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Understanding the Obamacare Repeal, via Kurt Vonnegut
Repealing Obamacare without a fit replacement will leave tens of millions uninsured. Who is responsible for the fall out? A moral hypothetical raised by Kurt Vonnegut can help.
The Trump administration just unveiled its health care plans. Tom Price, a physician and member of Congress for the state of Georgia, is the U.S. Secretary of Health and Human Services.
While his actions have been scrutinized for possible violation of congressional ethics codes before, there is a new question being raised by many people; can he maintain his commitment the Hippocratic Oath while still carrying out orders to end the Affordable Care Act, also known as Obamacare?
For those who need a refresher, the Hippocratic Oath is taken by all doctors as a rite of passage upon becoming certified, and is often summarized by the phrase “Do no harm”. Variations of it were heard recited in ancient Greece by new doctors in the name of the Gods, and it is commonly held to have been composed by the father of western medicine, Hippocrates.
Legally, it has no power; breaking it doesn't mean anything itself. The reciting of the oath is more so a tradition, a personal promise made when you take up the mantle of 'doctor' to always help those in need.
The question was raised as to how far it goes in deciding what a doctor can and cannot do in the state of Georgia. When a group of doctors tried to have a fellow doctor’s license taken away for actively participating in an execution, the state’s response was to make a law protecting such participation as being consistent with holding a doctor’s license.
Some medical students, who have organized into a group called Protect our Patients, have objected to the Trump administration's repeal of the ACA without a suitable replacement ready to go on the grounds that the effect would be to do harm – that which they have sworn against. Seeing the head of the department in charge of the removal of the law being one of their own makes it even more heated for the students.
Before the comments section gets too infuriated, the nonpartisan Congressional Budget Office shows that the repeal without replacement of Obamacare would leave tens of millions uninsured, along with a slew of other economic issues arising as well. It is a fact that repealing the ACA without a replacement will cause many people to suddenly lack quality health care.
The concerned physicians raise the vital question of how far a person's responsibility goes when an action that they take causes harm, suffering, or pain later. Even if they did nothing directly.
Kurt Vonnegut offered us an excellent illustration of this problem in 'Look At the Birdie'. Suppose you were to toss a cat over a high wall, only to have it land on another person’s head. Would you be responsible if it was to scratch their face up? Many people would say yes, at least to some extent.
But what if the cat landed on the ground and then attacked somebody an hour later? Are you still at all responsible? Remember, the wall was quite high, and you made the cat go over it. Many people see this as a different question, and insist that the cat tosser is not responsible at all here.
We could make the question a little more intensive. Suppose a child is inspired to become an ER doctor after the murder of his parents. He goes on to save many lives over the course of his career. Is the person who killed his parents also responsible for the good actions of the boy? After all, he did start the process that lead to the lives saved, even if it came at a small cost. That is where measuring consequences becomes tricky. How do you count everything? Do you hold everybody who participated responsible in some way?
In the event that Obamacare was repealed, and Dr. Price took a large role in that repeal, the question could be asked: is he participating in an action that will cause harm later, and does that mean that he is liable for it in any way? People who think the two cases above are very different say no, he isn’t. Those who think them similar would say that he will cause harm in the process, and is bound by honor to not do it.
Can a physician help take away people’s health care without violating the “Do no harm” aspect of their oath? Is the oath worth the paper it is read off of? Does Dr. Price run the risk of violating the oath by collaborating with the new administration in the repeal of Obamacare? The answer depends on how far out from an action you think responsibility for consequences follows.
Yale psychologist Paul Bloom believes policy should not be decided by appeals to the emotions of voters, but by hard data:
The COVID-19 pandemic is making health disparities in the United States crystal clear. It is a clarion call for health care systems to double their efforts in vulnerable communities.
- The COVID-19 pandemic has exacerbated America's health disparities, widening the divide between the haves and have nots.
- Studies show disparities in wealth, race, and online access have disproportionately harmed underserved U.S. communities during the pandemic.
- To begin curing this social aliment, health systems like Northwell Health are establishing relationships of trust in these communities so that the post-COVID world looks different than the pre-COVID one.
