We have an article just up in @thenation on Medicare "Dis-Advantage": on the waste and inequities that Medicare Advantage imposes on our healthcare system.

With @swoolhandler & David Himmelstein.

A Brief 🧵. There is not too much controversy at this point that Medicare Advantage bilks taxpayers.

MedPAC, Congress' nonpartisan Medicare advisory board, in March estimated some $83 billion in overpayments.

A New York Times 2022 expose shed some light on insurers' dodgy maneuvers.

Maybe we need more trials, but this must not be waved away & deserves attention: intensive blood pressure lowering reduces major vascular events per new RCT in the @TheLancet, & also all-cause mortality (as a secondary outcome).

Brief thread.

1/6

thelancet.com/journals/lance… I understand caution or even skepticism about such findings, but we need to take a step back & look at the big picture: for decades, RCTs again & again show major benefits of medical blood pressure reduction. SPRINT & now ESPRIT show benefits of more intense lowering.

2/6

Pfizer's EPIC-SR study is (finally) published (what took this so long?).

1: Primary finding: No benefit from Paxlovid on symptom alleviation among vaccinated or unvaccinated people.

2: Not a significant difference, but 0.8% of those who got paxlovid and 1.6% of those who got placebo had a COVID-19 hospitalization or death from any cause. Underpowered for this outcome & not really high-risk group (e.g. a single death from any cause among 1,288 participants).

Great reporting by @rmc031 on how some states are using Medicaid funds to help cover housing costs for some, i.e. "a prescription for housing."

I have some thoughts on the issue —  concerns, from a Left perspective.

1/X

vox.com/2024/2/13/2406… First, to be clear, there is zero question that social goods like housing are critically important for health, usually more than medical care — it is an urgent social and political prerogative to realize them.

That's not what's up for question to my mind.

2/X

As a general principle, if the reproductive number largely determines the share of a population that will be infected before a respiratory viral wave ends, then only those behavioral/interventional changes that permanently change the reproductive number will reduce ... the share of the population infected in a wave.

So the term "wave" can be misleading in this context because it suggests that waves eventually "pass through" a population with time: instead, they (typically) end because of the rise in population immunity.

Our new study just up in @JAMANetworkOpen :

We modeled health outcomes from three 2022 Supreme Court Decisions with major ramifications for health, finding that they could lead to nearly 3,000 deaths over a decade and many other adverse health outcomes.

jamanetwork.com/journals/jaman… We examined:

> NFIB v. OSHA, which voided COVID-19 workplace protections

> NYS Rifle and Pistol Association v. Bruen, which invalidated state laws restricing hand-gun carry

> Dobbs v. Jackson Women's Health Organization, which overturned Roe v. Wade

People made giant sacrifices during the pandemic to reduce viral spread, including many who did it not for themselves but for others — like barely seeing family and friends for months or even years on end.

Life is short: this was sacrifice, for a good end. People who say: "we never really had lockdowns in the US" are discounting the massive personal sacrifices that people made, and that bothers me.

Sacrifice isn't something bad: rather, it is something painful but worthwhile.

During the heated debate over the approach to COVID-19 vaccine prioritization, some worried that age-based prioritization would be inequitable — and consequently embraced an approach that prioritized essential workers. I sympathized with that view, but worried that it ... ... would save less lives, and so argued for an age-based scheme along with other measures, e.g. targeted outreach programs to improve delivery to disadvantaged communities, along with bolstered UI, M4A, etc.

usatoday.com/story/opinion/…

You can say masks should be used even if RCT evidence is lacking for plethora of reasons (observational data, basic science, minimal risk, global pandemic, can’t wait, etc.) without undermining case for RCTs more broadly. This article draws a bright line… scientificamerican.com/article/masks-… … between medicine and “engineering,” with the claim that RCTs are fundamentally the *wrong* tool to study interventions in the latter category. But that could presumably be used to justify use of all sorts of medical devices in people without RCT data. And notion that …

The implication of the "mystery", which will be immediately understood by his followers, is that a giant worldwide surge in strokes is due to COVID-19.

But if you trace back the links you get statistics referring to 1990 - 2019, or a NEJM paper published in 2018.

1/3

https://twitter.com/TRyanGregory/status/1654840715850002432

It shouldn't need to be said: severe COVID, manifested as overwhelming pneumonia, is as ghastly as described, the cause of horrifying surges in deaths and a once-in-a-century pandemic.

2/3

We have a new study out in @AMJPublicHealth examining risk of COVID-19 in 2020-21 in the US by workers' occupation and industry.

