Putting ‘skin in the game’
Michael B. Lax, MD, MPH
            A few years back I watched a video of SteffieWoolhandler, one of the physician founders of the single payer advocacy organization Physicians for a National Health Program (PNHP) debating Bill O’Reilly on his Fox News show. The topic was health care reform, and I was hoping to see her take O’Reilly down as I figured she had devoted much of her life to this issue and could easily run circles around him. Instead I was shocked, and I could tell she was too, by his opening gambit. He didn’t dive right into the specific pros and cons of single payer, but instead, with an aggressive question: “Why should I be paying for the bad choices someone else makes? They should be paying the consequences, not me?” Caught off guard, Woolhandler stammered a response that I don’t even remember.
            This was a revelatory moment, as I finally understood one of the central assumptions and preoccupations of the right wing opponents of single payer health care. The assumption is that ill health is largely a consequence of the choices that each individual makes.  A corollary assumption is that even in instances where individual choice has not played a role in causing someone’s disease, their choices determine their access to medical care. Work hard, make a decent living, get a job with health benefits and you earn your access to care. Slackers will just have to do without. The preoccupation is to make sure the burden of paying for those mistakes falls on the individuals who make them. Every individual should have the right to decide for him/herself whether or not to buy health insurance, and has the responsibility only for his/her own health and health care.
            Though right wingers profess great faith in the capacity of each individual to make the ‘right’ choices, and bristle at the idea that working class people are routinely duped by millionaires and billionaires posing as men and women of the people, they also assert that individuals often need ‘guidance’ to make sure their choices are the ‘right’ ones. Typically ‘guidance’ comes in the form of market based incentives that hit people where it hurts, in the pocketbook. This gets back to O’Reilly’s point as the right tries to translate what he was saying into actual health care policy. So how can individual responsibilityfor health decisions be translated into practice? The answer is that health care ‘consumers’ need to have what the right loves to call ‘skin in the game’.  In other words, if more of the costs of health care can be shifted onto patients (who are now called consumers), than costs can be controlled as ‘consumers’ try to minimize their expenses.  If the money spent on health care is your own, you will think twice about spending it, and you will try and find the best deal.
            There are huge problems with this approach. On what basis can an individual patient judge the difference between the health care options s/he is offered? Is the price of an option a reliable indicator of quality? How easy is it to even find accurate prices anyway? How likely is it that someone who is suffering from symptoms and is seeking rapid relief will be in a position to calmly and rationally research the possibilities for care and choose the best one? And how will the burden of increased risk affect the individual’s decision to seek any care, let alone identify the best care?
            Recently NPR aired a story about a physician with an academic appointment at a prestigious university. He decided to test the ‘skin in the game’ theory out in practice by putting his family and himself on a health insurance plan with a very high deductible and limited coverage.  His son needed a surgery, and he and his wife debated whether the son really needed to go to the follow up visit after the surgery. Eventually they decided the son should go. Later the father suffered an attack of a very rapid heart beat. He had had these episodes in the past but usually they lasted only a few minutes. This time it dragged on…thirty minutes…an hour. He became increasingly alarmed, but hesitated to seek care as he was worried about the bill. Finally, to his great relief his heart rate returned to normal.  The story beautifully illustrated how even a doctor, completely in the know, could have his decision making clouded by financial concerns. If patients had approached him with these same two problems, he unhesitatingly would have advised the person post op to go to the follow up appointment, and the person with the rapid heartbeat to go get care immediately. But when it came to the health of his son, or his own health, his money worries got in the way of optimal care. If even a doctor can be swayed, what does that say about everybody else?
            The doctor’s story nicely documents what is likely to be the major impact of forcing patient’s to shoulder more of the financial risk of health care. Patients will wait longer than they should to seek care, and will often not seek care at all. Sometimes they will be lucky, like the doctor with his heart beat, but at some point they will see their luck run out. The guy who collapses and dies from his heart attack might well have had a different outcome if he hadn’t delayed going to the Emergency Room when his chest pain began, because he was worried about the expense. And, as usual, it can be expected that those with the least means will be the slowest to seek care, as the potential financial hit for them carries the most impact and can be truly devastating.
            Are the Republicans and the right wingers advocating these kinds of policies aware of these likely consequences? It would be extremely difficult to believe they are not. They dress their ideas up with high sounding concepts like individual choice, and control of runaway health care costs. But at bottom, what they are proposing is entirely of a piece with Bill O’Reilly’s snarling question for SteffieWoolhandler: ‘if individuals can’t take care of themselves, why should I be responsible for them?’
            There are ways to control health care costs without penalizing individuals, often the most vulnerable individuals, for health conditions and need for care they actually have very little control over. Its called single payer health care. 
Promises, Promises:  The Republicans search for a replacement for Obamacare
By Michael B Lax, MD, MPH