COVID-19 deepens U.S. health disparities<p>Communities on the pernicious side of America's health disparities have their unique histories, environments, and social structures. They are spread across the United States, but they all have one thing in common.</p><p>"There is one common divide in American communities, and that is poverty," said <a href="https://www.northwell.edu/about/leadership/debbie-salas-lopez" target="_blank">Debbie Salas-Lopez, MD, MPH</a>, senior vice president of community and population health at Northwell Health. "That is the undercurrent that manifests poor health, poor health outcomes, or poor health prognoses for future wellbeing."</p><p>Social determinants have far-reaching effects on health, and poor communities have unfavorable social determinants. To pick one of many examples, <a href="https://www.npr.org/2020/09/27/913612554/a-crisis-within-a-crisis-food-insecurity-and-covid-19" target="_blank" rel="noopener noreferrer">food insecurity</a> reduces access to quality food, leading to poor health and communal endemics of chronic medical conditions. The U.S. Centers for Disease Control and Prevention has identified some of these conditions, such as obesity and Type 2 diabetes, as increasing the risk of developing a severe case of coronavirus.</p><p>The pandemic didn't create poverty or food insecurity, but it exacerbated both, and the results have been catastrophic. A study published this summer in the <em><a href="https://link.springer.com/article/10.1007/s11606-020-05971-3" target="_blank">Journal of General Internal Medicine</a></em> suggested that "social factors such as income inequality may explain why some parts of the USA are hit harder by the COVID-19 pandemic than others."</p><p>That's not to say better-off families in the U.S. weren't harmed. A <a href="https://voxeu.org/article/poverty-inequality-and-covid-19-us" target="_blank" rel="noopener noreferrer">paper from the Centre for Economic Policy Research</a> noted that families in counties with a higher median income experienced adjustment costs associated with the pandemic—for example, lowering income-earning interactions to align with social distancing policies. However, the paper found that the costs of social distancing were much greater for poorer families, who cannot easily alter their living circumstances, which often include more individuals living in one home and a reliance on mass transit to reach work and grocery stores. They are also disproportionately represented in essential jobs, such as retail, transportation, and health care, where maintaining physical distance can be all but impossible.</p><p>The paper also cited a positive correlation between higher income inequality and higher rates of coronavirus infection. "Our interpretation is that poorer people are less able to protect themselves, which leads them to different choices—they face a steeper trade-off between their health and their economic welfare in the context of the threats posed by COVID-19," the authors wrote.</p><p>"There are so many pandemics that this pandemic has exacerbated," Dr. Salas-Lopez noted.</p><p>One example is the health-wealth gap. The mental stressors of maintaining a low socioeconomic status, especially in the face of extreme affluence, can have a physically degrading impact on health. <a href="https://www.scientificamerican.com/index.cfm/_api/render/file/?method=inline&fileID=123ECD96-EF81-46F6-983D2AE9A45FA354" target="_blank" rel="noopener noreferrer">Writing on this gap</a>, Robert Sapolsky, professor of biology and neurology at Stanford University, notes that socioeconomic stressors can increase blood pressure, reduce insulin response, increase chronic inflammation, and impair the prefrontal cortex and other brain functions through anxiety, depression, and cognitive load. </p><p>"Thus, from the macro level of entire body systems to the micro level of individual chromosomes, poverty finds a way to produce wear and tear," Sapolsky writes. "It is outrageous that if children are born into the wrong family, they will be predisposed toward poor health by the time they start to learn the alphabet."</p>Research on the economic and mental health fallout of COVID-19 is showing two things: That unemployment is hitting <a href="https://www.pewsocialtrends.org/2020/09/24/economic-fallout-from-covid-19-continues-to-hit-lower-income-americans-the-hardest/" target="_blank" rel="noopener noreferrer">low-income and young Americans</a> most during the pandemic, potentially widening the health-wealth gap further; and that the pandemic not only exacerbates mental health stressors, but is doing so at clinically relevant levels. As <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413844/" target="_blank" rel="noopener noreferrer">the authors of one review</a> wrote, the pandemic's effects on mental health is itself an international public health priority.
Working to close the health gap<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDc5MDk1MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTYyMzQzMn0.KSFpXH7yHYrfVPtfgcxZqAHHYzCnC2bFxwSrJqBbH4I/img.jpg?width=980" id="b40e2" class="rm-shortcode" data-rm-shortcode-id="1b9035370ab7b02a0dc00758e494412b" data-rm-shortcode-name="rebelmouse-image" />
Northwell Health coronavirus testing center at Greater Springfield Community Church.
