Accad and Koka Episode 74: Can We Have a Reasonable Discussion About Vaccines?

Does the vaccine debate have to be polarized according to “Pro-Vaxx” or “Anti-Vaxx” camps?  Is it possible to have a reasonable discussion about harms and benefits of vaccines?  Are public health concerns about unvaccinated children sufficient to trump individual liberty?

Exploring the question with us is Dr. Niran Al-Aqba, a board-certified pediatrician in private practice in Washington State, an area hit by the recent outbreak of measles.  Dr. Al-Aqba is a prolific writer who speaks widely and openly on a variety of issues, including policy, ethics, and medical practice.  She is a regular contributor to the Kitsap Sun, to The Deductible blog, and to a variety of other outlets, including her own blog, MommyDoc.  She is a mother of four children who’s been voted best doctor in Kitsap County on multiple occasions.  She also serves on the clinical staff and admission committee at the University of Washington School of Medicine.

https://accadandkoka.com/episode74/

Are Mass Shootings Caused by Firearm Access or Economic Inequality?

Gun violence has become a public health epidemic.  Despite countless deaths in mass shootings over the last 2 decades, the Dickey Amendment—a provision inserted into the 1996 spending bill which blocked federal funding for research on gun violence—remains on the books.  While every politician, media pundit, and policy expert “know” the solution, the answers are not that simple. 

In reality, the factors which have fueled the rise in gun violence across America are largely unknown. And if the deep-pocketed gun lobby continues pouring millions into politicians’ war chests to stifle critical gun research, we may never know.  Science must be part of the mass shooting debate.  Congress must “stop dicking around and repeal the Dickey Amendment,” to fund federal research. 

What if the premise that more guns cause more mass shootings—a contentious debate that has the left and the right locked in battle—is entirely wrong? 

A 2018 study published in Frontiers in Public Health shows that income inequality in communities with higher than average household incomes have a statistically significant relationship with the incidence of mass shootings. 

This association is far stronger than the now-debunked theory that untreated mental health disorders are responsible for mass shooting events.  And while more research like the aforementioned study is necessary, it is highly likely that economic inequality increases the risk of mass shooting to a greater extent than even firearm access. 

For instance, the community of Littleton, CO—where Columbine High School is located—is among the 15% highest income neighborhoods in America. Newtown, Connecticut—a once-idyllic community where a 20-year old murdered twenty children and six adults at Sandy Hook Elementary School—is located in Fairfield County, the wealthiest metropolitan area in the country, according to the Labor Department's Bureau of Economic Analysis, yet it is also among the most unequal in terms in income distribution. 

Gun violence is not a new phenomenon, the number of deaths in children ages 12-17 by shooting increased 95% between 1980 and 1994.  Once considered a problem exclusive to poverty-stricken inner cities, today, gun violence has become pervasive in middle to upper class neighborhoods, which are no longer exempt from the unjustified carnage. 

According to the Economic Policy Institute, the three states with the highest income inequality are New York, Connecticut, and Florida.  Ironically, those same states have seen some of the deadliest mass shootings in U.S. history.  Thirteen people were killed at an immigration center in Binghamton, New York in 2009.  On June 12, 2016, In Orlando, Florida, 49 people were killed and 53 were wounded in a shooting at Pulse, a gay nightclub. Then, on Valentine’s Day 2018, a former student at Marjory Stoneman Douglas High School—in Parkland, Florida—killed 17 and wounded 17 more. 

While it is not well understood how economic disparity is related to the incidence of mass shootings, research indicates a perspective of ‘relative depravation,’ fuels anger, frustration, and resentment especially in young men between the ages of 15-34. Those young men living in highly income variable areas tend to view themselves as “superior,” feel more entitled, and are less willing to share resources they perceive as scarce.

The touchstone of social mobility, income opportunity, and social justice have given way to a harsh new reality in America where radically different trajectories are determined by the circumstances into which one is born. The opportunity gap, known as the “Great Gatsby Curve”, has widened dramatically over the last 40 years.  While household income for the lower half of Americans has barely grown, those in the top 20% of earners has soared, increasing by 75%.  Those earning in the top 5 percent of Americans have seen earning growth of 95 percent. An increasing proportion of society is watching the American dream slip away. 

