well.
So far, pricing has been moderated primarily through the aggressive use of narrow networks that are excluding high cost providers, and some quality improvements through the Medicare re-admission reduction program among others. But these are marginal changes within a dysfunctional quasi-competitive market.
Assuming that a full National Health Service style take-over of all providers is off this table (and I’ve not had enough shrooms to keep that option on the table) what are the policy options to increase competiveness in the provider market?
The first major option is to have the Federal Trade Commission aggressively review any medical merger in highly concentrated markets with a bias towards denial of mergers. This is something that can be done administratively and in an ideal world where the Republican Party was pro-competition instead of pro-pre-exisiting businesses, this could actually be an area of policy agreement between Democrats and Republicans. In this world, I think the first time a merger is denied, we would see three thousand gross rating points from either AFP or the RNC about bureaucrats in Washington meddling with senior’s health care choices. But regulating consolidation with a bias towards denial would be a good first option that would require the least amount of heavy lifting from Congress.
The second option is, to me, far more intriguing.
The policy change would be to tie universal Medicare/Medicaid/CHIP reimbursement to a provider’s contribution to a set of regional HHI indexes. A three person PCP office has absolutely no market power so they would get full regular government reimbursment. A chain of hospitals that controls 30% of the regional hospital beds has some market power might see a 1.5% decrease in general govenrment reimbursement. Big City Medical Group which controls 70% of the high end specialists for an HHI contribution of 4,900 points might see a 5% reduction in high end specialty reimbursment for every government paid claim. BCMG which controls 12% of the primary care provider network would see regular reimbursement for primary care codes.
The goal is call the bluff that consolidation is about efficiency instead of capturing more consumer surplus and redistributing it to internal stakeholders and the local BMW dealership. If conslidation truly is an efficient option, a firm that is considering moving from regular reimbursement to a 1.75% penalty HHI index would be clearly demonstrating that they think there is a real efficiency gain to be had instead of monopolistic rent gains. Threshold firms would have an incentive to stay at their same size or slightly decrease, thus improving overall market competition on the provider side.
Why do I think this will work? There are two analogue programs which offer strong evidence that these types of thresholds can significantly change behavior.
Medicare is seeing significant improvmeents in the re-admission rate of Medicare patients after they’ve been discharged:
Medicare is fining a record number of hospitals – 2,610 – for having too many patients return within a month for additional treatments, federal records released Wednesday show. Even though the nation’s readmission rate is dropping, [my emphasis] Medicare’s average fines will be higher, with 39 hospitals receiving the largest penalty allowed…
they will receive lower payments for every Medicare patient stay — not just for those patients who are readmitted. Over the course of the year, the fines will total about $428 million…
496 hospitals will lose 1 percent or more of their Medicare payments
Half a billion dollars in fines have changed hospital behavior. Medicare is seeing significant costs avoided, quality improve and patients satifisfied by universal penalties on narrow metrics. Hospitals have gotten their asses in gear to reduce preventable admissions and more importantly from a systemic point of view, these practices that are reducing Medicare insured re-admissions are not only being applied to Medicare patients; they are being applied on a general basis so there is positive system bleed-off.
The other example is Dodd-Frank. Dodd-Frank is the financial re-regulation bill of 2009. It authorized the designation of Systemically Important Financial Institutions (SIFIs) that if they blew up, they could take out the world economy. Dodd-Frank requires SIFIs to have a living will, and hold significantly more capital. Paul Krugman wrote more on this:
As Mike Konczal of the Roosevelt Institute points out, if being labeled systemically important were actually corporate welfare, institutions would welcome the designation; in fact, they have fought it tooth and nail. And a new study from the Government Accountability Office shows that while large banks were able to borrow more cheaply than small banks before financial reform passed, that advantage has now essentially disappeared. To some extent this may reflect generally calmer markets, but the study nonetheless suggests that reform has done at least part of what it was supposed to do.
Did reform go far enough? No. In particular, while banks are being forced to hold more capital, a key force for stability, they really should be holding much more….
There is now a decent disincentive for a large but systemically unimportant firm from getting just a little bit bigger and becoming systemically important. The End the World put has been priced instead of being free.
