Mushrooms, guns, and $5

Fall in Western Oregon brings rain, flocks of migrating geese, and mushrooms. Chanterelles, one of the magical gifts of the natural world, erupt from the loam of the forest floor of Oregon’s hills and mountains. They are delicious sautéed with butter and salt and eaten with salmon or on pizza. Foraging for the mushrooms in Oregon is more difficult this year because of the climate change-fueled wildfires, which have burned more than one million acres, destroyed lives, and closed roads. Following the advice I often give my patients - to get out into nature to reduce stress and anxiety and to recharge - our family set out this past weekend to an unburned section of the Mt. Hood National Forest. We left our liberal Portland neighborhood, bedecked with progressive political signs, and, one hour later, found ourselves in a different universe.

As we approached the spot where we wanted to look for mushrooms, we came upon several men in what looked like tactical gear, milling around their cars and trucks, apparently preparing for target practice. They had hunting rifles and what looked like - and later sounded like - semi-automatic assault rifles. As we passed, a couple of them smiled and waved. We pulled off a couple of miles down the road from there, still hoping to look for chanterelles. But when we got out of the car and heard the rapid, powerful bangs of weapons of war echoing around the hills, which frightened us and reduced our dog to a shivering puddle, we decided that that piece of National Forest was not for us that day.

We were not naïve to the reality that the National Forest has many uses, including hunting and shooting. In fact, we had carefully checked the Oregon hunting season calendar to be sure we were not in the forest during deer hunting. We had also, in an abundance of caution, brought hunter orange clothing and a vest for our dog. But to be confronted with the sights and sounds of assault weapons - weapons like those that have been use in countless school shootings and other mass shootings - when we, with our two young kids, were hoping for a respite in nature….

I have since read up on the rules governing target shooting in the Mt. Hood National Forest. Provided certain safety and anti-littering rules are followed, it is allowed, without user fees, in nearly the entire forest. There are only a few small areas where it is forbidden. We were actually in one of those areas where we pulled off to look for chanterelles, but we were well within earshot of the semi-automatic gunfire.

Unlike the wildlife, we were able to get into our car and drive lividly to a state park. We paid a $5 user fee and went for a lovely walk through a woods full or Oregon White Oak and cedar trees, hummingbirds, blue jays, chickadees, chirruping frogs, a rough-skinned newt, mosses, lichens, epiphytic ferns, many and varied fungi, and a blessed absence of assault weapons fire. But no chanterelles. We replenished our souls and left behind only footprints.

Now I am back in the city, back to the 2020 news cycle, back in the pandemic, and back to work in pediatrics where I still counsel my patients daily to get out into nature. I just hope they can afford the user fee.

Paid family leave is on the march in Oregon

I traveled to Salem, Oregon last night for a hearing on bill to create a paid family leave program. The bill, if passed, would allow new parents up to 26 weeks of paid parental leave. Workers caring for a sick family member or themselves could get up to 12 weeks of paid leave. And expecting mothers could get up to six weeks of leave before delivering. This would be paid for by a 0.5% or less payroll tax.

I had planned to testify in support of the bill on behalf of the Oregon Pediatric Society. But, I was pleasantly surprised when it turned out there were so many people already signed up to testify in support of the bill that there was not time for my oral testimony.

Lawmakers heard from mothers, fathers, sons, daughters, sisters, brothers, and spouses about how paid family leave would help them to care for their newborn or sick family member. There were many small business owners who were eager to have help from the community at large to provide paid family leave for their employees. In opposition to the bill were several representatives from Chambers of Commerce and a few business owners, most of whom spoke in generalities about how the regulatory environment makes it hard to do business in Oregon.

On the contrary, I think this law will be a tremendous benefit to business in Oregon, attracting new companies that want excellent benefits for their employees.

I am hopeful that lawmakers will pass this bill and bring Oregon up to speed with the world in providing paid family leave.

