“Deadly Consequences”: Public Health Experts Have Estimated How Many Americans Will Die If The Supreme Court Repeals Obamacare
When conservative American Enterprise Institute scholar Michael Strain published an article last week titled, “End Obamacare, and people could die. That’s okay.” he made two critical errors: He embedded a genuinely extreme view into a banal one, and then demanded absolution for both without defending the former.
Strain’s larger point is so uncontroversial, it barely needs reprising: Obamacare was not the final word in U.S. health policy, and if Republicans want to replace the Affordable Care Act with a different, less redistributive set of reforms, they should be able to try, without necessarily catching hell for preferring a system that tolerates marginally more avoidable deaths than Obamacare does (especially if they ply fiscal savings into different programs that alleviate poverty, or improve general welfare).
This is an unobjectionable point. Had Strain argued that the Republican presidential nominee should make an Obamacare alternative the centerpiece of his 2016 platform, nobody would have called it immoral. But the premise of his article is that conservatives (including himself, presumably) will be pleased if the Supreme Court intervenes to gut Obamacare, because it would provide Republicans the missing leverage they’ll need to impose a replacement through the political branches.
First comes god from the machine, and only then comes an Obamacare replacement.
If such a dramatic predicate carried no consequences, Strain’s cost-benefit argument would stand on its own. But when you account for the damage the Supreme Court would incur in order to provide Republicans their missing leverage, it collapses completely.
In a brief to the Supreme Court, dozens of public health scholars, along with the American Public Health Association, detail the harm the Court would create by ruling for the challengers in King vs. Burwell. Most of their analysis is rooted in the basic point that stripping insurance away from eight million people would dramatically impede their access to the health system. But they also flesh out the corollary argument that an adverse ruling would have deadly consequences, and ballpark the number of avoidable deaths such a ruling would cause.
“Researchers found that, in the first four years of the [health care reform] law in Massachusetts, for every 830 adults gaining insurance coverage there was one fewer death per year,” the brief reads. “Using the national estimate that 8.2 million people can be expected to lose health insurance in the absence of subsidies on the federal marketplace, this ratio equates to over 9,800 additional Americans dying each year. Although the specific policy context and population impacts of any policy cannot be directly extrapolated from one setting to another, the general magnitude and power of these findings from the Massachusetts study demonstrate that even when approached cautiously, these earlier findings carry enormous public health implications for withdrawing subsidies and coverage from millions of Americans.”
The Massachusetts story wouldn’t unfold precisely in reverse everywhere the subsidies disappeared, but the experience there suggests the Supreme Court ruling would have measurable mortality implications. These costs (read: deaths) couldn’t be paired against the benefits of increased spending on anti-poverty programs. These are the costs conservatives are eager to inflict on others simply to gain the leverage they need to advance an alternative that the status quo forecloses.
Responding to critics in a followup article, Strain brushes this all aside by stipulating that Republicans would never allow all this suffering. “I think it’s very likely that the congressional GOP would enact some sort of replacement if the Supreme Court strikes down Obamacare,” he writes. “They would very likely take measures to address the needs of those who lost their subsidies as a result of the Court’s action.”
To back up his suspicions, he cites a suspiciously limited set of news reports, quoting Republicans who claim to be working on such a plan—or, at least “talking about how to build consensus on a replacement.”
He does not quote from this Wall Street Journal article titled, “Republicans to Block Legislative Fix to Health-Care Law,” or this article by TPM’s Sahil Kapur titled, “Republicans Are At A Loss On What To Do If SCOTUS Nixes Obamacare Subsidies.”
For those who haven’t been keeping score all along, Republicans have spent the past several years cyclically promising and then failing to deliver an Obamacare alternative. They didn’t have an alternative prepared in 2012 when conservatives asked the Court to declare Obamacare unconstitutional. They didn’t have an alternative prepared later in the year, when Mitt Romney was their presidential candidate. They didn’t have an alternative prepared when they shut down the government as part of an ill-fated effort to defund Obamacare. They didn’t run on an Obamacare alternative in 2014. And they don’t have an Obamacare alternative prepared this week, though they’re scheduled to pass another repeal bill on Tuesday.
