In the public health department

Let's see what day was this?  It was a long weekend and I have no idea what I did with most of it.  Was it Friday?  I think it was Friday.  Anyway I went to see Tim Faust speak at Garden District Book Shop.  The book he's promoting is called Health Justice Now: Single Payer and What Comes Next.  I'm sure it's very good. I did buy a copy but it's at the bottom of a pile quite similar to if not worse than this one from the middle of the summer. I'll get there eventually.  If you've seen, read or heard any of Faust's work advocating for a better health care system than the nightmare we live and die at the hands of today, then, well, this talk was very much like that.

In his talk, Faust says the US is "the most dangerous place to be sick the most dangerous place to be poor, the most dangerous place to be black or brown, the most dangerous place to be disabled, the most dangerous place to be queer..." There is a mutually reinforcing relationship between poverty and illness. The so-called "health-wealth gap" in the United States adds up to a 20 year difference in life expectancy between the richest and poorest. All of these states of precariousness are direct reflections of an unjust health system. 

By that, he means the US health care delivery apparatus is fraught with such waste and unfair distribution that the negative health outcomes compound upon each other. "In the US all prices are fake," says Faust. The costs of primary and preventative care are grossly inflated as large corporate providers force smaller health clinics out of business in order to charge hospital rates for everything. And, of course, insurance companies can only profit by denying patients care when they need it. 

Unjust wealth allocation leads to unequal health outcomes in all sorts of ways.  Faust travels all over the country talking to people about health care and gave a few examples. In Houston the prisons have become warehouses for people with untreated mental illness. In Memphis environmental racism has led to a situation where black children die at 20 times the rate of white children.  When Indiana Governor Mike Pence inhibited needle exchange programs during the height of an opioid crisis, it  resulted in "one of the biggest HIV outbreaks in decades."  These are all essentially questions of resource allocation.

The day after I saw Faust talk, I read in the Advocate that the state has finally responded to public pressure at least to the point of agreeing to study the effect of the Denka neoprene plant on cancer rates in St. John Parish. As we know, the State of Louisiana subsidizes the proliferation of plants like Denka to the tune of billions of dollars each year.  Poor Louisianians are subsidizing the profits of the petrochemical industry with their very bodies.

The US spends over $3.6 trillion annually on health care. According to Faust at least 1/3 of that is "waste." It would cost approximately 10 percent less to implement a single payer system. And the savings can be applied to giving people better housing, better transit, better food access, a fairer criminal justice system etc. all of which support better health outcomes.  So the fight for health justice really is at the center of a struggle for a radical societal overhaul.  Efforts to combat the problem at the margins via schemes like Obamacare or Medicaid as we know it are not good enough. It is in Faust's words a question of giving people "insurance or emancipation."

Which is why the expansion of Medicaid under Obamacare that John Bel Edwards' reelection campaign touts as a major accomplishment doesn't get us where we want to go. In Louisiana, Medicaid is privatized. And the MCO contracts, in addition to just being inefficient means of shoveling money to for-profit insurers and providers, amount to one of the biggest slices of political patronage a Governor can hand out. This year, the dispute over those contracts has left over half a million Medicaid patients in a wholly unnecessary state of uncertainty just as the start of open enrollment for next year looms. 


Finally, Faust fielded a few skeptical questions from audience members about whether or not a single payer system would garner support from doctors, some of whom, at least, might find certain aspects of their practices less profitable. But, while that isn't really true for most doctors,  the question did remind me that a professional association of Louisiana doctors has endorsed Ralph Abraham for Governor.

The Louisiana Medical PAC hasn't issued an endorsement in the most recent governor's races, but jumped at the chance to endorse one of their own.

“It’s been a number of years since we decided to take a position in the governor’s race, but we have one of our own running,"  Dr. Robert Bass, chairman of the PAC, said in a statement. "We believe that physicians supporting physicians is important, and when you have a candidate like Dr. Abraham, it’s very easy to make this decision.

"Dr. Abraham has a wealth of knowledge that is critical to helping Louisiana improve healthcare outcomes."

That's interesting. As it happens, this week the Bayou Brief provides us with an example of one health outcome Dr. Abraham has used his "wealth of knowledge" to bring about.

“Opioids—mainly synthetic opioids (other than methadone)—are currently the main driver of drug overdose deaths,” states the CDC. “Opioids were involved in 47,600 overdose deaths in 2017. A staggering 67.8% of all drug overdose deaths are due to opioids, and while nationwide these numbers have declined, Louisiana is one of a handful of states in which deaths from opioid overdoses have increased.

During the past year, overdose deaths went up by 4.7% in Louisiana.

“Louisiana also ranks among the top 10 states with the most opioid prescriptions written per capita, according to its state’s lawsuit against 17 companies, including Purdue Pharma,” according to a report published yesterday by APG Wisconsin. “Since 2007, the state has spent at least $677 million ‘for treatment of opioid use and dependence.’”

During the seven-year timeframe, Abraham’s pharmacy in Winnsboro doubled the number of opioids it dispensed to patients; opioid prescriptions filled at his pharmacy in Mangham, which is located near his former medical clinic, surged a staggering 67%.

In Mangham (2017 population: 638), Abraham’s pharmacy supplied enough opioid medication to provide every man, woman, and child 6.1 doses every year (or 43 pills in total) for seven consecutive years; his pharmacy in Winnsboro (2017 population: 4,652) could have provided every resident 4.4 doses per year (or 31 in total). (Note: Annual doses per person were based on Census estimates, not the most recent American Community Survey).

If a single payer system focused on health justice for all means a less profitable pill pushing scheme for Dr. Feelgood that's just something we are going to have risk.