The deadliest mass shooting in U.S. history took place in Las Vegas, Nevada on October 1, 2017. A man on a high floor of a hotel opened fire on a country music festival crowd, killing 58 and wounding 422 others.  Does the fact Nevada is ranked 4^th highest in income inequality in the U.S. have any bearing?  Don’t you want to know if it does?  I certainly do.  

Economic inequality may have an even greater impact on the incidence of mass shootings than firearm access.  While the rampages in Gilroy, California, El Paso, Texas and Dayton, Ohio dominate the national narrative, with all due respect, America is having the wrong conversation.  Congress has a golden opportunity to right this wrong: Repealing the Dickey Amendment would - finally - fund critical research on gun violence and foster healthy conversations between policymakers, physicians, and patients. 

The Need to Protect Teenagers from Predators Too

A man convicted of procuring a girl under the age of 18 for prostitution should not get away with serving only 13 months in prison.  A level 3 registered sex offender shouldn’t hobnob with Harvard’s finest or be able to fraternize with prominent New Yorkers, such as President Trump and President Clinton, while repairing his tarnished reputation. 

But, in the United States, registered sex offender Jeffrey Epstein, managed to do both. 

Is the notion of adult males having sex with tweens considered quasi-acceptable by society at-large?  After all, Epstein told the New York Post in 2011, “I’m not a sexual predator, I’m an ‘offender,’…It’s the difference between a murderer and a person who steals a bagel.”

The pediatrician in me finds this notion reprehensible. The mother in me is scared beyond belief.  Teenage girls are still children. It is high-time our society started seeing them that way. Bagels, however, will never quite be the same for me, again.

Jeffrey Epstein is accused of running a pyramid-like sex trafficking scheme involving dozens of underage girls between 2002-2005.  In early July, he was arrested on charges that he "sexually exploited and abused dozens of minor girls at his homes" in Manhattan and Palm Beach, Florida. Evidence in the recently unsealed federal indictment indicates Epstein may have a sexual preference disorder, most likely, hebephilia, meaning he is sexually attracted to pubertal children.  Scientifically, hebephiles are not that different from pedophiles, who target younger children who have not yet entered puberty.

 

If convicted of the charges, Epstein could be sentenced to 45 years in prison.  Knowing the average child molester offends 200–400 times before being caught makes four and half decades seem like a slap on the wrist.  Hebephiles are predators.  They tend to engage in frequent, indiscriminate, and compulsive sexual encounters with young victims. They also target at-risk children:  those who live with a single parent that has a live-in partner are 20 times more likely to be sexually abused and those in foster care are 10 times more likely to be victims of sexual abuse than children who live with both parents.

 

Perpetrators take pleasure in abusing children sexually.  They believe their needs are more important than those of the children they harm.  But there is something even more sinister at play: underneath their often-charming facade lurks a sense of pathologic entitlement to take what one wants regardless of consequences, coupled with a lack of empathy for the children they abuse.      

         

Abusers often rationalize their actions by telling themselves what they are doing isn’t harmful or the child ‘consented’ to the sexual contact.  For instance, in a recent conversation with publicist R. Couri Hay, Epstein claimed that his conviction did not constitute pedophilia.  Epstein reportedly told Hay that the girls he had sex with were “teens and tweens,” as if that fact makes his actions less objectionable. 

  

Like pedophiles, hebephiles were often molested as children and had no control over the situation.  By sexually assaulting children, molesters gain the upper hand through a reversal of roles.  Unfortunately, their sexual attraction to children is highly resistant to change. Yet, Epstein’s defense team argued he has lived a law-abiding life for the past decade and should be permitted to await trial in his $77 million Manhattan mansion. Ironically, it is inside this very same mansion where authorities found hundreds of nude and seminude photographs of underage females on the night of his arrest. 

U.S District Court Judge Richard M. Berman denied bail, citing concerns that Epstein posed a danger to underage girls and his extraordinary wealth and overseas connections made him a flight risk.  Berman said, "it seems fair to say that Mr. Epstein's future behavior will be consistent with past behavior." Judge Berman is unequivocally right.

 

This week, Epstein “appears to have made a suicide attempt” resulting in non-life-threatening injuries.  If accurate, Epstein engaged in non-suicidal self-injury (NSSI,) an action intended to quickly alleviate intense negative emotions.  While one hopes he is experiencing tremendous guilt for those he allegedly harmed, it is far more likely that his mounting frustration after being denied bail, finally got the best of him.

