“The United States health system, more than any other in the developed world, forces patients to manage their health care on their own. They pay a lot of their own money for medical care. They have to make sure their specific doctor is covered by their specific insurer. And even if their doctor believes they need a certain treatment, patients must follow rules set by their health insurer, or risk delays in treatment or ultimately having their insurance claims denied.
Patients run into these obstacles all the time — with serious consequences for their well-being. A recurring finding in health care research is that when patients run into any friction, whether high cost-sharing, limited access to providers, or something else, they tend to receive less timely and appropriate care. Over time, that will make people more likely to develop serious health conditions and, ultimately, die younger than they would with proper care.
It starts with the sheer cost of health care to US patients. Out-of-pocket spending per person is higher in the US than in any other wealthy country save Switzerland, and roughly twice as much as in countries like the UK, the Netherlands, and Japan. Recent research has found that even small cost obligations, as little as $10 for a prescription, can discourage patients from taking their medicine as prescribed. A third of Americans have reported in public opinion surveys that they skip medications or other necessary medical care because of the cost.
But the US health system puts up other, subtler hurdles. Insurers don’t cover care at every doctor’s practice or hospital; they instead contract with certain providers to create provider networks, within which their patients must seek care for their treatment to be covered. These networks put the onus on patients to figure out where they can go for care, at the risk of incurring huge medical bills if they get it wrong. That problem came to the forefront in the recent debate over surprise billing: Many people were going to the hospital for an emergency, only to find out after the fact that either the hospital or a doctor who treated them was not covered by their insurer.
That has been a common experience for American patients: About one in four heart attacks lead to the patient being charged for out-of-network care in the emergency department or if they are admitted.
Networks also make shopping for health insurance more difficult. Patients have to try to figure out in advance whether their existing primary care doctor or specialists, or the local hospital, will be covered by their new plan.”
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“Patients can run into the same kind of problem with drug formularies, a list of approved drugs that health plans use to prioritize coverage for certain medications. If a drug is not on a plan’s formulary, customers must pay more of their money than they would for approved drugs. Sorting out which drugs are covered or preferred under a health plan’s formulary can be a headache, and research has shown that such restrictions lead to patients using fewer medications.”
“There are a few ways to think about these bureaucratic struggles. One, coined by Annie Lowrey in a 2021 Atlantic feature, is the “time tax” — the amount of time and energy that people waste interacting with the government. But my preferred term, popularized by the academics Donald Moynihan, Pamela Herd, and Hope Harvey is “administrative burden” — which refers not only to the concrete loss of time and money, but to the cognitive and psychological burdens of having to learn and comply with government rules.
It’s hard to say just how much administrative burden there is. There’s no attempt to synthesize information about it even at the federal level, let alone the state and local governments that are responsible for implementing most safety-net programs. The best way to understand it is to look at all the labor involved to access a specific program: unemployment benefits in North Carolina, for example.
The one overarching truth is that administrative burdens particularly harm people already marginalized because they’re most in need of assistance and because they’re most likely to have difficulty jumping through all the hoops. Maybe they don’t have a computer, maybe they don’t speak English or understand legalese, or maybe they have to forgo shifts at work just to go to the right office to submit a form.
By extension, any restriction on who is eligible for benefits increases administrative burden, not only for people who apply and are found ineligible but also those who have to do more work to prove eligibility in the first place. The Covid-19 test webpage could be easy because there were no restrictions; it didn’t need to ask about anything besides your address.
There’s also a second-order way that making programs universal fights administrative burden: When politically empowered, privileged Americans are inconvenienced by something, they’re more likely to make noise and get it to change.
But there is little if any political incentive to reduce the burden on people who politicians don’t typically listen to or need to court, such as noncitizens or people disenfranchised due to criminal records.”
“the Supreme Court handed down a pair of unsigned opinions that appear to be at war with each other.