Under my proposal, there would be a clear price on medical providers from becoming too consolidated, and a clear gain for smaller provider groups. There will be times when the returns to scale such as implementing an EMR significantly outweigh the new price on being a market moving/price setting player, but there would be numerous times where there is no net value from rent extraction in a merger or there is a significant value in one large group splitting into seperate groups. The gains from the less consolidated provider market would not just accrue to the government programs that are gaining from the lower reimbursement rates, but the more fragmented market would mean commercial insurers could get better rates which means lower premiums for privately and Exchange insured individuals as well.
How could implementation occur? I see two routes. The first is the Independent Payment Advisory Board has the authority to change provider payment structures if the growth of Medicare costs per capita exceed certain targets. This would be a massive change to provider payment structures that aligns long term incentives towards producing a more competitive market, so if you can squint correctly, this would be in the remit of IPAB. I am not a lawyer, nor do I play one on the internet, but I think this would be a high risk move as the cost savings would most likely not occur in the first year of recommendations — this is a glide path change, not a curve jumper.
The second is the Health Provider Reform Act of 2021 which would be a massive provider side reform that makes PPACA look like a light lift. For that to happen, states like Maryland and Massachusetts should experiment with their current Medicare and Medicaid waivers as well as Massachusett’s global budget approach with this cost control system. Several years of good data and learning what does not work in a few states could have national significance once Congress is capable of approaching a massive public policy issue concerning healthcare with either large Democratic majorities or a rump faction of the GOP willing to publicly count to eleven with their shoes on without fear of being primaried.
Good news, from the NYTimes:
At least one chapter of the Ebola saga neared a close Sunday, as most of the dozens of people who had direct or indirect contact here with Thomas Eric Duncan, the Liberian man who died of Ebola, had been told by officials that they were no longer at risk of contracting the disease…
All of those whose monitoring was coming to an end had been potentially exposed to Mr. Duncan before he was admitted and put into isolation at the hospital on Sept. 28. They have been released from monitoring in stages. At least 14 of them had been released by Saturday. Others were released Sunday afternoon and some, like Ms. Troh, were released midnight Sunday. A few others may be released after Monday, officials said.
“It’s a significant hurdle for us to get over,” Mayor Mike Rawlings said. “It brings a little bounce in our step, because we know the science is working.”…
And, per NYMag, the hospital lab worker who went on a Carnival cruise has tested negative for the virus. The BBC reports:
The Spanish nurse who became the first person to contract Ebola outside West Africa has now tested negative for the virus, the Spanish government says.
The result suggests Teresa Romero, 44, is no longer infected – although a second test is required before she can be declared free of Ebola…
Meanwhile, European foreign ministers are due to meet in Luxembourg on Monday to discuss how to strengthen their response to the threat posed by the spread of the Ebola virus.
European nations have committed hundreds of millions pounds to help the West African nations of Liberia, Sierra Leone and Guinea reinforce overstretched healthcare systems and mitigate the damage Ebola is doing to their economies.
But BBC Europe correspondent Damian Grammaticas says there is a growing realisation that there is an urgent need for more medical and military teams to be sent to the region, and for more laboratories and hospital facilities to be built.
He adds that the aim to isolate the virus – not the nations affected.
Meanwhile, the World Health Organisation is expected to declare Nigeria to be officially free of Ebola later on Monday, after six weeks with no reported cases… Senegal has already been declared free of the disease.
Also too, commentor & medical lab professional LAMH36 has volunteered to answer questions tonight at 8pm EDT.
Apart from quietly unbunching some panties, what’s on the agenda as we start another week?
Nothing can be made foolproof, because the fools are so ingenious. From the NYTimes, “Life in Quarantine for Ebola Exposure: 21 Days of Fear and Loathing“:
… As the Ebola scare spreads from Texas to Ohio and beyond, the number of people who have locked themselves away — some under government orders, others voluntarily — has grown well beyond those who lived with and cared for Mr. Duncan before his death on Oct. 8. The discovery last week that two nurses at Texas Health Presbyterian Hospital here had caught the virus while treating Mr. Duncan extended concentric circles of fear to new sets of hospital workers and other contacts…
Dr. Howard Markel, who teaches the history of medicine at the University of Michigan, said the quarantines recalled the country’s distant epidemics of cholera, typhus and bubonic plague.
“Ebola is jerking us back to the 19th century,” he said. “It’s terrible. It’s isolating. It’s scary. You’re not connecting with other human beings, and you are fearful of a microbiologic time bomb ticking inside you.”