Babies Are Everywhere! (in Germany)

I recently had the opportunity to travel to Munich, Germany for vacation. My partner and I spent most of a day crisscrossing the center of the city on foot, visiting churches, seeking currywurst, and wandering through the Englischer Garten. We noticed parents with their infants everywhere we went, eating breakfast at the cafe, strolling along the sidewalk, lying on picnic blankets in the park. Bonding, playing, loving. Unlike in the United States, these infants were not just one or two months old, but one to 15 months old. And, unlike in the US, they were as likely to be with Dad as with Mom.

Germany, like most of the rest of the world excepting the United States, has a robust paid parental leave policy. That policy is evident on the streets of Munich.

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Paid family leave improves child and maternal health

Paid family leave allows new parents to spend time at home with their newborn or adopted child, developing the nurturing, protective bonds that enhance brain development and ward off toxic stress. In addition, parental leave has direct, immediate impacts on the health of infants:

• Maternity leave correlates with higher rates and longer duration of breastfeeding (1, 2)

• Maternity leave is associated with higher birth weights and lower infant mortality (3)

• Parental leave improves rates of vaccination and well-child checkups (4)

Paid family leave is also important if a child becomes seriously ill and requires more than a few days of hospitalization or care at home.

For new mothers, maternity leave correlates to increased energy, decreased fatigue, and decreased symptoms of depression (5, 6).

Paid family leave can help relieve childhood poverty

Access to paid family leave in the United States is extremely limited. In most states, employers can choose not to provide paid family leave. Nationally, it is a privilege that only 13% of workers have (7), and they tend to be higher earners. Only 5% of earners in the lowest quartile have access to paid family leave, while 21% of earners in the highest quartile do (7). The birth or adoption of a child, or a child’s serious illness, are events that increase household emotional and financial stress. Low-income workers are least likely to be able to afford a disruption in pay during one of these events. As a result, many parents who get unpaid leave after the birth or adoption of a child return to work early because they cannot afford to go without pay.

Universal paid family leave would allow many more parents to take leave, and to receive pay during that leave, at a time when financial demands on a family are relatively high. These benefits would accrue especially to low-income families.

United States lags behind on parental leave policy

Relative to 20 other wealthy nations in the Organization for Economic Cooperation and Development (OECD), the United States parental leave policy – The Family and Medical Leave Act (FMLA) of 1993 – falls short:

• Parental leave is shorter than in other countries – 24 weeks total for both parents versus an average of 95 weeks, median of 60 weeks

• Parental leave is unpaid, compared to an average of 23 weeks fulltime-equivalent paid leave, median of 20 weeks (8)

In addition to these limitations, many US workers do not qualify for FMLA. There are key requirements that exclude many parents from eligibility: 

• the employer must have 50 or more employees

• the employee must have worked for 12 months for that employer

• the employee must have worked at least 1250 hours in the previous year for that employer

These requirements exclude part-time, temporary, and seasonal workers. They also exclude many low-income workers who work more than 40 hours per week but hold more than one part-time job.

The FAMILY Act

The Family and Medical Insurance Leave (FAMILY) Act, first introduced in 2013, would make qualifying family leave, such as the birth or adoption of a child or long-term care for a seriously ill child, available to all workers. The Act would:

• Provide up to 12 weeks of family leave with partial pay

• Provide 66% of wages during the leave, up to a capped amount

• Be paid for with a payroll tax of 2 cents per $10 in wages

• Be available to every worker, including part-time and seasonal workers, and those who work for small businesses

The FAMILY Act, if implemented, would make paid family leave available to every working mother, father, and adoptive parent. This is likely to improve breastfeeding rates and vaccination rates, and help low-income and middle-class families afford to take time off from work to bond with their newborn or tend to their sick child.

References

1. Ogbuanu C, et al. 2011. The effect of maternity leave length and time of return to work on breastfeeding. Pediatrics 127(6):e1414 

2. Guendelman S, et al. 2008. Juggling work and breastfeeding: effects of maternity leave and occupational characteristics. Pediatrics 123(1):e38-e46

3. Rossin M. 2011. The effects of maternity leave on children’s birth and infant health outcomes in the United States. Journal of Health Economics 30(2):221-239

4. U.S. Department of Health and Human Services. 2014. Work family supports for low-income families: Key research findings and policy trends. Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/14/WorkFamily/rpt_WorkFamily.pdf

5. Chatterji P and Markowitz S. 2004. Does the length of maternity leave affect maternal health? National Bureau of Economic Research Working Paper No. 10206

6. McGovern P, et al. 1997. Time off work and the postpartum health of employed women. Medical Care 35(5):507-521.

7. US Bureau of Labor Statistics. 2014 http://www.bls.gov/ncs/ebs/benefits/2014/ownership/civilian/table32a.htm

8. Ray R et al. 2009. Parental leave policies in 21 countries. Center for Economic and Policy Research

Getting to Single-Payer

If we changed our health care system overnight to single-payer, we would not instantly save $1 trillion per year.