 

The bottom line is that there are no effective treatments for hebephilia or pedophilia, so our society should focus on protecting innocent children, including vulnerable “teens and tweens.” Epstein has appealed the bail decision to the 2^nd U.S. Circuit Court.  While Epstein seems to be capable of convincing almost anyone of anything—just look at U.S. attorney Alexander Acosta—let’s hope the buck stops with the U.S Circuit Court of Appeals. 

Do Not Turn Away from the Casualties of Immigration

Sometimes an image captures the heart of a nation by putting a face on a human crisis.  The one of Óscar Alberto Martínez Ramírez and his 2-year-old daughter Valeria lying face down in the Rio Grande after drowning was powerful.  Their family had been turned away from crossing the border and decided to take their chances and swim across the river.  They were not successful. 

Why did this picture seize our attention?  Is it because Valeria’s’ tiny body is tucked inside her father’s shirt and we can vividly see her clinging to him as they drowned?  Or is it because we know if they had made it across safely, the two would have been separated anyway?  Or is it because every parent understands the desperation it took for a father to swim across a swirling river while carrying his 2-year-old daughter on his back? 

After staring at this image long enough, this girl becomes mine.  And if circumstances had been different, Valeria could belong to any one of us.  Immigrants arriving at the Southern U.S. border have the right to request asylum without being criminalized or separated from their children.  And I have lost my patience with those people who are trying to justify treating migrant children like animals. It is intolerable to deprive a child of food, shelter and sanitation.

Pediatricians and other health personnel must be allowed access to the border facilities holding migrant children.  Border patrol officials must be trained to care for ill or injured children while in detention facilities.  In addition, we must change the way America looks at those seeking asylum in this country.  And, in my opinion, American mothers, are the ones to do it.

    

Language has the power to shape public opinion. Labeling immigrants as “illegals,” serves to dehumanize them and justify holding them in bondage.  Propaganda can be very persuasive.  The language used in reference to immigration has been weaponized to the extent that our nation has been deaf to the cries of children separated from their mothers.

 

Our nation has been here before.  History is filled with propaganda-driven cruelty against ethnic or racial groups. Slave owners considered slaves to be personal property and thought nothing of tearing apart families.  Our nation was indifferent to the forced incarceration of Japanese Americans, some of whom endured family separation as well.

 

Unfortunately, this time, we are brutalizing children who are unable to protect themselves.

Children are not small adults.  They have unique physical, emotional and medical needs.  Children cannot reach their potential living in deplorable conditions.  Children need healthy food.  Children need soap and toothbrushes.  Children need to feel safe, have adequate sleep, and time to play.

Despite the fact that President Trump says the conditions are acceptable, make no mistake, children are being harmed at our southern border.  Dr. Sara Goza, the current president of the American Academy of Pediatrics, recently toured two border facilities.  She said, "the first thing that hit me when we walked in the door was the smell. It was the smell of sweat, urine and feces.”  She continued, "No amount of time spent in these facilities is safe for children."

Immigrants are first and foremost, human beings.  Migrant children are no different than our own children.  Outbreaks of chicken pox, scabies, and shingles will go on to become measles and meningitis if we do nothing.  Teams of pediatricians, nurses, social workers, psychologists, and other support staff—who have passed background checks—should immediately be given access to examine every child and provide necessary medical care in every single detention center in the country holding children under the age of 18. 

Border patrol officials have no training or expertise in caring for young children. They have been providing one lice comb for children to comb through each other’s’ hair, yet in the absence of hot water or rubbing alcohol to sterilize the comb between uses, combating lice is impossible. As a mother to four children, I cannot tolerate the idea of any child being held in such deplorable conditions. 

The government is just as incapable of managing the immigration crisis as they are at fixing our healthcare system.  Everyday Americans must do it.  Every time we turn away from the preventable suffering of a child, we lose a piece of our humanity.

Do not turn away.  The lives of too many children are at stake. 

Is Racism at the Root of Health Disparities?