While a quarantine is designed to protect those on the outside, it also fuels the community’s fear, and sometimes its cruelty.
In Payson, Ariz., paranoia ignited after word spread that a missionary who had traveled to Liberia on a church trip was spending three weeks under a self-imposed quarantine with his wife and four children. The missionary, Allen Mann, strung yellow caution tape and a “No Trespassing” sign around his front door and left a bucket in the yard for neighbors to drop off food and treats for his children.
While most neighbors understood there was scant risk that Mr. Mann, 41, had carried the disease home, rumors nevertheless coursed around town that he had tested positive for Ebola and would soon be medically evacuated. Mr. Mann said an anonymous commentator on a local news website had suggested burning down his house.
“People had this lynch-mob mentality,” he said.
As with other aspects of the Ebola response, the criteria for recommending or requiring quarantine have often seemed ad hoc, random and evolving…
For the record, before I’m accused of wanting to kill innocent people: Quarantine can be a vital tool of public health, and used correctly has saved millions of lives. It’s the “used correctly” that’s an issue. There’s a part of our brains that never evolved beyond a bunch of primates squatting on a patch of brush, bristling in suspicion of the bunch of primates in the patch of brush over there, who are known to be filthy disease-bearing sub-primates with disgusting personal habits just slavering to befoul our precious primate bodily fluids and destroy our primate way of life. And every petty would-be leader knows that screaming imprecations at those primates-who-are-not-us will attract followers…
Also in the NYTimes, “In Europe, Fear of Ebola Exceeds the Actual Risks“:
… Across Europe, as in the United States, a virus that, outside Africa, has infected only a handful of people, all of them medical workers in hospitals treating Ebola patients, has stirred a wave of alarm that doctors and psychologists say reflects the insecurities of the modern mind far more than any significant danger to public health.
In Alcorcón, a town on the outskirts of Madrid where a Spanish nurse lived until she contracted Ebola virus while treating a sick priest, local businesses reported this week that their revenues had plummeted as customers stayed away. Among those hit by the scare was a hair salon where the nurse, María Teresa Romero Ramos, had gone for a waxing before she tested positive…
In Italy, which has had no confirmed cases yet of Ebola, the organizers of an international food fair in Turin asked delegates from Sierra Leone, Guinea and Liberia not to attend this year’s event, which opens next week. Paola Nano, a spokeswoman for Slow Food International, the sponsor of the fair, said that this was not because of any fear of contagion but only because they “might have problems getting here.”
Claudine Burton-Jeangros, a sociology professor at the University of Geneva, said that panic over the disease springs from a paradox at the heart of modern life: the more we master the world through science and technology the more frightened we are of those things we can’t control or understand. “We live in very secure societies and like to think we know what will happen tomorrow. There is no place in our rational and scientific world for the unknown.”…
The result has been a string of unfounded Ebola scares, which in some parts of Europe have led to entire buildings being sealed off and the people inside being held so they could be examined for symptoms…
In one particularly extreme example of overreaction, health authorities in Macedonia sealed off a hotel in the capital Skopje and kept its guests locked up there for days after a British businessman took ill in his room and died soon after being taken to the hospital. Doctors later said his problem was alcohol abuse and general ill health, not Ebola.
French authorities last week sealed off a building that houses a health and social security office in Cergy-Pontoise near Paris after two ill-looking Africans were spotted inside. They tested negative for Ebola…
Russian media, happy to report on a health crisis that has so far not challenged Russia’s already overextended health service, has given extensive coverage to alarm over the virus in Europe and the United States. At the same time, Africans living in Russia have also faced suspicion and scrutiny, as has been the case in Western Europe.
Even in Germany, which has seen little panic about Ebola, some newspapers have stoked alarm. Bild, a popular daily, reported that every second German is scared of getting infected. It gave no details of how it got the figure…
Dr. Petra Dickmann, who runs a risk-communication consultancy in London, said many other diseases pose a far bigger threat to life but Ebola had taken on fearsome dimensions.
“We have been watching Africans dying for months, but think that Africans die all the time from nasty diseases that we don’t have,” she said. “We need to get Ebola out of this box of a scary African monster” and start communicating the real risks clearly, she said.