The story’s a little different today in that the subsidies really could disappear by fiat, harming millions of people, under GOP control of Congress. Republicans genuinely haven’t encountered a motivating force this strong in the five years since Obamacare became law. If in defiance of such a remarkable pattern, Republicans manage between now and June to come up with a workable plan or a stopgap—one that President Obama will sign—they will have filled the hole in Strain’s argument. Five months might seem like a long time in politics, but remember: It took Democrats more than twice that to pass Obamacare, and almost 10 times as long thereafter to implement it.
By: Brian Beutler, The New Republic, February 2, 2015
“A Pressing Public Health Problem”: The Study That Gun-Rights Activists Keep Citing But Completely Misunderstand
Few issues divide people like guns.
Just consider the starkly split response to our piece this week about how the U.S. Centers for Disease Control and Prevention still had not resumed researching gun violence, two years after President Obama ordered the agency to do so.
Gun rights supporters argue the CDC shouldn’t get involved. The agency should stick to controlling and preventing disease, they say.
There’s also a healthy dose of distrust of any research the CDC might conduct – which is why the agency essentially stopped studying the issue in 1996 after the NRA accused the CDC of advocating for gun control. The resulting research ban caused a steep decline in firearms studies nationwide. As a University of Pennsylvania criminology professor explained it, “I see no upside to ignorance.”
But even that is a contentious point. So the recent article on the CDC’s continued failure to kick-start gun studies was met by wildly different responses.
Here’s Everytown for Gun Safety, Michael Bloomberg’s advocacy group.:
The CDC still isn’t researching gun violence, despite the ban being lifted two years ago http://t.co/fuEuehM7bw pic.twitter.com/PpUNWyokKT — Everytown (@Everytown) January 15, 2015
And the response is from Dana Loesch, a conservative talk show host and author of “Hands Off My Gun: Defeating the Plot to Disarm America”:
@Everytown Seriously? Yes they did. And it wasn’t the outcome you wanted: http://t.co/SKgRhMGzhn #gunsense #MomsDemand2A — Dana Loesch (@DLoesch) January 15, 2015
Loesch’s point was echoed by many: The CDC studied gun violence in 2013, after Obama’s order, and found a wealth of facts that didn’t fit the narrative that guns are dangerous. And that’s why the study didn’t receive the attention it deserved.
An article in the New American Magazine summarized the study: “If the president was looking to the CDC report for support on how to reduce the threat of firearm-related violence through legislation restricting the rights of American citizens, he was sorely disappointed. Perhaps that’s why so few of the media have publicized the report.”
Game over, some activists declared:
@DLoesch @Everytown They need to just suck it! — Jodee (@jodeenicks) January 15, 2015
So what does the study say?
It’s hefty, running 121 pages. The title is “Priorities for Research to Reduce the Threat of Firearm-Related Violence.” The National Academies’ Institute of Medicine and National Research Council published it in 2013.
And the study clearly makes the case for why more gun-violence research is needed.
The CDC requested the study to identify research goals after Obama issued his January 2012 executive order. The National Academies’s study authors clearly see gun violence as a problem worth examining: “By their sheer magnitude, injuries and deaths involving firearms constitute a pressing public health problem.”
The authors suggested focusing on five areas: the characteristics of firearm violence, risk and protective factors, interventions and strategies, gun safety technology and the influence of video games and other media. The document is peppered with examples of how little we know about the causes and consequences of gun violence — no doubt the result of an 18-year-old CDC research ban.
But gun-rights supporters zeroed on in a few statements to make their case. One related to the defensive use of guns. The New American Magazine article noted that “Almost all national survey estimates indicate that defensive gun uses by victims are at least as common as offensive uses by criminals, with estimates of annual uses ranging from about 500,000 to more than 3 million per year, in the context of about 300,000 violent crimes involving firearms in 2008.”
