Health Care/Joan Retsinas

Health Policy: A Little Good News

The news on the health-front (and most other fronts) is grim. Opioid addictions are the highest ever. Maternal mortality is the highest of the developed nations. More people are underinsured. The Veterans hospital system remains troubled.

The challenge: find any policy that the Administration has pushed that has improved Americans’ health. I can’t.

But glimmers of good news portend better times. Maybe.

Thanks to $600 million from private donors, New York University Medical School will no longer charge tuition (and will refund tuition that current students have paid.)

School debt looms over university graduates, who may leave with a degree and a $100,000 debt (payments start right after graduation). Medical school tuition averages $40,000 – 50,000 – another $200,000 of debt for the would-be physician. About a quarter of medical students graduate debt-free – the fortunate ones; most leave with the equivalent of a mortgage hanging over them.

There are a few ways to minimize debt, but only a few. Columbia’s Medical School offers need-based scholarships; UCLA offers merit-based grants to 20% of students. The National Health Service will forgive debt for physicians who work in underserved areas. The military will pick up the tab, in return for years of service.

For most new physicians, however, debt is a fact of life. Not surprisingly, most medical students are middle-to-upper middle class, with parents who provide a cushion. Debt does not deter these fledgling physicians: they will earn at least $100,000 after residency. Again, not surprisingly, newly-hatched MDs weigh residency choice against debt: orthopedic surgery versus primary care.

NYU’s decision will not instantly re-shape the demographic profile of physicians. Nor will it necessarily skew residency choices; research suggests that debt is not the key deciding factor. But NYU has opened the doors to change.

Epi-pens: the price has dropped. Remember the headlines a few years ago. Over 3 million Americans, including a lot of children, reach for a life-saving epi-pen when they have an allergic reaction, often to nuts. In 2007 Mylan, the manufacturer, charged $100 for a two-pack, with an expiration date of one year. At the same time, Mylan was pushing regulations that would force airlines and schools to regularly stock the pens – a safety move, but one that was profitable too. Mylan had a monopoly on the pens; it even made the generic. In 2016 Mylan raised the price to $608. Mylan’s executive, who earned $18 million annually, heading a company that netted $11 billion annually, explained the decision to a disgusted Congressional committee.

Life in monopoly-land is not always easy. Congressional disgust, coupled with inventory shortages of epi-pens, prompted action.

Recently, the Food and Drug Administration approved a new generic, one not made by Mylan, but by Teva Pharmaceuticals. Competition works: expect the price to plummet. Soon Walmart and CVS may market their own versions.

The tale of epi-pen may nudge the FDA into action against some of the other drugs whose prices have spiked in the past few years. An optimistic hope.

Technology and tuberculosis. Public health departments struggle to stop the spread of tuberculosis. Patients must take the medication faithfully; but patients, who don’t feel sick, may miss a dose or two, or stop. Local health departments rely on “directly observed therapy:” an official, often a nurse, will travel to the patient to watch him or her take the dose. Effective? Yes. Costly? Very. In rural areas, nurses travel miles to see one patient. And this local visit marks an intrusion into patients’ lives – they are, after all, patients, not criminals, yet they are treated a bit like parolees who must clock in with their parole officer.

Smartphones have come to the rescue, at least for some health departments, for some patients. Developed by researchers from the University of California Davis and Johns Hopkins, the gizmo lets a patient relay a video to the health department, showing him/her taking the medication. The researchers hope that the smartphone replacement for “directly observed therapy” may propel control of tuberculosis in the developing world. Another optimistic hope.

States have joined to force drug companies to broadcast their prices, explain price increases. States – Brandeis’ “laboratories of democracy” — are stepping up to the plate. While this Administration bemoans the hike in drug prices, 24 states have passed 37 bills to force companies to disclose prices, as well as to justify increases. The headline proclaims the emergence of state-power: “States Rush to Rein In Prescription Costs, and Drug Companies Fight Back.” The New York Times singles out Connecticut: if the price of a drug rises by at least 20% in one year, the companies must justify the hike. Companies are marshalling their lobbyists to justify the hikes, to argue against transparency. One state is unlikely to prevail; but the combined power of states might force action that the federal government won’t. Another optimistic hope.

Despite a federal government that seems intent on making Americans sicker, progress is possible. If only the Administration could be a tail wind.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, October 1, 2018

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