Yeah, I’m moderately obsessed, because Perfect Storm of Stupid. There are so many useful things we could and should be doing, and yet… from the Paper of Record:
President Obama raised the possibility on Thursday that he might appoint an “Ebola czar” to manage the government’s response to the deadly virus as anxiety grew over the air travel of an infected nurse.
Schools closed in two states, hospitals and airlines kept employees home from work, and Americans debated how much they should worry about a disease that has captured national attention but has so far infected only three people here…
Earlier in the day, lawmakers on Capitol Hill pummeled federal health officials for their response to the public-health emergency that erupted after a Liberian man, Thomas Eric Duncan, tested positive for Ebola last month…
Also in the NYTimes:
Adding a new and troubling dimension to the search for Americans possibly exposed to the Ebola virus, the State Department said Friday that an employee of Texas Health Presbyterian Hospital who may have had contact with specimens of the disease had left the United States aboard a cruise ship.
The employee and a traveling partner, who were not identified by name, had agreed to remain isolated in a cabin aboard the vessel, the State Department said, and “out of an abundance of caution” efforts were underway to repatriate them. A physician aboard the cruise ship had said the employee was in good health…
“The employee did not have direct contact” with Mr. Duncan, the statement said, “but may have had contact with clinical specimens collected from him.”…
Meanwhile, on the “might actually be of some use” front, per Slate:
Now that we’re all agreed that Ebola is everyone’s problem, we’re all totally going to do better fighting it, right? Right. Beyond simply getting hysterical about the widening web of cases in the U.S. and elsewhere, fighting the virus at its source would also seem like a good idea—for everyone. Exactly one month ago—on Sept. 16—the United Nations set up an Ebola Trust Fund seeking $1 billion to do just that. On Thursday, U.N. Secretary-General Ban Ki-moon offered a status report on which countries are ponying up cash and how much they gave.
It presumably didn’t take the U.N. too long to crunch the numbers on contributions. Of the $1 billion needed, only one contribution has been made, of $100,000—by Colombia. That means the U.N. is still, approximately, $9,999,900,000 short of what it thinks it will take to combat Ebola. As a barometer of global commitment, the U.N. trust fund isn’t all that encouraging…
Amy Davidson, in the New Yorker:
… “We know how to stop this,” Sylvia Burwell, the Secretary of Health and Human Services, said in a conference call with reporters. That is all well and good, but the C.D.C. and other health authorities, at every level, can’t just “know”; they also have to act. They can’t just keep repeating that simple competence, prudence, and sympathetic good sense are the answers, while exhibiting none of those traits. Those are the answers: but we have to live them.
The doctors and health workers of Médecins sans Frontières, or Doctors Without Borders, have done so, in heroic, lonesome fashion. The group has been fighting Ebola in the villages of West Africa, where the entire social structure has broken down, since well before the West cared, and with desperately few resources. Pierre Trbovic, an M.S.F. volunteer from Belgium, wrote a few weeks ago about taking on what was regarded as the most awful job at an Ebola center in Liberia: telling people that there were no more beds. “The first person I had to turn away was a father who had brought his sick daughter in the trunk of his car. He was an educated man, and he pleaded with me to take his teenage daughter, saying that while he knew we couldn’t save her life, at least we could save the rest of his family from her. At that point I had to go behind one of the tents to cry,” he said. The center couldn’t admit more without putting all the patients at risk; there was a constant struggle “to keep the tents clean of human excrement, blood, and vomit, and to remove the dead bodies.”
In August, M.S.F. had six hundred and fifty people in the field; now, it has three thousand, in six locations in Liberia, Sierra Leone, and Guinea. “Now we have reached our ceiling,” Brice de le Vingne, the director of operations, said on Tuesday, according to Reuters. The same day, the group noted that sixteen of its workers had tested positive for the Ebola virus, and nine had died. That here, with our bright hospitals, we would allow the disease to spread through simple carelessness feels like a betrayal.
Apart from despairing that there’s no cure for stupid and it has an unfortunately high R0-value, what’s on the agenda as we wrap up the week?
Steve Day's autopsy showed severe black lung. This proved a top doctor wrong & now the program he leads is suspended. http://t.co/eHgxfu3X7d
— ProPublica (@ProPublica) October 9, 2014
From Chris Hanby’s Buzzfeed article:
After working underground in the coal mines of southern West Virginia for almost 35 years, Steve Day thought it was obvious why he gasped for air, slept upright in a recliner, and inhaled oxygen from a tank 24 hours a day.