So it would appear the “good use” of guns outweighs the “bad use.” That may be true, except the study says all of those statistics are in dispute — creating, in the study authors’ eyes, a research imperative.
The study (available as a PDF) calls the defensive use of guns by crime victims “a common occurrence, although the exact number remains disputed.” While it might be as high as 3 million defensive uses of guns each year, some scholars point to the much lower estimate of 108,000 times a year. “The variation in these numbers remains a controversy in the field,” the study notes.
The authors also say gun ownership might be good for defensive uses, but that benefit could be canceled out by the risk of suicide or homicide that comes with gun ownership. The depth of the relationship is unknown “and this is a sufficiently important question that it merits additional, careful exploration.”
Another point gun-rights activists make about the National Academies’s report is that “the key finding the president was no doubt seeking — that more laws would result in less crime — was missing.”
And they’re right. The key finding is missing. But that’s because we don’t know the answer — one way or the other.
That, some would say, is exactly why the CDC needs to conduct research.
By: Todd C. Frankel, The Wonk Blog, The Washington Post, January 16, 2015
“HO, HO, NO!: The NRA’s Twisted List For Santa
You might have heard that the U.S. Senate last week finally voted to confirm the president’s nominee for surgeon general, Dr. Vivek Murthy.
You also might have wondered what all the fuss was about. The vote on America’s top doctor was held up for nearly a year, thanks to a campaign by the National Rifle Association. Dr. Murthy was endorsed by the medical community, but the NRA’s lobbying machine turned his nomination into a political battle. All because Murthy believes that gun violence, which kills an average of 86 Americans every day, is a public health issue.
For most of us, acknowledging that America has a gun violence problem is stating a fact. For the NRA’s leadership, it’s heresy.
The gun lobby’s goal is to expand its customer base—and boost gunmakers’ bottom lines, no matter the risk to public safety. So a new surgeon general committed to reducing gun violence isn’t what the gun lobby wanted for Christmas.
The NRA’s wish list looks more like this:
• Guns for felons. The NRA has fought for the rights of felons to buy and own firearms. That means successfully restoring gun rights to convicted murderers, robbers, rapists, and people guilty of transferring explosives to international terrorists.
• Guns for terror suspects. The NRA has opposed efforts to block terror suspects from buying guns. Today the FBI can stop terror suspects from boarding a plane, but not from purchasing firearms.
• Guns for domestic abusers. The NRA objects to restraining orders that require domestic abusers to give up their guns. This year, six states—including Scott Walker’s Wisconsin and Bobby Jindal’s Louisiana—defied the gun lobby and enacted laws that will help keep guns out of the hands of abusers.
• Guns for the mentally ill. The NRA opposed a new California law that will help prevent gun deaths, homicides and suicides both. Police and family members now can present evidence to a judge, who can order temporary custody of a mentally ill person’s guns for a brief, emergency period.
• Gun gag orders. The NRA objects to doctors asking patients basic questions about gun ownership. For example, before Congress repealed it in 2012, an NRA-authored gag order barred doctors and military officers from talking about guns with service members at risk of suicide.
• Guns on campus. The NRA has pushed for “campus carry” laws—despite near unanimous opposition from college presidents, law enforcement, and parents—and for arming educators in K-12 schools.
• Guns in bars. The NRA has pushed to allow guns in bars—despite the fact that 40 percent of people convicted of homicide had been drinking alcohol at the time of their offense.
• Guns in restaurants and grocery stores. The NRA supports the open carry of guns in cafes, burrito shops, and the produce aisle. They reiterated their position in June, after a staffer first made the mistake of calling open carry demonstrations “weird” and “scary.”
• Gun lawsuits. The NRA wants the ability to sue local officials for passing laws that protect public safety. They push for so-called “preemption” bills in statehouses—which allow them to file expensive lawsuits against towns, cities, and even mayors and city commissioners.