In the United States, the health of African-Americans lags behind most other racial minority groups.  Compared to whites, black men and women face higher risks of chronic illness, infection, and injuries.  Taken altogether, the average life span for African Americans is 6 years less compared to whites.  If we can begin to acknowledge that health outcomes are often dependent on factors outside of the control of individual patients, their physicians, or their health coverage, then we can begin to understand why reforming the healthcare system is proving to be an indomitable task. 

The strongest predictor of health is socioeconomic status (SES.)  While financial instability is considered the fundamental cause of health disparities, this association between socioeconomic status and health is dependent upon race.

For instance, the mortality rate for babies born to black mothers with a masters or doctorate degree is far worse than the mortality rate for babies born to white mothers with less than an 8^th grade education. And black women are far less likely to have breast cancer, yet are 40 percent more likely to die from it.

 

These differences in mortality rate are unrelated to socioeconomic status.  Actually, health disparities are paradoxically greater between middle to upper class African Americans when compared to middle to upper class whites.  Why does upward mobility so minimally alter the health status of African Americans in particular?

This has been a topic of much scientific debate.  One possibility is that different genetics lead to different outcomes; however, the degree of health disparity with regard to race does not hold true for most other countries of the world.  A more likely factor is that financial stability does not guarantee fewer encounters with discrimination.  And, in fact, racial minorities report unfair treatment more frequently in higher SES than lower SES groups.

 

Structural racism is the biased societal approach to housing, education, employment, healthcare, and criminal justice.  As scientists study racial health disparities in depth, a picture begins to emerge that there are bigger, stronger, and more insidious forces at play than economics alone. The psychological stress generated by unfair treatment may trigger a biological series of events that lead to worsened health outcomes in the long term.

For instance, in the six months after September 11, 2001, women living in California who were of Arab descent were far more likely to give birth to a low birthweight or preterm infant than in the six-month time period prior to September 11.  As a group, Arab-American women consistently have low rates of low birthweight or preterm infants. These findings lend support to the possibility that increased activation of the stress response system has a tangible effect on health outcomes.

In addition, there is a growing body of evidence that shows it is the chronicity rather than the severity of exposure to unfair treatment that most strongly correlates with higher morbidity or mortality rates. It makes sense that over a lifetime, repetitive discriminatory encounters can exact a heavy toll.  In order to address the root cause of racial health disparities, we need to take an honest look back at previous attempts of the government to care for marginalized minority populations.

One example is “The Tuskegee Study of Untreated Syphilis in the African American,” conducted by the U.S. Public Health Service between 1932 and 1972.  In collaboration with Tuskegee University—a historically black college in Alabama—600 impoverished African American sharecroppers from Macon County, Alabama were enrolled in a study with the purpose of observing the progression of untreated syphilis while providing free healthcare to the underserved.

By 1947, penicillin had become the standard treatment for syphilis, yet researchers continued to observe the ill men while intentionally withholding antibiotic treatment.  No care was provided when the men went blind, insane, or experienced severe complications.  By the time this unethical study was terminated in 1972, 28 men had died from syphilis, 100 more had succumbed to complications of the disease, 40 spouses contracted the disease, and 19 children had been born with congenital syphilis.  All victims were African American.

 

President Bill Clinton issued a formal apology to the Tuskegee victims on behalf of the US Government on May 16, 1997: 

 “What was done cannot be undone.  But we can end the silence.  We can stop turning our heads away…what the US government did was shameful, and I am sorry…it is in remembering the past that we can build a better present and a better future.” 

More than twenty years later have we really built a better future?

    

In a word, no.  Today, a black woman is 22% more likely to die from heart disease than a white woman.  A black woman is 71% more likely to die from cervical cancer than a white woman.  A black woman is 243% more likely to die from pregnancy or childbirth-related causes than a white woman.

  

Even after controlling for age, gender, marital status, region of residence, employment status and insurance coverage, African Americans have worse health outcomes than whites in nearly every illness category.  Expanding healthcare coverage is more of a temporary Band-Aid than a long-term solution. Instead, reducing racial health disparity requires acknowledging the affects structural racism has on health status and then working toward sweeping, trans-formative change in our society as a whole.

Licensed to Live: An Insurance Company Tried to Destroy My Career with Dr. Niran Al-Agba

An Insurance Company Tried to Destroy My Career with Dr. Niran Al-Agba

Jun 26, 2019 · 39 min · (31.3MB)

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This episode features a discussion with Dr. Niran Al-Agba, a pediatrician and prolific writer.