Recent Quotes from Republican politicians

“Don’t worry, it’ll be better than Obamacare.”
“We’re gonna have the best health care in the world!”
“Nobody will lose their insurance. Everyone will be covered.”

Really?? Its hard to figure out if the republicans believe their own fantasies or are engaged in a conscious campaign of obfuscation. They act as if they can just get rid of the features of Obamacare they don’t like (the requirement that everyone buys insurance, regulation of the plans insurance companies offer) and keep a few of the things that are popular (keeping kids on their parents insurance until 26, maybe the prohibition against excluding people with pre existing conditions from buying insurance). But the pieces of Obamacare fit together like a puzzle into a whole and if you take out big pieces the rest won’t fit together into anything coherent.

So far the Republicans have had about 7 years to come up with a replacement for the law they hate. And so far the only things they have come up with are warmed over old ideas that would mostly just take health care back to pre-Obamacare days, with some free market based twists. Ideologically they are committed to getting the government out of financing, regulating, and delivering health care. What that means in practice is a system that is ideally, entirely based on people buying health insurance from private companies. Medicare would be privatized. Medicaid would be federally funded, but through block grants to the states, giving the states discretion over how to spend the money.

Under the Republican plans, individuals and employers would be free to buy insurance or not. Insurance companies would no longer have to offer a standard plan or minimum levels of coverage, but would be free to create insurance plans of various kinds, which would likely range from the gold plated plans congress has given itself, to plans that offer catastrophic care only after a very high dedeuctible has been met.

Unfortunately, the individual mandate to buy insurance is a key reason Obamacare works. Take it away and the system falls apart. Insurance works when the pool of people insured includes both the sick and the healthy. The healthy don’t use much care and the insurance companies make money on them. That allows the companies to absorb the costs of taking care of the sick. Eventually the healthy will get sick and need care but a new crop of healthy insured people will subsidize their care. Without the individual mandate a good number of healthy people will choose to either go without insurance or to choose a cheaper plan with a high deductible that provides fewer services. Those with health conditions will be left behind in more expensive plans that no longer will be able to count on a pool of healthy people to keep costs down. Prices for the insurance will go up and people will at some point no longer be able to afford the insurance.  They will be forced to find other cheaper plans that have more out of pocket costs: deductibles, co pays, charges for medications and treatment for conditions that are not covered.

Republicans, however, say the problem of costs can be controlled. Individuals can set up savings accounts before they are taxed (Medical Savings Accounts or MSAs) and then spend the money on health care when they need it. They also say that the truly needy will receive government subsidies to help them buy insurance. The republicans are obsessed with costs, but specifically with controlling the costs corporations and government pay for health care. For that reason, their assurance that people in need will receive enough help to allow them to buy insurance rings exceedingly hollow, as they will not be willing to publicly finance the true needs of people.

The MSA idea also runs into problems when confronted with current reality. Most working class, and even middle class Americans are having a lot of difficulty saving money for retirement or other needs.  Listen to the news for awhile and you will run into a story warning Americans about their savings deficit for retirement and other needs. The idea that most people are going to put enough away to cope with essentially uncontrolled medical costs on top of struggling to save for non health needs is pure fantasy. The people MSAs would work for are those who need it the least: the rich.

The Republicans have been very coy about releasing details of their plans to replace Obamacare. Initially this was attributed to a desire to wait until the head of Health and Human Services was confirmed and in a position to lead the effort. More recently, however, it looks more and more like the Republicans don’t yet have a comprehensive plan beyond repeal. The implications of the ideas they have put forth so far are politically threatening for them. Perhaps they have recognized the impossibility of fulfilling their health care promises with their chosen, ideologically driven, solution of privatized profit driven health care.