Credit: Northwell Health<p>Novel coronavirus may spread and infect indiscriminately, but pre-existing conditions, environmental stressors, and a lack of access to care and resources increase the risk of infection. These social determinants make the pandemic more dangerous, and erode communities' and families' abilities to heal from health crises that pre-date the pandemic.</p><p>How do we eliminate these divides? Dr. Salas-Lopez says the first step is recognition. "We have to open our eyes to see the suffering around us," she said. "Northwell has not shied away from that."</p><p>"We are steadfast in improving health outcomes for our vulnerable and underrepresented communities that have suffered because of the prevalence of chronic disease, a problem that led to the disproportionately higher death rate among African-Americans and Latinos during the COVID-19 pandemic," said Michael Dowling, Northwell's president and CEO. "We are committed to using every tool at our disposal—as a provider of health care, employer, purchaser and investor—to combat disparities and ensure the <a href="https://www.northwell.edu/education-and-resources/community-engagement/center-for-equity-of-care" target="_blank" rel="noopener noreferrer">equity of care</a> that everyone deserves." </p><p>With the need recognized, Dr. Salas-Lopez calls for health care systems to travel upstream and be proactive in those hard-hit communities. This requires health care systems to play a strong role, but not a unilateral one. They must build <a href="https://www.northwell.edu/news/insights/faith-based-leaders-are-the-key-to-improving-community-health" target="_blank" rel="noopener noreferrer">partnerships with leaders in those communities</a> and utilize those to ensure relationships last beyond the current crisis. </p><p>"We must meet with community leaders and talk to them to get their perspective on what they believe the community needs are and should be for the future. Together, we can co-create a plan to measurably improve [community] health and also to be ready for whatever comes next," she said.</p><p>Northwell has built relationships with local faith-based and community organizations in underserved communities of color. Those partnerships enabled Northwell to test more than 65,000 people across the metro New York region. The health system also offered education on coronavirus and precautions to curb its spread.</p><p>These initiatives began the process of building trust—trust that Northwell has counted on to return to these communities to administer flu vaccines to prepare for what experts fear may be a difficult flu season.</p><p>While Northwell has begun building bridges across the divides of the New York area, much will still need to be done to cure U.S. health care overall. There is hope that the COVID pandemic will awaken us to the deep disparities in the US.</p><p>"COVID has changed our world. We have to seize this opportunity, this pandemic, this crisis to do better," Dr. Salas-Lopez said. "Provide better care. Provide better health. Be better partners. Be better community citizens. And treat each other with respect and dignity.</p><p>"We need to find ways to unify this country because we're all human beings. We're all created equal, and we believe that health is one of those important rights."</p>
A study by UK archaeologists finds that longbows caused horrific injuries similar to modern gunshot wounds.
- UK archaeologists discover medieval longbows caused injuries similar to modern gunshot wounds.
- The damage was caused by the arrows spinning clockwise.
- No longbows from medieval times survived until our times.
Battle of Agincourt.
The angle of entry into a cranium found during the excavation at a medieval Dominican friary in Exeter, England.
Credit: Oliver Creighton/University of Exeter
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Vegans and vegetarians often have nutrient deficiencies and lower BMI, which can increase the risk of fractures.
- The study found that vegans were 43% more likely to suffer fractures than meat eaters.
- Similar results were observed for vegetarians and fish eaters, though to a lesser extent.
- It's possible to be healthy on a vegan diet, though it takes some strategic planning to compensate for the nutrients that a plant-based diet can't easily provide.
Comparison of fracture cases by diet group
Credit: Tong et al.<p>The results showed that vegans were especially vulnerable to hip fractures, suffering 2.3 times more cases than meat-eaters. Vegetarians and pescatarians were also more likely to suffer hip fractures, though to a lesser extent.</p><p>One explanation may be that non-meat eaters consume less calcium and protein. Calcium helps the body build strong bones, particularly before age 30, after which the body begins to lose bone mineral density (though consuming enough calcium through diet or supplement can <a href="https://ods.od.nih.gov/factsheets/Calcium-Consumer/" target="_blank">help offset losses</a>). Lower bone mineral density means higher risk of fracture.</p><p>Protein seems to help the body absorb calcium, <a href="https://www.bonejoint.net/blog/did-you-know-that-certain-foods-block-calcium-absorption/#:~:text=Historically%2C%20nutritionists%20have%20warned%20that,may%20increase%20intestinal%20calcium%20absorption." target="_blank" rel="noopener noreferrer">when consumed in normal levels</a>. The recent study, along with past research, shows that people who don't eat meat tend to have lower levels of both protein and calcium. When the researchers accounted for non-meat eaters who supplemented their diets with calcium and protein, fracture risk decreased, but still remained significant.</p>
Credit: Pixabay<p>Another explanation is body mass index (BMI). Non-meat eaters tend to have a lower BMI, which is associated with higher fracture risk, particularly hip fractures. In the new study, vegans with a low BMI were especially likely to suffer hip fractures. That might be because having more body mass provides a cushioning effect when people fall.</p><p>Still, the study has some limitations. For one, White European women were overrepresented in the sample. The researchers also didn't collect precise data on the type of calcium or protein supplementation, diet quality or causes of fractures.</p><p>Another complicating factor: Producers of vegan products, such as plant-based milk, are increasingly fortifying foods with nutrients like calcium and protein, so modern vegans are potentially at lower risk of deficiency.</p><p>The researchers wrote that their findings "suggest that bone health in vegans requires further research."</p>