Link Here:  https://podcasts.google.com/?feed=aHR0cDovL2xpY2Vuc2VkdG9saXZlLmxpYnN5bi5jb20vcnNz&episode=MzAyOGQyNDYxZmRlNGM2YjlkZDE2MzQyYmZkZGMwNzM&hl=en&ep=6&at=1566671069131

In this episode: 

1) 4:00 We discuss her happiness as a general pediatrician.

2) 7:00 Dis-empowered by an insurance company, she had to spend time, money, and heartache fighting the system.

3) 21:00 Why you should lawyer up to defend your ground.

4) 27:00 Learn about the power of blogging to help heal others and tell a powerful story.

Dr. Niran Al-Agba:

MommyDoc on Facebook

@silverdalepeds on Twitter

MommyDoc Blog:  http://peds-mommydoc.blogspot.com/

Op-ed Columnist at the Kitsap Sun:  https://www.kitsapsun.com/search/niran/

Associate Editor at the Deductible:  https://thedeductible.com/?s=niran

Measles Exemptions: The New Loophole in Washington State

This week, the measles outbreak reached a record-breaking number of more than 1,000 cases spread across 28 states in the U.S.  In the first half of 2019, there have been more cases than in any other year since measles was “eradicated” in the year 2000. 

Washington State had 81 measles cases, 71 of which were in Clark County this past year.  Measles is extremely contagious and 90% of those who contracted the disease were unvaccinated.  Therefore, the Washington State Legislature went to great lengths to pass House Bill 1638, a law that removed the personal or philosophical exemptions for vaccination against measles, mumps, and rubella, believing this would reduce the chance of another measles outbreak.

 

While Washington lawmakers had good intentions, their actions were largely symbolic, because they overlooked a few issues that will interfere with this law having its’ intended effect.  According to the Washington State Constitution, “absolute freedom of conscience in all matters of religious sentiment, belief and worship shall be guaranteed to every individual...”  And to that end, the new vaccine exemption form replaced the philosophical exemption with a new box for parent-initiated religious exemption.

 

Parents can make an autonomous choice to exempt their child for religious reasons.  In order to honor a religious exemption, Washington State schools requires the patient be seen by a physician, nurse practitioner, physician assistant, or naturopathic physician.  These same health professionals may also grant a medical exemption if they see fit to do so.  This created another loophole. 

Naturopathic physicians have considerable expertise in the use of natural medicine; however, tend to be less supportive of the standard immunization schedule. Studies show care from a naturopath is associated with fewer vaccinations and a greater likelihood of contracting vaccine preventable disease.  A survey of naturopathic students in Canada found approximately 12.8% were supportive of the pediatric vaccination schedule.  And finally, a survey of Massachusetts naturopaths and homeopaths noted that most did not recommend vaccination at all.

According to Brigham Young University, only Washington and Oklahoma recognize the signature of a naturopath on a religious vaccine exemption form.  Three states—Washington, Oregon, and California—recognize the signature of a naturopath on the philosophical exemption form.  And based on my research, it seems only one state honors a medical exemption signed by a naturopath: Washington State.  (California honors a medical exemption by a naturopath, but only with physician supervision.) 

Will HB 1638 reduce the risk of contracting measles in Washington State?  It is unlikely.

About a dozen families in my practice have already obtained medical exemptions from naturopathic physicians in order to attend school next fall.  Over the last month, I have had more requests for religious exemptions than in the last seventeen years combined. HB 1638 does nothing to address the reasons behind low vaccine rates in the first place.

 

Fifty years ago, the idea that any parent would refuse vaccination against life-threatening disease was beyond comprehension.  But today, we have arrived at a place where many do not trust mainstream medicine.  In my opinion, laws which mandate medical interventions in the name of patient safety do nothing to solve this problem.  Even worse, enforcement of such regulations alienates families from seeking medical care when necessary.  Parents who decline immunizations for their children are not crazy.  They love their children and deserve a chance to have open dialogue with their physician to discuss the risks and benefits of vaccinations. Public health agendas laced with fear do not build trust and will not produce meaningful change.