More than half a dozen doctors who saw the masses in his lungs or the test results showing his severely impaired breathing were also in agreement.
The clear diagnosis was black lung.
Yet, when I met Steve in April 2013, he had lost his case to receive benefits guaranteed by federal law to any coal miner disabled by black lung. The coal company that employed the miner usually pays for these benefits, and, as almost always happens, Steve’s longtime employer had fought vigorously to avoid paying him. As a result, he and his family were barely scraping by, sometimes resorting to loans from relatives or neighbors to make it through the month.
Like many other miners, he had lost primarily because of the opinions of a unit of doctors at the Johns Hopkins Medical Institutions that had long been the go-to place for coal companies seeking negative X-ray readings to help defeat a benefits claim. The longtime leader of the unit, Dr. Paul Wheeler, testified against Steve, and the judge determined that his opinion trumped all others, as judges have in many other cases.
Today, however, there is final and overwhelming evidence that Wheeler was wrong: Steve’s autopsy.
On July 26, what was left of Steve’s lungs gave out. He was 67 years old. The doctor who performed the autopsy found extensive black lung. With the permission of Steve’s family, I shared his autopsy report with three leading doctors who specialize in black lung and related diseases. Each said essentially the same thing: Steve had one of the most severe cases of black lung they had seen…
Reached by phone, Wheeler said, “I’d love to talk to you, but the hospital has asked that everything be referred to the legal team.”
A Johns Hopkins spokesperson would not comment on Steve’s case, but noted that the black lung X-ray-reading program headed by Wheeler has been suspended, pending an internal review. The spokesperson refused to provide details about the review, saying only that it “is proceeding as rapidly as possible, and I can assure you that Johns Hopkins takes it very seriously.”…
White House briefing, shorter: Yesterday: WHY IS OBAMA TRAVELING B/C EBOLA Today: WHY IS OBAMA NOT TRAVELING B/C EBOLA
— Derek Wallbank (@dwallbank) October 15, 2014
News about the second nurse to contract Ebola, from the local Dallas/Ft. Worth station:
… CBS News Medical Correspondent Dr. John LaPook reports that Vinson called the CDC several times before boarding the plane concerned about her fever.
“This nurse, Nurse Vinson, did in fact call the CDC several times before taking that flight and said she has a temperature, a fever of 99.5, and the person at the CDC looked at a chart and because her temperature wasn’t 100.4 or higher she didn’t officially fall into the category of high risk.”…
“Those who have exposures to Ebola, she should not have traveled on a commercial airline,” said Dr. Frieden. “The CDC guidance in this setting outlines the need for controlled movement. That can include a charter plane; that can include a car; but it does not include public transport. We will from this moment forward ensure that no other individual who is being monitored for exposure undergoes travel in any way other than controlled movement.”
Frieden specifically noted that the remaining 75 healthcare workers who treated Thomas Duncan at Texas Health Presbyterian Hospital will not be allowed to fly. The CDC will work with local and state officials to accomplish this…
Cleveland’s Public Health Director, Toinette Parrilla, said Vinson was visiting in preparation for her wedding. While there, she visited her mother and her fiance…
Hindsight being as always 20/20, how hard would it have been to reimburse the cost of Vinson’s (probably non-refundable) ticket, and set her up with Skype to discuss wedding details with her mom and fiance? She figured her personal costs against what the appointed authorities told her about the risks, and it turned out to be a bad gamble. Now “we” are going to pay a great deal of money to contact-trace, decontaminate, probably isolate more people and certainly waste a vast amount of time reassuring the ‘worried well’ that having once flown on a Frontier Air plane in 2004 is not a serious risk factor.
John Sopel at the BBC has a good op-ed on “The Ebola Fumble in Dallas“:
… This is a crude, and damning, statistic but so far Medecins sans Frontieres (Doctors without Borders) has treated thousands of people in West Africa with Ebola, and has seen 16 medical workers contract the disease. This hospital in Dallas has treated just one patient, and has two sick healthcare staff…
The Independent has a article showing that confining an Ebola outbreak can be done:
Nigeria will be officially declared Ebola-free in less than a week after containing the disease that has killed more than 4,000 people.