Removing the individual mandate, reducing regulation of insurance, MSAs, block grants to states for Medicaid all lead in one direction: the loss of health care for millions. Estimates of the health impact of these kinds of changes includes 22,000 people dying due to their inability to get care. Some commentators have called the republican health care project ‘cruel’. It seems reasonable, however, to call a plan that leaves 22,000 dead criminal.

Other ideas

Medicaid- how it works, managed care, privatized, block grants- how have states already signaled or actually shown what they want to do with more discretion over medicare

Patient skin in the game

These are the kinds of things the Republicans tell us when asked about what’s going to replace Obamacare. I wouldn’t count on any of these assertions being true.

            The Republicans assure us that the things that are popular about Obamacare will be kept like: no one can be denied insurance coverage for a pre-existing condition; kids can be kept on their parents insurance until they are 26; and millions who previously did not have insurance are now covered.

             So far, there are no specifics, including in the testimony of Tom Price, the physician nominated to be the head of the Department of Health and Human Services (HHS), at his confirmation hearing.  But its possible to predict what some of the likely contours of Obamacare’s replacement based on the past statements of some of the key players. And those predictions don’t bode well for the health care system or our health.

            Republicans have been particularly antagonistic to the mandatory purchasing of health insurance by every individual and seem universally committed to eradicating the mandate. In addition Republicans want to ‘free’ insurance carriers to be able to offer various insurance plans to individuals without requiring all plans to include a standard minimum group of services.


Universal Access to Health Care: a step on the road to health justice

By Michael B Lax, MD, MPH

            In the age of Trump, the trashing of Obamacare seems to be inexorably moving from rhetoric to actual repeal of the law. But at least some Republicans recognize that more than 20 million Americans have been able to access health insurance and medical care with Obamacare. Anyone supporting a replacement that threatens that insurance will have a lot of very angry constituents on their hands. While some Republicans may be working overtime to blame the Democrats for any fallout if Obamacare is repealed without a decent replacement, it is pretty certain that most of them know who the vast majority of the 20 million will blame.

            For all its flaws, (and I should state right up front that I support a single payer, Medicare for all type system), the Affordable Care Act  (ACA) did improve access to health care for many people. That is something that is worthwhile defending. The idea that health care should be a right for everyone, not a privilege for some, has always seemed to me to be a no-brainer, but I’ve come to understand that that sentiment is hardly universally shared in this country. Pragmatists tell us that universal access is a nice ideal, but cost considerations make it impossible to achieve. So we do the best we can with incremental and “realistic” reform.  The ACA reflects that approach. Free market or neoliberal ideologues oppose on principle any increased government role in financing or delivering health care. For them, in health care as in everything else, market forces should rule, elevating cost containment and profit considerations to top priority, and relegating universal access to less than an afterthought.  Besides, for ideologues, individuals should bear the consequences of their “choices”, good and bad. If you “choose”: an unhealthy lifestyle and get diabetes or have a heart attack; a low paying job that doesn’t include health insurance; to spend your money elsewhere and can’t afford health insurance, then you are out of luck.

            I would argue that any health care reform should place universal access at the top of the priority list. What justifies this position? Any rights that we enjoy have been defined and won through debate and struggle. The rights we in the United States see as the bedrock of our society including: freedom of speech, freedom of the press, freedom of religion, were all created by people with a vision of what a just society would look like. These rights were not ordained by God or some other superhuman entity, but came from the minds of people like us. After almost 250 years as a nation it has become clear that our constitutional rights do not guarantee that everyone has an equal opportunity to prosper in our capitalist system.  In fact, that’s a gross understatement. Almost 14% of the population, and 20% percent of children live in poverty, while 13% of households go hungry. And this is just a description of some of the most extreme manifestations of inequality. Throw in underfunded, troubled public schools; lack of low cost child care; poor public transportation; lack of decent paying ‘middle class’ jobs; gangs; violence; and drugs. On top of that add institutionalized discrimination on the basis of race, gender, and sexual orientation among others. The result of all these chronic and worsening problems is the entrenchment of hugely unequal life chances, and massive privileges for the few.