The first, National Federation of Independent Business v. Department of Labor, blocks a Biden administration rule requiring most workers to either get vaccinated against Covid-19 or to routinely be tested for the disease. The second, Biden v. Missouri, backs a more modest policy requiring most health care workers to get the vaccine.
There are some things that differentiate the two cases. Beyond the fact that the first rule is broader than the second, the broader rule also relies on a rarely used provision of federal law that is restricted to emergencies, while the latter rule relies on a more general statute.
But the Court gives little attention to substantive differences between the laws authorizing both rules. Instead, it applies an entirely judicially created doctrine and other standards in inconsistent ways. The result is two opinions that are difficult to reconcile with each other.
The NFIB case relies heavily on something known as the “major questions doctrine,” a judicially invented doctrine which the Court says places strict limits on a federal agency’s power to “exercise powers of vast economic and political significance.” As the NFIB opinion notes, the vaccinate-or-test rule at issue in NFIB applies to “84 million Americans” — quite understandably a matter of vast economic significance.
But, if this manufactured doctrine is legitimate, then it’s not at all clear why it doesn’t apply with equal force in both cases. As Justice Clarence Thomas points out in a dissenting opinion in the Missouri case, the more modest health workers’ rule “has effectively mandated vaccination for 10 million healthcare workers.” That’s still an awful lot of Americans!
What if the Biden administration had pushed out a rule requiring 20 million people to get vaccinated? Or 50 million? The Court does not tell us just how many millions of Americans must be impacted by a rule for it to count as a matter of “vast economic and political significance.” And it’s hard to draw a legally principled distinction between 10 million workers and 84 million.
Similarly, in NFIB, the Court notes that the agency which created the broad rule at issue in that case is the Occupational Safety and Health Administration (OSHA) which, as its name suggests, deals with health threats that arise in the workplace, and Covid-19 is not unique to the workplace. “COVID–19 can and does spread at home, in schools, during sporting events, and everywhere else that people gather,” the majority opinion notes.
But, as the three liberal justices point out in dissent, OSHA regulates threats that exist both inside and outside the workplace all the time, including “risks of fire, faulty electrical installations, and inadequate emergency exits.” It’s not at all clear why Covid-19 is any different. And the only explanation that the majority opinion gives — that a vaccination “cannot be undone at the end of the workday,” unlike the donning of fire-safety gear — applies with equal force to both the OSHA rule and the narrow health worker’s rule that the Court refused to block. Doctors’ vaccinations can’t be undone any more than an office worker’s can be.
The Court, in other words, appears unable to articulate a principled reason why some vaccination rules should stand and others should fall.”
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“The opinions suggest that the Court will uphold rules that five of its members think are good ideas, and strike down rules that five of its members think are bad ideas.”
“Before the pandemic, the flu alone could sometimes push hospital systems into crisis mode, where they cancel elective procedures and limit other kinds of care. Now there’s Covid-19, which has done the same thing on its own.
Suddenly conjuring more hospital capacity every winter to handle the expected surges of flu and Covid-19 is not going to happen. Thousands of additional hospital beds are not coming in the next few years, and the US would not have the doctors and nurses to staff them anyway. It will take much longer — years or maybe decades — to improve the gaps in America’s health care infrastructure and workforce that have been exposed during Covid-19.
This means the imperative to “flatten the curve,” to limit the spread of these viruses to stop hospitals from being overwhelmed, will be with us for a long time. But the makeup of the curve will change, measuring multiple diseases instead of one.”
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“Vaccination is the best way to stop a bad Covid-and-flu season before it starts.”
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“Surveillance is critical, starting with early-warning systems. Public health institutions have long monitored the flu and they are already tracking Covid-19 in a similar manner. Monitoring the amount of virus detected in local wastewater has proven to be a reliable leading indicator of new Covid-19 waves during the pandemic. And widespread, reliable testing will be essential — including at-home tests for both Covid-19 and the flu.”