A quick thread ...

ajph.aphapublications.org/toc/ajph/0/0 Many studies have identified workplaces as important site of COVID spread. And national data show disparities in death by occupation — although death risk can also reflect differences in health status, & death-certificate data may not account for many confounding factors.

This study has been years underway — I'm happy to see it published today in the Milbank Quarterly.

"Century-Long Trends in the Financing and Ownership of American Healthcare."

A short thread. Using numerous historical & current data sources, we examined public vs. private financing AND ownership of US healthcare over the past 100 years.

First, financing. It's well known that an increasing share of health spending is taxpayer-financed, e.g. Medicaid & Medicare.

There is not some magic about a "social insurance model" that provides more resources than a national health service model. If resources are lacking than more resources need to be invested.

ft.com/content/b03dda… Fundamentally the reason why cost control happens in most nations with national health insurance OR national health service systems is the same: single-source public financing (a point made by Robert Evans some years ago), which effectively creates the political *means* &

A couple of thoughts on the new BMJ post-COVID complication study. I remain rather hesitant about electronic health record data analyses — specifically use of diagnostic codes — for the assessment of symptoms; they certainly say little if ...

bmj.com/content/380/bm…

1/4 ... anything about the mechanisms of symptoms. That said, a strength of this analysis vs. VA EHR studies is the use of a test-negative design: investigators had access to all PCR test results nationwide, and controls were those with *negative* results. Diagnostic codes ...

2/4

Paxlovid associated with reduced risk of hospitalization AND death among those 50 years and older — including the vaccinated — in a new observational study in @AnnalsofIM.

A few thoughts...

acpjournals.org/doi/10.7326/M2… Observational studies of treatments can be hopelessly confounded, and so not informative. But notably, here, those prescribed paxlovid were:
(1) older
(2) had more chronic illness &
(3) more likely to be vaccinated.

Despite that, hospitalization/death risk was...

Study last week reported equal (and low) rates of viral rebound with or without Paxlovid treatment

Some important limitations that might explain low rates: cohort was hospitalized (so later in illness course), and testing was not systematic - looked at people who had 3 PCR tests

https://twitter.com/drklausner/status/1602005621104316417

Also, rebound defined differently than some previous studies: as a particular drop in PCR cycle threshold.

That all being said, there is so much uncertainty re: rebound as a Paxlovid effect that I do *not* think it should be a major factor in deciding for/against treatment.

I belong in a lonely group of people who simultaneously believe: (1) reduced seasonal viral circulation during Covid explains current big surges; (2) reduced common viral circulation during Covid will likely, all else equal, still have had net have health benefits … … (e.g. fewer dangerous COPD exacerbations); (3) that “primary infections” of RSV, influenza are effectively inevitable in childhood; (4) that incremental reduction in common respiratory virus circulation will still have pop health benefits, especially for vulnerable adults; …

I think before COVID-19 there was a general lack of recognition that while "cold viruses" typically just cause colds, they can also cause bronchiolitis, asthma exacerbations, COPD exacerbations, and even pneumonia — which can be deadly.

https://twitter.com/washingtonpost/status/1583255665212284928

I don't have the answers for how to mitigate all respiratory viral disease in a sustainable fashion, but the first step to an answer is recognizing that there is a problem — an age-old problem — and acknowledging that we need to marshal resources to better understand & address it

Improving rates of vaccination — for COVID, influenza, pneumococcus, whatever — will require a truly universal, primary-careacentered, national heath program. The elimination of cost barriers for care is not enough — we need what Julian Tudor Hart called “whole population care”. *primary-care centered.

The biggest benefit of COVID vaccination for an individual is prevention of pneumonia & consequently death. However, on a population level, vaccines' more modest impact on reducing one's risk of any COVID infection can also mitigate harm society-wide by reducing spread, ...

1/3 ... providing more support for use of boosters for even those at very low individual risk of COVID pneumonia. I support trials in coming years to clarify benefits of boosters, particular timing intervals, etc.

However, at this time, with thousands of COVID-19 deaths ...

2/3

Another case of what sounds like a woman with previable premature rupture of membranes who was not offered termination because of Texas’ abortion ban — and who could have died of sepsis as a result.

people.com/health/texas-w… Pregnant patients with “premature rupture of membranes” (PPROM) — i.e. “water broke” — **before** fetal viability are offered both option of initial termination and “expectant management.” The latter is associated with higher risk to health of the pregnant individual. However,