            Given this reality, a just and humane society today would recognize the equal fundamental value of each and every one of its members. In practice that would mean recognizing that many need a helping hand to eat, to earn a living wage, to get a roof over their heads, to go to a decent schools, and yes, to go to the doctor if they get sick. A just and humane society recognizes that the basics of existence are essential for anyone to thrive and to have the chance to take advantage of the opportunities life offers them. Access to health care fits into this framework as one of the basics that everyone should be guaranteed.

            To the ‘pragmatists’ I would say your vision for health care is impoverished. Almost every other developed country in the world has embraced universal access to health care and has achieved it, while at the same time spending substantially less than we do in the United States. On top of that, many of those countries have populations that are even healthier than we are in the United States. The ‘fact’ that it can’t be done is a myth contradicted not by a theory, but by a reality lived every day in many countries.

            To the ‘ideologues’ I would say your vision is inhumane, and is actually a recipe for the ongoing enrichment of the few with the continued impoverishment of the rest. The remedy will require a struggle to ensure more equitable opportunities for all. Universal access to health care is a crucial piece of that struggle.


Access to Medical Care in Workers' Compensation is in Crisis

By Michael B. Lax 

The creation of the state’s Workers’ Compensation was premised on two fundamental goals for workers injured or made ill on the job:

1)     Rapid access to appropriate medical care

2)     Rapid access to adequate wage replacement benefits

New York’s Workers’ Compensation is a failure when measured by either of these two goals.  Lack of access to medical care is the focus of this piece.

Chris Glorioso, a New York City news reporter recently ran a story about a man who suffered an eye injury at work and needed an ophthalmologist for treatment. He contacted over 60 eye doctors listed by the New York State Workers’ Compensation Board as accepting Workers’ Compensation as payment for treatment. When called, none of the physicians would see the patient because it was a Workers’ Compensation case. Here’s the link to the full story: http://www.nbcnewyork.com/news/local/NY-Refers-Injured-Workers-to-Docs-that-Dont-Accept-Workers-Comp-372153352.html

(Full disclosure: I was interviewed for that story)

Glorioso’s report highlights a problem that we see every day in our Occupational Health Center. It’s a problem that’s getting worse, and can impact an injured worker’s health and ability to earn a living in serious ways. Here are some recent examples from central New York:

A young man works construction and is required to do a lot of lifting and moving of heavy building materials. He had a hernia several years ago and began experiencing similar groin pain more recently. It got to the point where he can’t work due to the severity of the pain. His family doctor told him he has a hernia likely due to lifting, but that doctor doesn’t take Workers’ Compensation (WC). After telling him the problem is work related the doctor told him he needs a surgeon, and then probably billed the patient’s health insurance for the visit. The patient went to a surgeon and heard the same story: “you have a work related hernia, but I don’t take Workers’ Compensation”.  At this point three months or so have gone by, the patient has brought home no income, his WC claim has not been initiated, and he has received no treatment. He drives more than two hours to our clinic where I told him that I’m not a surgeon so I can assess causation but I’m not experienced in diagnosing hernias, nor can I operate if he has one. We referred him to another surgeon whose office says he takes WC. The patient returned to our clinic a couple of months later stating things didn’t work out with the second surgeon either, and he wants another referral and he’s willing to make the long drive to Syracuse. Since no treatment has been initiated it looks like the patient will not be able to return to work at the start of this construction season, leaving his family and him without income for an indefinite period.

A woman works in an office where she and several co-workers develop asthma after being exposed to chemicals used in a construction project on the building they work in. She continues to have regular flare ups of her asthma, requiring urgent medical attention. Her primary care doctor provides the care for these acute episodes. After several years he announces to the patient he will no longer be accepting WC and she will have to seek care elsewhere for her asthma. He suggests that our occupational clinic can play that role. Unfortunately our clinic is about two hours away from where she lives, making it completely impractical and dangerous for her to travel when she is having trouble breathing. Initially she seeks care at the local Urgent Care and eventually we are able to help her locate a new primary care doctor near her home.