In reality, Washington lawmakers have tried to place a Band-Aid over a gaping wound.  Life-threatening diseases, once eradicated, have made a roaring “comeback” for a variety of reasons that were not addressed by lawmakers.  If they want to make a difference, lawmakers have a decision to make: mandating vaccinations for school attendance or allow people the autonomy to make their own decisions on this issue. Either way, lawmakers did not “solve” this public health crisis.  HB 1638 missed the boat entirely.

Alabama is Not Pro-Life. Here's Why

I will never forget her face.  She was only thirteen.  She had a significant cognitive disability, a result of a brain injury at birth.  She found her way to my clinic one late Friday afternoon in July almost two decades ago.  Her mother was a nurse and noticed her daughter had not had a period in the last two months.  Her pregnancy test came back positive.  I wanted to cry.
  

The questions I had to ask this young girl were agonizing.  When asked if she had sex, she looked at me and shook her head back and forth, to say no, she had not had sex before.  She was telling the truth.  Having sex implies consent.  When I asked if someone had touched her private area, she nodded her head up and down and said there were two boys.  She thought they might have been about her age. She did not know who they were.  She had never seen them before or since. I asked if she could remember their faces.  She could not. 


The two boys pushed her down on a grassy area next to the high school football field when she was walking home one day.  She remembered it was raining because she had been looking up at the sky until they stopped hurting her.  She told me about the pain she experienced, down there, and she pointed to her vaginal area.  She told me there was some bleeding afterward at home.  She did not tell anyone about what had happened, even her mother.  I am not sure if she really understood what had been done to her.  I tried to put myself in her place to understand how hard it must be to be telling me her story now.
  

Taking her small hand in mine, I told her she was pregnant.  Her shoulders slumped forward and she looked at the floor.  “Do you know what that means?”  She nodded her head up and down, then said “there is a baby in here” gesturing toward her abdomen.  It was more question than answer.   She was not capable of understanding how horrifying it was that she never made a choice to become a mother. 


She was still a child herself.
  

For the record, in regard to my uterus, I am pro-life.  I believe children are a gift to those of us who are lucky enough to have them, if even for a fleeting moment.  As a pediatrician, I have devoted my entire life to taking care of children, from the instant they are born until they go on to have their own children.  And then I have the privilege to care for those children as well.  There is no greater thing on earth than a child and protecting that child, the one in front of me, will always be my priority.
  

But how can any civilized society reconcile being pro-life with forcing one child to bear another child – one that the child never consented to produce in the first place? 


It is inhumane. 


How many other victims can tell this same story?  There are far more than the pro-life movement wishes to acknowledge.


In fact, the Alabama Human Life Protection Act is not intended to protect human life; this legislation is a veiled attempt to place value on one life over another.  And by exempting victims of rape and incest, Alabama will serve as judge and jury, disrespecting the work already done by the highest court in the land.  The question of legalized medical abortion has already been asked and answered by the Supreme Court in 1973.


The Alabama legislature is sanctioning physicians to be jailed for up to 99 years for performing an abortion, while at the same time, knowing full well that a first-time rape conviction carries a sentence of 20 years or less.  The pro-life movement wants the nation to believe being pro-choice is akin to being anti-life, while obscuring the fact that women and children will be forced to give birth after victimization. Fighting to protect the right of women and children to make decisions about their own bodies is not the same as being pro-abortion.
  

In my opinion, Alabama is not pro-life.  They are trying to legalize morality, which is dangerous.  For the record, I am pro-life; the kind of pro-life that believes all human beings are equal.  No civilized society should prioritize the life of an unborn child over that of the defenseless child who stands in front of them.  Physicians, especially, must not acquiesce to politicians who want to force vulnerable women and children into back alleyways with coat hangers.   The lives we must protect are those of the innocent women and children and their choice not to give birth to children they did not consent to make. 

CHI Settlement Returns Some Balance to Market

The State Attorney General's office this week settled the antitrust lawsuit with CHI Franciscan, claiming the acquisition of WestSound Orthopedics and affiliation with The Doctors Clinic violated antitrust laws by reducing competition and resulting in higher prices.  As part of the settlement, CHI must divest their majority stake from the ambulatory surgery center in Silverdale and pay $2.5 million to the state.  That amount will be distributed to four entities in an effort “to increase access to health care on the Kitsap Peninsula” according to a recent press release.