Eight of the 20 people infected in the country died and there have been no new cases confirmed since 8 September.
It means it is less than a week short of the 42-day period needed by the World Health Organisation (WHO) to confirm Nigeria has quashed its Ebola outbreak…
The outbreak started in July, when a Liberian-American development consultant, Patrick Sawyer, collapsed in the arrivals hall of Lagos airport…
The conditions seemed ripe for it to spread through the densely-populated city of 21 million people and beyond, through the workers travelling in and out of Lagos every day and international travellers flying from its airport around the world.
Knowing the potential of Mr Sawyer’s symptoms, staff at the clinic caring for him refused to let him leave despite alleged pressure from the Liberian ambassador.
Staff at the First Consultants Medical Centre paid a high price for their courage – 11 workers and their family members contracted Ebola and four died….
An emergency presidential decree enabled officials to access mobile phone records and use law enforcement agencies where necessary to track down people at risk.
Almost 900 people – 362 in Lagos and 529 in Port Harcourt – were traced and monitored for symptoms for 21 days to ensure they had not contracted Ebola.
Every one of those people had to provide health authorities with updates about their health twice a day, often through methods like text messaging.
Anyone who didn’t feel well or failed to respond was checked on, either through a neighbourhood network or health workers…
Nigeria’s Port Health Services worked with airlines to ensure outbreak notifications were made and the Ministry of Health activated an Ebola Incident Management Centre to lead the national response.
The Lagos state government, federal institutions, the private sector and global non-governmental organisations were all drawn in to control the outbreak and the operation seems to have been a success…
And, yes, any feints towards such BIG GUBMINT OVERREACH DIKTATER OBOLA FEMA CAMP efforts would’ve been cried down in Dallas, although the screaming across the interwebs would’ve been mostly a stalking horse for the real problem: All that preventive action costs money, and requires large-scale public service coordination, two things to which our modern Robber Barons and their Kochsucking enablers are deathly allergic.
For your further edification (triangulating the medical/social distance between Nigeria & the USA), the NYTimes has an excellent article on how “Spain Exposes Holes in Plans to Treat Ebola“:
The scene conveyed a First World precision: A 75-year-old Spanish priest, stricken with Ebola in Liberia, arrived in Madrid on a special military jet. A helicopter buzzed overhead as ambulances transported him for treatment. Expressing confidence in the preparations, a Spanish health official said the risk of the virus’s spreading was “virtually nil.”
There was just one problem: The city’s infectious disease center had been mostly dismantled as part of a government cost-cutting plan, and a temporary Ebola ward would have to be hurriedly constructed.
After the priest died on Aug. 12, the unit was closed again, and the same exercise repeated when a second Ebola-infected priest was airlifted from West Africa in September. He died two days later, and last week an auxiliary nurse who changed his diaper and helped clean his bed was found to have the disease…
A team of European Union investigators has found fault in the layout of the Ebola ward, while Ms. Romero’s co-workers have said they were forced to remove their gear in a very small space, with limited room to maneuver, even as temperatures rose quickly inside the suit…
Recriminations in Spain, like those in the United States, have been loud and swift, with blame aimed variously at cost cuts, inadequate training and safety protocols, government officials, and the nurse herself…
Beyond the uncertainty over how the infection occurred, much of the public confusion, and anger, is focused on the seemingly loose monitoring of Ms. Romero for more than a week after the death of the second priest. Even as she called in complaining of a low-grade fever and of feeling queasy, she was never told to return to Carlos III…
Javier Rodríguez, Madrid’s regional health minister, initially blamed Ms. Romero for her infection, saying she also may have lied to doctors, remarks that drew angry criticism. He also later seemed to mock the importance of training workers to remove their protective suits…
Unquestionably, the Ebola crisis has exposed the deep divide between health workers and Madrid’s government. In December 2012, Madrid officials announced a broad plan to cut costs by restructuring the public health system, privatizing some hospitals and closing two others, including Carlos III…
I remember some newsmedia-comment chatter about how ‘she wasn’t even a *real* nurse, just a glorified janitor from a tenement in the slums, so nobody important cared if she got sick’. There is a very old Spanish proverb: “God punishes all knaves and fools — but the fools, first.” Pretty clear Ms. Romero (like Ms. Pham and Ms. Vinson, in Dallas) got to serve as our unwitting ‘fools’…