Let's look at how we spend our health care dollars now. According the Centers for Medicare and Medicaid Services (CMS), this is how, in 2015, we spent $3.2 trillion:
- $1 trillion (up 5.6% year over year) on hospitals
- $635 billion (up 6.3%) on physician and clinical services
- $88 billion (up 5.9%) on other professional services (e.g. podiatry, physical therapy, optometry)
- $118 billion (up 4.2%) on dentistry
- $163 billion (up 7.8%) on "other health, residential, and personal care services" (e.g. school-based care, workplace health care, community centers, ambulances)
- $89 billion (up 6.3%) on home health care
- $157 billion (up 2.7%) on nursing home and retirement care
- $325 billion (up 9.0%) on prescription drugs
- $49 billion (up 3.9%) on durable medical equipment
- $59 billion (up 3.7%) on non-durable medical equipment

That leaves about $520 billion, or 16% of the total spending, unaccounted for. This is overhead. Estimates vary about how much money we could save by cutting insurance overhead costs. Medicare, the federal single-payer system for those older than 65, has an overhead of about 2% whereas private insurance overhead averages about 12%. Steffie Woolhandler and David Himmelstein estimate that we "could save approximately $504 billion annually on bureaucracy" by going to single-payer.

Besides bureaucratic overhead, why else is American health care so expensive? Prices. We pay more for CT scans, MRIs, pharmaceuticals, hospital services, and procedures. And why are prices so high? Compared to other countries, we have done less to regulate the health care industry and the prices in that system. For example, the UK’s National Health Service is a massive purchaser of pharmaceuticals and negotiates favorable prices; it then controls the growth in those prices. America’s Medicare, by contrast, is not allowed to negotiate drug prices. (It mystifies me that supposed ‘free-market’ conservatives defend this plainly anti-capitalist statute.)

To this list of reasons for high health care costs in the US — bureaucratic overhead, high prices, and dysfunctional and counterproductive regulation — add system fragmentation, perverse incentives, and severe under-investment in health promotion and disease prevention, including transportation, food systems, healthy housing, healthy communities, open spaces, pollution control, etc.

A single-payer health care system has the potential to diminish, if not cure, many of these ills. Bureaucratic overhead would be much lower than 16%, if not as low as Medicare’s 2%. A cohesive public health and health care system could align incentives with outcomes; invest in prevention and realize the saving in health care delivery; make pricing transparent and competitive.

Further, with guaranteed health care, Americans would be free to start a business, change jobs or industries, or go back to school, and not have to worry about how they would afford health care for themselves or their employees. I struggle to imagine a more potent injection of entrepreneurial energy into the American economy.

Unfortunately, the road to single-payer is riddled with obstacles. Public opinion is starting to shift in its favor, but political will is lagging. There are many entrenched interests wishing to defend their $1 trillion, give or take, who currently benefit from our fragmented, inefficient, opaque, and wasteful system. I believe the public option - in which individuals could choose to buy insurance from the federal government rather than private companies - is the most viable route to single-payer. Another, more attractive, option would be to enroll every child under 18 in a federal health insurance system - Medicare for kids. Then, year by year, increase the enrollment age by one year to 19, then 20, etc, thus creating an entire generation that is fully insured. (We could, at the same time raise the national smoking age, year by year, creating a smoke free generation — imagine the savings!)

No matter the path to single-payer, I think it is inevitable that we will get there. Whether this century or the next will determine what other things, with a spare $1 trillion per year, our nation can accomplish.

Why Not Universal Coverage?

