Thursday, April 9, 2020

Learning health policy during a pandemic

Last week marked my first major foray into virtual teaching. At Georgetown, the first-year medical student class was told to stay home after Spring Break in order to slow the spread of COVID-19 in Washington, DC and its suburbs. The week of teaching health policy went about as well as I could have expected - my home wireless network held up, no one Zoom bombed any lectures or large group activities, I figured out how to use Panopto, and with fewer distractions than during a normal year, few students missed learning sessions. I also updated my podcast from last year, recording a new conclusion to the episode (embedded below) on health care reforms since the Affordable Care Act.

We are living in unprecedented times, with our health care system under enormous stress from the COVID-19 pandemic and little relief in sight. At this time last year, I predicted that incremental health care reforms would be the most likely outcome of the upcoming Presidential and Congressional elections, regardless of who won. But the evolving U.S. response to the novel coronavirus has exposed glaring deficiencies in our national preparedness, as well as the organization of the health care workforce and the usual way we practice medicine. It’s forced us to re-examine questions such as: how much health care really needs to be provided in person? Does our current physician-centered payment system discourage developing innovative models of care? And perhaps most importantly, in the face of a highly contagious disease, is excluding 25 or more million uninsured persons from the health care system no longer justifiable, if it ever was?

As the COVID-19 curve begins to show signs of flattening in New York and New Jersey after a staggering death toll, the pandemic continues to expand rapidly in Illinois, Michigan and Louisiana. And public health observers are starting to realize that this novel coronavirus does, indeed, discriminate, hitting majority-minority communities much harder than others. Perhaps that explains why Alabama, whose population is 26 percent African American, was projected just a few days ago to have the highest COVID-19 mortality rate in the nation - even greater than New York's? (A revised projection now places it in the middle of the pack.)

Coincidentally, there's a feature article in this week's New Yorker about another deadly health disparity in Alabama that disproportionately affects minorities. Cervical cancer is one of clinical prevention's great success stories. Women who have periodic Pap smears and, more recently, tests for cancer-causing subtypes of human papillomavirus (HPV), can have precancerous lesions identified and treated long before they progress to cancer. Vaccines against high-risk HPV subtypes, when administered before exposure through sex, prevent infections in the first place, and are routinely recommended for women and men between the ages of 11 and 26. So nearly all of the 13,000 U.S. women who are diagnosed with cervical cancer and the 4,000 who die from it each year have one thing in common: it's been too long since they saw a gynecologist or family doctor.

Why is this tragedy more likely to occur in Alabama, as compared to New York City (25% African American) or Washington, DC (47%)? In Alabama, to qualify for Medicaid as a parent in a family of four, one's household income must be below 18% of the federal poverty level - that is, less than $393 per month. Try to house, feed and clothe a family of four and pay for health insurance or health care of any type (including inexpensive direct primary care) on $400 or $500 a month! The numbers don't even come close to adding up.

Enter health policy. In 2014, a key provision of the Affordable Care Act went into effect that provided at least 90% federal matching funds to states that expanded Medicaid eligibility to 138% of the poverty level. Alabama said no, and it and 13 other states - including most of the solid South, continue to say no, even though studies suggest that additional budgetary costs to states from Medicaid expansion would be more than offset by improvements in the health and earning potential of their residents and the financial footing of their health care institutions.

Developing preventable cancers while being poor and uninsured in Alabama and 13 other states is not only a problem for African Americans, but for persons of all races and backgrounds. If Alabama expanded Medicaid today, the expansion "would provide coverage for roughly three hundred and forty thousand additional Alabamians. About half of the newly insured would be low-income whites." Among other benefits, these newly insured persons could then access coronavirus testing and treatment. Social distancing, widespread testing, contact tracing, and vaccine development won't be enough to halt the pandemic if we leave millions of Americans behind; it's no wonder that Medicaid expansion has been proposed as a potent policy tool for mitigating the health and economic impact of COVID-19.