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.

Catching Up -- Lightning Round

Executive Orders

1. January 23 -- Reinstating the global gag rule (restricting international funding for organizations that provide abortions or information about abortion). Bad for the health, independence, and self-determination of women around the world.

2. January 23 -- Freezing the federal workforce (hiring freeze). Hard to see how the federal government can do all that it does effectively if it cannot hire people to do the work. Of course, dysfunction may be the goal. There is an exception for positions related to military, national security, and public safety. Some of our biggest and/or notable public safety threats are climate change, drinking water contamination (Flint, MI and other cities), and guns. So, naturally, I expect the hiring freeze does not apply to the EPA, NOAA, OSHA, HUD, USDA, HHS. And there will be new hires at the CDC to research gun violence.

3. January 24 -- Expediting environmental reviews on infrastructure projects. The opposite of a health-in-all-policies or kids-in-all-policies approach. Profit for crony capitalists now; environmental cleanup ... someday.

4. January 25-27 -- (1) The wall, (2) Pursuit of undocumented immigrants (includes defunding so-called sanctuary cities), (3) Visa and refugee program reforms (includes so-called Muslim ban). These actions hurt immigrant and refugee children and their families. They are unnecessary for increasing our security and improving our economy. They will instead worsen our security and decrease our economic growth potential. Children don't migrate, they flee. Here is an excellent article on the harms to children of Trump's immigration ban.

5. January 27 -- Strengthening the military. Already more than half of our discretionary spending goes to the military. Imagine if we spent just some of that money on foreign aid, education for women and girls around the world, climate change research, global renewable energy infrastructure, and diplomatic missions. If we did that, I think our need for military defense would be much less. And the world would be better off to boot.

6. January 30 -- Reducing regulation. An arbitrary mandate that for each new regulation, two are struck. This is premised the false notion that regulations, by definition, are bad. Robert Reich makes excellent arguments that refute this idea in his book, Saving Capitalism: For the Many, Not the Few and in abbreviated form in this blog post. Regulations are instrumental to a functioning democratic capitalist society. Regulations protect us from corporate abuses that privatize profits and socialize costs (see #7 below). Regulations protect our life savings, keep our food supply safe, and decrease water and air pollution. This is not to say that regulations should not be reviewed, or that some may be outdated or ill-conceived. But they are not inherently bad.

7. February 3 -- Financial system regulations and the fiduciary standard. This is likely to relax regulations that were put in place during the Great Recession to prevent future financial calamities. Steve Mnuchin, the new treasury secretary, profited from the housing bust. Imagine who might gain from the next preventable financial collapse?



January 13 -- Budget Resolution clearing the way to repeal the ACA. Since this passed, Republicans in Congress seem to be having difficulty replacing the ACA. That's because it is a good policy that helps millions of Americans.

January 24 (House) -- Permanent ban on the use of federal funds for abortions or health insurance that covers abortions. This will make health care less affordable and reproductive health care less attainable. Each year, hundreds of thousands of women make the heart-rending decision to have an abortion. That number is declining, probably due to increased access to contraception through the ACA. Instead of restricting access to legal abortion we should expand access to contraception and comprehensive sex education. When unintended pregnancies are carried to term, we should support moms and families with the social safety nets they need to thrive.

February 2 -- Repeal of the stream protection rule. Makes it easier to mine coal and pollute ground and surface water. No explanation needed here, except to say: If we want to decrease the impact of global warming, instead of burning more coal, we need to sprint in the opposite direction and invest heavily in renewable sources of energy. We cannot continue to support an industry that is contributing to our planet's demise. Clean coal isn't.

February 3 (House) -- Repeal of rule that addresses waste generated during oil and gas production. See above. Once again privatizing profit and socializing costs, spoiling our planet.

February 7 (Senate) -- Approval of nomination of Betsy DeVos to be Education Secretary. Belief in the value of public education is a prerequisite for this post. Fifty Republican Senators and VP Mike Pence thought otherwise. Of note, DeVos had donated $26,000 to Republicans on the Senate HELP committee from 2014 to 2015.

February 8 (Senate) -- Approval of nomination of Jeff Sessions to be Attorney General. The nation's top law enforcement official is now someone who has a sketchy history of racism, is a hardliner on immigration, and is a climate-science skeptic. He is also so close to President Trump that his independence cannot be trusted.

February 10 (Senate) -- Approval of nomination of Tom Price to be Secretary of HHS. A list of Price's qualifications to be HHS Secretary: he is a physician. All indications are that Price will be an instrument of destruction on the ACA and Medicaid, harming low-income children and children with special health care needs.

February 13 (Senate) -- Approval of nomination of David Shulkin to be Secretary of the VA. Shulkin is highly qualified for the job. The VA has very little impact on children. However, children of vets will benefit if and when their parents get improved access to mental and physical health care.

Trump's First Hours

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.

Welcome to Kids In All Policies

Welcome to my nascent website/blog! My goal with this website is to lead conversations about the well-being of children in public policy decisions. I have been thinking about doing this kind of thing for some time, but now feel spurred to action by the Trump administration's early and aggressive assault on our children's future, starting with climate change denial and repeal of the Affordable Care Act.

I will attempt to document most policy actions and my immediate impressions of their impact on children in real-time (i.e. within a week) as I truly believe that virtually every action affects kids. I also want to keep a record - for me, and for the world - of everything President Trump and the Congress do to harm children to serve as a guide for rapid reversal of those policies when Trump is no longer in office. Meanwhile, with any luck, by increasing scrutiny on the administration and Congress, we can decrease the harm that is done and maybe even do some good. As I have time, I will circle back to policy issues with more in-depth thought and analysis.

A disclaimer: I am a fairly well-informed citizen and pediatrician with public health training. I am not a policy expert and I certainly have areas of strength (health policy) and areas of weakness (international trade, for example). I will be reading and listening and learning as I go. Finally, all content and opinions on this website are my own, unless otherwise cited.

Thank you for reading this blog. I welcome polite comments, discussion, and suggestions.