It is a well-known fact that one of the largest obstacles to affordable health care is the high cost of American hospitals. In 2018, Americans spent nearly $1.2 trillion on hospital care and the average daily cost of a hospital stay in the U.S. was 2.6 times that of the average of other industrialized nations.



The single greatest driver of higher hospital prices is the rise of monopolies.  The ACA triggered an epic buying spree as hospitals acquired independent medical practices.  Since 2010, hospitals have merged into larger and larger conglomerates, which used their increased market power to extract higher reimbursements from the commercially-insured.



For instance, in August 2013, Harrison Hospital affiliated with the Franciscan Health System and shortly thereafter, Franciscan Health re-branded as CHI Franciscan.  In February 2019, CHI merged with Dignity Health to become Common Spirit, which is a colossal $29 billion health system comprising 142 hospitals and more than 700 care sites across 21 states. 

According to data from the Center for Medicare & Medicaid Services (CMS), hospital care in Kitsap County is 40% more expensive than in the surrounding communities.   In documents filed as part of the lawsuit, a former physician president at TDC summed up the affiliation with CHI best: “You can now get your outpatient care in a complex, relatively unsafe, and vastly more expensive location.”



What exactly does this settlement mean for Kitsap County residents?



While not perfect, the settlement goes a long way toward restoring balance to our one-hospital community.  The ambulatory surgery center (ASC) is simply a hidden gem, where same-day surgical, diagnostic, and preventive procedures can be performed for a fraction of the price of a hospital outpatient department (HOPD.) 



ASCs perform more than 7 million procedures for Medicare beneficiaries annually and cost Medicare just 53% of the amount paid to HOPDs for the same procedure.  For example, Medicare pays hospitals $1,745 for performing cataract surgery while paying ASCs $976 for the same procedure. In general, Medicare beneficiaries pay half as much out-of-pocket at an ASC compared to at a HOPD.



A second important settlement term requires CHI and TDC to inform patients of alternative imaging options to Harrison Medical Center. Kitsap has a freestanding imaging center, which offers high-quality care at a competitive price.  InHealth Imaging is another hidden gem, which in my personal and professional experience costs one-fifth the price of imaging at the hospital. 



Most importantly, this settlement signifies a symbolic change in the healthcare landscape as the consolidation trend appears to have played itself out. For the first time, the percentage of medical practices owned by hospitals has actually fallen, from a high of 32.6% in 2016 to 28% of the market in 2018.  Hopeful hospital administrators have now learned hospital-owned medical practices are not as profitable as once believed to be, despite the fact that facility fees boost reimbursement considerably.  One example is CHI’s CFO Mike Fitzgerald, who once wrote “I am all for taking advantage of hospital-based pricing… it would be great to drop a couple of million more to our bottom line.”  Unfortunately, the financial windfall has never materialized. 



I commend Attorney General Bob Ferguson for doing his part to improve access for patients to affordable healthcare and have come to believe the way to change the system is through the courts or legislation. 



To that end, Rep. David Cicilline (D-R.I.), who chairs the antitrust subcommittee of the House Judiciary Committee, has stated that hospital consolidation is one of his top priorities. Rep. Jim Banks (R-IN) has introduced the Hospital Competition Act of 2019. In the future, legislation like this would reduce cost of healthcare and protect small communities from hospital monopolization. 



This bill would:

1.      Approve a 400% increase in FTC staff to ensure hospital mergers do not increase costs,

2.      Reduce the incentive to merge by lowering Medicare reimbursement rates in monopolized markets,

3.      Provide grant funding for states trying to improve hospital competition,

4.      Eliminate the facility fee and reimbursing HOPDs at the same rate as independent physicians,

5.      Repeal incentives for accountable care organizations (which have not saved money),

6.      Repeal the ban on physician-owned hospitals, and

7.      Require hospitals to publish the cost of their 100 most common services

When healthcare prices increase, everyone pays, whether consumers realize it or not.  Higher insurance premiums are passed on by employers, the uninsured pay through bankruptcy proceedings, and the increased cost for Medicaid/Medicare patients is borne by the taxpayers.  Competition lowers prices.  And this settlement is a step in the right direction for patients in Kitsap County who value choice. 