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“Frequent testing lets people know that they should isolate. If they are at higher risk of severe illness, they can get on antivirals quickly. The current therapies are most effective at stopping serious symptoms that could require hospitalization if they are taken within the first few days of an illness. Research in the last decade has found that flu antivirals are too often underprescribed for patients who would benefit most; improving prescription rates is only more critical now that the health system will be contending with both the flu and Covid-19 going forward.”
“about 600 Americans under the age of 18 have died of COVID-19 during the pandemic. A new study from the Centers for Disease Control and Prevention (CDC) took a closer look at young people who were hospitalized for COVID-19 in July and August, while the delta variant wave took hold, and largely found that healthy young people continue to mostly evade the worst of COVID-19.
The study found that most young people who suffer severe COVID-19 outcomes had underlying health conditions. The most common, especially for teenagers, was obesity.”
“The highly contagious omicron variant of the COVID-19 virus often does an end run around the immunological protections of vaccination or prior infection. But recent data from the U.K. and Canada indicate that these breakthrough omicron infections are much less dangerous than first-time infections in unvaccinated people.
Ontario public health authorities report that as of yesterday, 2,093 and 288 people are being treated for omicron variant infections in hospitals and intensive care units (ICUs), respectively. The hospitalization rate per million among unvaccinated people stands at 532.7; it’s 105.9 for folks vaccinated with at least two doses. This means that the reduction of hospitalization risk for those inoculated with at least two doses is 80.1 percent.
The ICU occupancy rate per million is 135.6 for unvaccinated people and just 9.2 for those who have gotten two doses of COVID-19 vaccines. So vaccination reduces the ICU risk by 93.2 percent.”
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“These British and Canadian findings mirror those most recently reported by the New York State Health Department. It finds that the daily rate per 100,000 of COVID-19 hospitalizations stands at 4.56 for fully vaccinated people, compared to 58.27 for unvaccinated people. That means vaccinations are 92.3 percent effective at preventing hospitalization from COVID-19.”
“The Biden administration’s response to the omicron variant is belatedly kicking into gear. The White House announced Wednesday that it would soon ship 400 million N95 masks to US pharmacies and community health centers to be given away. Americans can submit their bills for at-home tests to their health insurer for reimbursement, and on Tuesday, a new federal website launched that lets people order a few free at-home coronavirus tests.
Free tests and free masks are finally here — after some public health experts have been calling for them since omicron was first detected around Thanksgiving or even earlier. But the tests and masks might not arrive in Americans’ hands until the end of the month.
“By the time the masks and tests get there, the surge will probably be over,” Monica Gandhi, an infectious diseases doctor at the University of California San Francisco, told me. It’s possible — but far from certain — that the omicron wave has already peaked. The average number of daily cases has dropped by 50,000 in the last week, a 6 percent decline.”
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“Experts point to three main factors in the US government’s slow response to omicron: an over-reliance on vaccines, a failure to develop contingency plans, and the fracturing of the expert consensus on what the appropriate public health interventions would be.”
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“There are limits on what the federal government can do under our federalist system of government. Mask mandates and social distancing restrictions are largely the purviews of state and local authorities. The Biden administration did attempt to take sweeping actions, such as a vaccine mandate for large employers, that got tied up in the courts.”
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“Public health experts were never a monolith. But early in the pandemic, there was a fairly clear consensus about what to do about Covid-19: Close some businesses, ban most large gatherings, mandate masks, and develop a vaccine. A New York Times survey of hundreds of epidemiologists found in the summer of 2020 that more than half were in agreement about the timeline for resuming many activities that had been stopped because of Covid-19, such as vacationing within driving distance or eating out at a restaurant.
But as the pandemic has dragged on, expert opinions diverged. In spring 2021, the Times ran another survey of epidemiologists, asking them how long people would need to wear masks indoors, the answers varied wildly; 20 percent said half a year or less, while another 26 percent said people would wear masks indefinitely, at least in certain situations. As the Biden administration debated booster shots this summer and fall, some experts were full-throated supporters of giving everybody an additional dose, while other prominent experts argued boosters made sense only for certain people.”