A man presents to an orthopedist with symptoms suggesting a nerve is being pinched in his hand.  The doctor agrees it is probably work related after many years of repetitive, forceful hand use as a mechanic in an industrial plant. The orthopedist accepts WC, but only after the case has been accepted. He will not do the work to get the case established and accepted but will be happy to take payment for the surgical procedure once someone else has taken care of arguing causation. The worker has to drive almost three hours to our clinic for us to carry out the work the orthopedist has decided is not worth his time.

Finally, a man goes to a lung specialist after developing severe shortness of breath. The lung doctor agrees the problem is most likely a result of inhaling isocyanate containing paint fumes over a period of years. The doctor accepts WC and files a report with the WC Board. However, when the patient’s lawyer approaches him and asks for some additional information crucial to getting the WC claim established, the doctor balks and refuses to take the time. The patient eventually initiates care at our occupational health center.

Every week additional patients could be added to this list from those seen at our clinic. The problems these patients have accessing medical care lead to delays in diagnosis and treatment often with worsening of the condition, sometimes permanently. These delays can also deprive a patient and his/her family of income necessary to survive: to buy food, pay a mortgage, keep a car from getting repossessed.

So, when it comes to access to medical care, the WC system is a miserable failure. Major reform is necessary to try and keep doctors in the system, and bring back those who have dropped out.

Despite the difficulties, however, doctors have a responsibility to serve their patients. WC provides crucially necessary benefits to injured workers, and advocating for patients in the WC system should be seen as a necessary part of the treatment for work related health conditions. It is unfortunate that many physicians in New York continue to divest themselves of this responsibility. 

Michael B. Lax is the Medical Director of the Occupational Health Clinical Center


Football and Brain Trauma: A Workplace Health Issue

By Michael B. Lax MD, MPH

The news that almost one third of NFL football players can expect to suffer the effects of brain trauma made headlines in major media. (See for example: The New York Times 9/12/14 article “Brain Trauma to Affect One in Three Players NFL Agrees”) While it is not surprising that large men, often leading with their heads, bashing each other week after week suffer some consequences, what was unexpected was how many players are likely to be injured, and that the NFL actually acknowledged this reality.

Obviously, the findings lead to the question of what to do about it besides compensate the injured. In the context of workplace injuries the injury rate in this industry is tremendously high and the severity of the resulting health conditions,  including life altering and shortening conditions such as Alzheimer’s disease, chronic traumatic encephalopathy, and Parkinson’s disease should raise serious alarm bells and initiate efforts to reduce the injury rate.
A major question is whether players can really be protected from head trauma given the way the game is played and the personal protective equipment that is available. The League put administrative controls in place a year or two ago, trying to limit certain types of contact to avoid butting heads, but injuries continue to occur. Helmets, the primary protective gear are technologically limited and cannot be designed to really protect the brain from serious trauma. Professional football is an example of work that cannot be made safe, at least without fundamentally altering the way the game is played.
As might be expected, some (many?) voices are calling for the game to be banned, and parents are being urged not to let their kids play tackle football. Others are defending the game and a common argument the defenders use is that professional football players are highly paid and knew the risks going in. They freely chose to take the risk, and others should not be denied from making the same choice.
Our freedom to choose in all areas of life is an idea that is American as apple pie. But the idea of “choice” requires closer examination. Although we like to think of ourselves as individuals who are capable of objectively analyzing every situation and making choices through our reasoning ability, the reality is that our choices occur in a context. That context allows us to see some things and not others, filtering our reason through personal experience, emotional response and who knows what other influences.
To illustrate: how does an NFL football player “choose” to become an NFL football player? To be an NFL player is to join the ranks of an elite group who enjoy all the perks of being a celebrity: fame, fortune, prestige, admiration. If a kid is big and talented, dreams of an NFL future can be stoked early on and nurtured through a long march through high school and college. Other less glamorous possibilities pale in comparison, especially for kids who don’t see other avenues for themselves, or without a scholarship wouldn’t be going to college. Dazzled by the promise of such a glamorous future, how likely is it that a kid is going to listen to the statistics regarding head injuries and future health problems and make a decision to seek some other less traumatic, and much less exciting career path? In this context can a young person ever really be said to ‘understand’ the risks? He is too busy trying to rationalize the risk away because that NFL future is just too hard to let go of.
NFL football is a multi billion dollar business and the owners, team employees, uniform and equipment manufacturers, merchandise makers and sellers, stadium food vendors, sports media, cities collecting tax and other revenue, and the rest of the massive enterprise are all depending on the continuing popularity of the game to keep the money and profits flowing. Toward this end, the product has to continue to satisfy the audience, which has come to expect the excitement of tough men hitting each other as hard as they can. Maximizing the violence, maximizes the excitement and maximizes revenue.
In this enterprise, the players are simultaneously central and peripheral. Obviously the players make the game what it is and star players are celebrated endlessly. But once a player gets old and loses a step, or gets injured they are unceremoniously dumped in favor of someone else who will get the job done better. The game depends upon a continuous pipeline of fresh young players to replenish the ranks thinned by those cast aside. The point is that professional football is not only responsible for ignoring the epidemic of head injuries for so long, but also for painting the picture and creating the system that entices young people into the pipeline, knowing full well that the dream is unachievable for the vast majority who try, and that many will suffer head injuries along the way, often long before they even get close to the NFL. Untold numbers of young people, their lives altered forever, are unmentioned by the NFL’s late epiphany.
The result is an as yet unknown number of high schoolers, college players, and professionals suffering the effects of football induced brain trauma. And likely all of them, after they are injured, will lament the ‘choice’ they made to chase the dream.