• Guns for everyone, no questions asked. The NRA opposed Washington State’s gun-sale background checks ballot measure this year. The measure passed with 59 percent of the vote. Like background check laws across the country, it will help keep guns out of dangerous hands, reduce gun crime, and save lives.
That’s the gun lobby’s wish list for America—more guns for everyone, everywhere, anytime.
The new surgeon general certainly has his work cut out for him. But in 2014, numerous states passed common-sense public safety laws, showing that the momentum for gun safety is building. And just like Dr. Murthy’s confirmation, that’s bad news for the NRA.
By: John Feinblatt, President of Everytown for Gun Safety; The Daily Beast, December 23, 2014
“Losing Services Of Many People”: The Media’s Overreaction To Ebola Is Sending A Chill Through My Coworkers At Doctors Without Borders
One of my colleagues is ill with Ebola that he contracted while working in West Africa for Medicines Sans Frontiers, otherwise known as Doctors Without Borders. Dr. Craig Spencer is having a hard enough time fighting the disease, but it’s only been made worse for him and his family by the criticism and outrage that was heaped upon him by the press, including The New Republic. It has sent a chill through other MSF field workers, whose job is challenging enough without the added burden of facing similar treatment upon return home.
It is neither fair nor accurate to accuse Dr. Spencer of moral failings for not quarantining himself on his return. He did not run about New York while “sick,” as Julia Ioffe contends, and did not put people in danger. As has been made clear since the beginning of the outbreak, only people with symptoms can transmit Ebola. At the first sign of illness—a fever on October 23, when he still would have represented only a minimal risk of contagion—he contacted the MSF office, which then alerted city health authorities. He was then taken directly to Bellevue Hospital, well before he posed a threat to the public.
Armchair physicians note that a couple days before this, Dr. Spencer was feeling “sluggish.” This is not the onset of Ebola, this is the normal condition of those who have been working around the clock for weeks in a stressful setting prior to travel across several time zones. Nor should one read into his abstaining from work a need to protect his patients. He needed rest. MSF advises all aid workers back from the field to get rest before going back to work, and it goes further with people working in Ebola projects, mandating that they not return to work for three weeks to reduce their exposure to sick people from whom they might catch something that might be confused with Ebola and cause unnecessary alarm.
Howard Markel implies that Spencer presumed he would never get Ebola and therefore took a risk with himself and others. MSF does not send people like that to the field. Everyone who departs on an Ebola mission with MSF is made very aware of the risks involved and how to manage them. What’s more, Dr. Spencer worked with a team that had seen people dying from Ebola every day, and this includes MSF staff. MSF has lost thirteen staff members during this outbreak, and two international staff members like Dr. Spencer had to be evacuated from the field after contracting Ebola. No one who works for MSF in the field thinks Ebola could not happen to them or is unaware of its risks to others. No one.
Noam Scheiber is mistaken in writing that “it’s become our policy in this country to quarantine anyone who had direct contact with an Ebola patient.” This was not federal or state policy when Scheiber wrote his story, nor is it MSF policy. If the public feels that things should have been done differently, they should direct their complaints at MSF, not at Dr. Spencer. We are happy and ready to have this conversation. MSF have been bringing people back from Ebola outbreaks for almost 20 years, and we have an evidence-based policy for how they should protect the public on their return; it does not involve self-quarantine. The World Health Organization does not mandate quarantine for their staff, either. Nor does the CDC feel this is warranted. Only now, after Dr. Spencer’s diagnosis and the excessive reaction to it, are some states beginning to require this, even though public health experts know this is a bad idea. Our colleague Kaci Hickox had the misfortune of arriving back in the U.S. just as the new quarantine requirement was announced, and her haphazard and harsh treatment will not be encouraging to others.
Thus far, MSF has had great fortune finding people willing to go to West Africa to fight Ebola. They have set aside fears, reassured their families, and obtained leave from their ordinary responsibilities to join us. This speaks to the character and commitment of the people who work with us—people like Dr. Spencer and Kaci Hickox. If they are discouraged by the prospect of three weeks of near total isolation on their return, we may lose the services of many good people. That will damage the effort to counter the outbreak at its epicenter, which remains the best way to protect the public at large, in any country.