There are Ways to Save -- and Expand -- Medicare

Medicare is a national health insurance program which provides health insurance for Americans aged 65 and older, and those who are disabled or have specific chronic conditions. Medicare covers 17 percent of the U.S. population, including the nation’s oldest, sickest, and most disabled citizens. Medicare has achieved two important goals: ensuring access to health care for elderly and disabled citizens, and protection from the financial risks associated with health care.  By ensuring access, Medicare has contributed to a five-year increase in life expectancy after age 65.

Before implementation of Medicare in 1966, 48 percent of Americans 65 and older had no insurance; today, that figure hovers at 2 percent. Older Americans used to cover 56% of their health care expenses directly out-of-pocket, today, they pay only 13 percent.  Medicare is funded through a combination of a payroll tax, beneficiary premiums, co-pays and deductibles, and U.S. Treasury revenue; it is administered by the Centers for Medicare and Medicaid Services (CMS.)

Medicare is divided into four Parts. Part A covers hospital costs, skilled nursing, and hospice services. Part B covers physician and other clinical outpatient services.  For both A and B, there are copays and deductibles, as well as gaps in insurance coverage.  There are no annual out-of-pocket spending limits for Parts A and B, therefore supplemental coverage, known as Part C, protects from financial hardship. 

Medicare has significantly improved the well-being of citizens over 65 years of age.  

The single greatest threat to long-term survival of the Medicare Program is runaway costs, an issue which must be addressed before expanding the program to all of us. Between 1970 and 2013, spending per Medicare beneficiary increased 500 percent from $385 to $12,210, or 0.7 to 3.5 percent of GDP.  Current projections predict that Medicare spending will make up 5.1 percent of GDP by 2030. 

At the same time, researchers at the Dartmouth Institute for Health Policy and Clinical Practice estimated 30 percent of all Medicare spending and could be avoided without worsening clinical outcomes. According to the Congressional Budget Office, eliminating this waste could save as much as $700 billion annually.

Some bipartisan measures that might contain costs include: funding additional primary care physician residency positions, eliminating accountable care organizations, and allowing Medicare to negotiate drug prices with pharmaceutical companies.

First, the Balanced Budget Act of 1997 capped the number of residency slots in teaching hospitals which were eligible for Medicare payments. This mistake has facilitated a shortage of primary care physicians across the country.  A larger supply of primary care physicians is associated with a lower mortality rate. In fact, adding 10 primary care physicians per 100 000 population increases life expectancy by nearly two months, whereas the same increase in specialty physicians only improves life expectancy by 19 days. U.S. Senators Bob Menendez (D-N.J.), John Boozman (R-Ark.) and Chuck Schumer (D-N.Y.) introduced the Physician Shortage Reduction Act of 2019 to increase Medicare-supported doctor training slots by 15,000.  Investing in primary care reduces overall expenditures by lessening morbidity and mortality; at the same time, this legislation would address the physician shortage and improve access to care for patients. 

Second, in 2008, the Congressional Budget Office (CBO) warned Congress that Accountable Care Organizations (ACO) would not save Medicare dollars, yet the Affordable Care Act required CMS to establish them within Medicare.  ACO’s—similar to HMO’s –use narrow networks in an attempt to control cost yet bear considerable financial risk, because pay is on a per-enrollee basis with the obligation to provide all medically necessary services for enrollees.

After nearly a decade, studies consistently demonstrate that ACOs fail to achieve cost reduction, just as predicted.  Universal care plans must strike a balance between a free market and government regulation necessary to protect patients.  By eliminating the ACO construct, patients and private businesses will flourish.

And finally, federal law prohibits Medicare from negotiating prices for prescription drugs with pharmaceutical companies in order to reduce costs for nearly 43 million seniors enrolled in Medicare Part D.  U.S. Senator Tammy Baldwin (D-WI) and Senator Amy Klobuchar (D-MN) have reintroduced the Empowering Medicare Seniors to Negotiate Drug Prices Act. Enabling the federal government to negotiate for reduced drug prices is a policy supported by a majority of Democrats (96%), Republicans (92%), and Independents (92%).

Over the last 50 years, Medicare has improved the delivery of healthcare services for nearly one-fifth of the U.S. population.  Cost containment must be coupled with implementation of Medicare For All.  Without it, universal access will be unsustainable.