So what should be done?

Any other industry found to be this hazardous to its workers would probably be shut down. Since that’s not likely to happen (though maybe a player should file an OSHA complaint and see what happens), other actions are possible. First would be an aggressive campaign to reduce the legitimacy of NFL football as a sport, and to characterize it for what it really is, gladiatorial combat to entertain the masses. Parents might think long and hard before giving permission for their kids to participate, communities might pressure their schools to get rid of their football programs, and people could stop going to NFL games. This would have to be coupled with efforts that are serious and effective in opening up other avenues to fame and fortune, or at least a decent living, for kids who otherwise might see chasing the NFL dream as their only way out of poverty and what they see as dead end lives.   

Posted September 22, 2114

Describing low-wage, precarious work: What's it like?

By Jeanette Zoeckler

Low wage work

The existence of low paying and temporary work arrangements creates a workforce at high risk for occupational injury and illness. Workers are at high risk due to the lack of a living wage, insecure work arrangements, high frequency of wage theft, poor health and safety conditions, lack of union representation and discrimination.

Temporary staffing and other low wage work arrangements with high turnover rates have suspended and replaced full time work at living wages, allowing for a competitive advantage for employers who improve profit margins by cutting the costs they pay in wages and benefits. Employers become habituated to the flexibility in their staffing planning, which translates into irregular work schedules for workers and decreased risk involved with the hiring decision.

These trends lead to increased poverty, increased risk for work related death, injury and illness, and inferior socio-economic conditions. Establishing the relationship between precarious work arrangements, low wage work arrangements and health is beginning to be seriously undertaken. Looking upstream for solutions designed to sustain socio-economic improvement for low-wage workers, to improve the conditions for workers in low-wage jobs and for the prevention of occupational fatality, injury and illness in this vulnerable group will likely necessitate working across political boundaries.

Job insecurity

Job insecurity implies a vaguely defined employment arrangement or basic job instability. It carries with it the implicit notion that the work arrangement is "precarious" or not permanent and may be terminated at the employer's whim. Workplace rights don't seem to apply as the employee is only temporary. Occurrences of job insecurity might include scenarios when the individual senses there will be layoffs due to external economic conditions, plant closures, corporate downsizing, or instability within the employer revenue streams. It can also occur when supervisor bullying is present and the employee feels under vigilant threat of being fired. Additionally, job insecurity can occur when an individual is ill-suited to the work assigned and performance objectives are not satisfactorily met. Job insecurity can also be present if hours assigned to work fluctuate severely from week to week.

NOTE: Job insecurity is related to poor psychological health outcomes. Instability of work is also associated with poor self-rated health in a "dose-response" pattern. So, the degree of instability in the work is related to how poorly folks rate their own health.