By: Dr. Armand Sprecher, Public Health Specialist at Médecins Sans Frontières in Brussels; The New Republic, October 30, 2014
“Stop Bashing The CDC”: Government Is The Enemy Until You Need A Friend
After a rough start dealing with America’s first Ebola cases, the Centers for Disease Control and Prevention appear to be getting the problem under control. This doesn’t mean that there won’t be more incidents; a health care worker was diagnosed with the virus in New York yesterday after returning from West Africa. But the CDC now seems better able to control secondary infections, particularly among health care workers, who are at the greatest risk.
As the 21-day incubation period lapses without new infections in Texas, dozens of people are being cleared from the watch list. But Ebola lingers as a reminder of how easily safety organizations can weaken and what we must do to keep them effective.
“Government is the enemy until you need a friend,” said former Secretary of Defense William Cohen. Government organizations like the CDC, the Army Corps of Engineers, the Federal Emergency Management Agency and the Federal Aviation Administration exist mostly to be our friends when we need protection from harm.
Unfortunately safety organizations like these don’t get much love in between disasters. They get attacked by those who covet their budget. They get attacked by those who hate government in general. They get attacked by corporations that don’t want to spend the money to comply with regulation. And they face political pressure to paper over potential problems that could embarrass some elected official. It’s hard to retain talent under conditions like that.
When we don’t take care of our safety organizations and don’t listen to them, they atrophy. Then disasters happen, and whoever is on watch ducks the blame. The person on watch always uses words like “Nobody could have foreseen …” For example: “Nobody could have foreseen” that the Army Corps’ levees in New Orleans would crumble during Hurricane Katrina. “Nobody could have foreseen” that terrorists might hijack an airplane and fly it into a building on 9/11. “Nobody could have foreseen” that dismantling Glass-Steagall Act protections would lead banks to gamble with taxpayer-guaranteed deposits. Not true. In most cases, agency staff anticipated the problem and tried to warn their bosses, but the boss didn’t pay attention because it was politically inconvenient or too expensive.
Frankly it’s a wonder that our safety agencies work as well as they do. The CDC is a case in point; they got many things right after their original poor response:
- They quickly acknowledged that procedures were not working.
- They didn’t circle the wagons. They listened to international medical organizations that had more experience in handling Ebola in the field.
- They rapidly rolled out new procedures and equipment for protecting staff and training people in the proper use of the equipment.
- Without succumbing to hysteria and political pressure, they updated travel regulations to ve rify the health of travelers from Africa while allowing essential aid workers to move unimpeded.
CDC did not do what so many agencies and private sector entities do in similar situations: Deny the problem, conceal data, refuse to change and retaliate against critics. The CDC responded and recovered more quickly than most. For example, they responded even more quickly than the U.S. Army did in giving our troops adequate protection against improvised explosive devices in Iraq.
Whatever the mistakes of government safety organizations, private sector safety organizations – the ones that exist inside corporations – are often much, much worse. Halliburton Co. and their contractors undercut internal safety processes in the prelude to the Deepwater Horizon disaster, and four years later, they’re still fighting over who’s to blame. American International Group Inc.’s internal risk-management processes failed dismally in the subprime mortgage crisis, and rather than accept responsibility, they’re still arguing over the terms of the taxpayer bailout that saved them from bankruptcy.
Fast recovery is perhaps the best we can realistically ask of any safety organization, public or private, which faces infrequent, catastrophic risks. If we want these organizations to do the job, we need to treat them right. We need to give them the budget they need to conduct drills and stay sharp. We need to give them professional leadership and not put political appointees in charge. And we need to drop the hypocrisy of treating them as the enemy in between those rare but inevitable moments when we need them to save us. Far from failing, the CDC performed well under the circumstances. We won’t always be so lucky.
By: David Brodwin, Economic Intelligence, U. S, News and World Report, October 24, 2014
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