Imagine if you decided to quit your job. Or if you were fired? What if you wanted to start a new business? Or go back to school? Or take a few months for travel or to write the next Great American Novel?

How would you maintain health insurance coverage for yourself and for your family?

You might get expensive COBRA coverage. You might go to healthcare.gov (when it is not down for maintenance) and find insurance on the ObamaCare exchange. You might go without insurance for a while and hope that you and your family do not get sick or injured.

But what if your health insurance were guaranteed to you and your family as a public good? Would you be more inclined to start a new business? Or get more education or job training? Or spend more time volunteering or pursuing something creative? What if you had less stress about finances or the unexpected?

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Now picture a Congress that has more time, energy, and political capital to address the most pressing needs of the country and the world -- climate change, crumbling infrastructure, corporate greed, income inequality, poverty, famine, displacement, violent conflict -- because they are not fighting over health care.

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Finally, imagine if, as a country, we spent 9.7% of GDP on health care like the UK, or 11% like Sweden, or 10.9% like Japan, or 11.3% like Germany, or 9.6% like Australia instead of 17.2% of GDP on health care (data from Organisation for Economic Co-operation and Development). If we spent only 12% of GDP -- still more than other OECD countries (except Switzerland, 12.4%) -- on health care, we would save almost $1 trillion every year and $10 trillion over 10 years.

How to spend that money is for another post, but for some perspective: we could rebuild the entire US highway system twice over every year, or pay off the national debt of almost $20.5 trillion in 28 years, or give our 3.2 million public school teachers a $300,000 raise.

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1. Guaranteed health care. 2. Lawmakers focused on other major national and world problems. 3. $1 trillion in savings. This is the dream of single-payer advocates, such as Vermont Senator Bernie Sanders.  For the average American, it's win-win-win-win: greater economic and personal freedom, less stress, fewer medical bankruptcies (or none!), no news stories about the next GOP attempt to trash ObamaCare, more public and private dollars for investments in America's and the world's future.

So what is the hold up? One trillion dollars every year. The difference between what we spend on health care (17.2% of GDP) and what other wealthy countries with excellent health care spend (12% or less) is $1 trillion of fat that now goes to insurance companies, hospitals, pharmaceutical companies, medical device manufacturers, nursing facilities, pharmacists, doctors, shareholders of the medical-industrial complex, and thousands of industry lobbyists. A lot of people are made wealthy by the inefficiency of our health care system. And, right now, these powerful interest groups have more sway with lawmakers and public opinion than single-payer advocates.

That is starting to change.

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Up next, driving the change to single-payer.

An Ounce of Prevention Is Worth One Pound Eight Ounces of Cure

NPR reported this morning on a health care system in Pennsylvania -- Geisinger -- that is helping its diabetic patients by prescribing fresh foods. They are seeing dramatic improvements in hemoglobin A1c, a marker of blood sugar control, and expect to reap $24,000 in savings for each $1,000 spent on the program.

That loud bang you hear is not a secret airplane landing with a sonic boom but the sound of public health researchers and advocates smacking their foreheads. The public health community has long been pushing for upstream interventions to improve health, like improving access to fresh foods, building safe communities so people can be outside getting exercise, getting tobacco out of public spaces.

This is not to diminish what Geisinger is doing. On the contrary, we need more health systems to innovate in preventive care. But under the traditional payment model -- where every widget (or toe amputation) is reimbursed -- health care organizations stand to make more money treating sick patients than they would keeping populations healthy.

Over the last three decades we have made gradual progress in changing the incentives to encourage more preventive and higher quality care. Hospitals are paid for bundles of service, e.g. heart bypass surgery and rehabilitation, and are on the hook for preventable complications such as post-operative infections. Some health systems provide standard per member per month (or PMPM) payments to health care providers to keep their populations healthy and care for them when they are sick. The Affordable Care Act mandates that health insurance pay for certain 'essential health benefits,' including preventive care such as pediatric well-child visits.

The Geisinger experiment and public health research show that we should be investing a great deal more in keeping Americans healthy and preventing illness in order to reduce suffering and death. And save money.

In its current form, the Republicans' health care reform bill, the AHCA, gives millions of dollars in tax breaks to the wealthy and drops essential health benefit coverage.

This will cost us.

'Smoking is good for you' and other deadly lies

Imagine you knew nothing about climate change and wanted to learn the basics. What would you do? Many people would search the internet. When I google "climate change," the first page of results includes the NASA and EPA websites on climate change. Exploring the EPA website, I quickly found A Student's Guide to Global Climate Change where I read the following:

"The Earth is getting warmer because people are adding heat-trapping gases to the atmosphere, mainly by burning fossil fuels. These gases are called greenhouse gases. Warmer temperatures are causing other changes around the world, such as melting glaciers and stronger storms. These changes are happening because the Earth's air, water, and land are all linked to the climate. The Earth's climate has changed before, but this time is different. People are causing these changes, which are bigger and happening faster than any climate changes that modern society has ever seen before." [emphasis added]

On the same website there is a simple animation showing how human-produced carbon dioxide is contributing to global warming. EPA administrator Scott Pruitt should check out his own agency's website. He might learn a thing or two before hitting the delete key.

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Pruitt is not cautiously skeptical of climate science, as he would have you believe. He is willfully ignorant of it. In the most egregious and deadly case of privatized profits and socialized costs since Big Tobacco, Pruitt and Company are handing the fossil fuel and car industries billions of dollars in profits at the expense of our children's lives.

Climate change is already affecting the health of children around the world: increased morbidity and mortality from extreme weather events, new exposures to vector-borne infectious diseases such as malaria, food insecurity as a result of crop failure, increased morbidity and mortality from allergic and respiratory disease as air pollution increases and warm seasons lengthen, mental health impacts of increased migration and social strife due to climate change.

Big Tobacco has taught us that corporations -- and their shareholders -- are willing to lie and cheat their way to bigger profits, even if it means their customers are getting sick and dying from using their product. Big Tobacco lied about the health impacts and addictiveness of cigarettes. They aggressively marketed (and continue to market) to youths to get them hooked on tobacco. They manipulate their product to maximize addictiveness. And they spend millions of dollars lobbying to keep the rules in their favor.

Meanwhile, 480,000 Americans die each year (1,300 per day) of tobacco-related causes and we spend $170 billion annually in tobacco-related health care costs and lose $156 billion in lost productivity due to illness and premature death. This is after decades of work by scientists, physicians, and public health advocates fighting Big Tobacco and making significant progress to expose their lies.

Big Oil is Big Tobacco's protégé. Aided by mouthpieces and enablers like Pruitt and Company, Big Oil is peddling lies about greenhouse gases and climate change. They are spending millions on lobbying for favorable rules and subsidies. They are making huge profits while making us sick.

But, whereas tobacco has the power to sicken individuals and families, fossil fuels -- and the global warming they cause -- are sickening whole populations and our planet.

So when Pruitt says, "there's tremendous disagreement about the degree of impact [of carbon dioxide], so no, I would not agree that it's a primary contributor to the global warming that we see," what he really means is, "my fossil fuel buddies' billions in profits disagree with overwhelming scientific evidence that we are causing climate change."

His willful ignorance is killing us.

Advancing the Keystone XL and Dakota Access Pipelines

The Keystone XL and Dakota Access pipelines were both halted by the Obama administration but were given new life by President Trump this week. These pipelines would promote the extraction of oil from Canadian oil sands and the Bakken Shale in North Dakota. Moving oil by pipeline is probably safer than moving it by rail, but an even safer option is not to move oil at all and instead leave it in the ground. By further developing fossil fuel resources, rather than promoting energy conservation and development of alternative energy resources (e.g. wind and solar), we are moving in the wrong direction on climate change. Coming on the heels of the warmest year on record, Trump's actions demonstrate a stark disregard for the health of our planet and our children in favor of corporate profits.

Obamacare under fire early in Trump administration

During President Trump's first few hours in office, he signed an executive order to "relieve the burdens" of Obamacare. This is Trump's opening salvo on the Affordable Care Act, Obama's signature health care reform bill that has extended health insurance to millions of Americans resulting in our highest insurance coverage rate in history and providing financial security for millions of American families.