As responses to the novel coronavirus outbreak ramp up globally, in this latest edition of The Health Wrap Associate Professor Lesley Russell gives an overview of related developments in the United States and more widely.
Writing from Colorado, she also reports on the latest challenge to Obamacare, and recent news on obesity, social prescribing, and wellbeing budgets.
Lesley Russell writes:
The world is obsessed with issues around the growing spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), nowhere more so than in the United States.
Here the issues are not just around how to contain the spread of this disease and the adequacy and appropriateness of the current measures put in place by President Trump and the White House Coronavirus Task Force, but about how the recognised advice gets implemented in a country where so many people do not have affordable access to health care.
“Stay home from work if you get sick. See a doctor. Use a separate bathroom from the people you live with. Prepare for schools to close, and to work from home.” These are measures the Centers for Disease Control and Prevention (CDC) has recommended to slow the outbreak in the United States.
But many Americans don’t have health insurance, don’t get paid sick leave or care leave, and don’t have the ability to work remotely. This will likely make the coronavirus harder to contain in the US than in other developed countries that have universal benefits like healthcare and family leave. And unequal access to precautionary measures will exacerbate the inequalities based on income, education and race already found in the US.
A key issue is who pays the health care and quarantine costs for COVID-19, specifically in cases where quarantine has been mandated and especially for uninsured and under-insured Americans?
For example: this story about two people who were held in mandatory hospital isolation for suspected infection with coronavirus and now find themselves with thousands of dollars in outstanding medical bills.
There are fears that many people will not stay home and not access care in a timely fashion because of cost. This will risk undermining the recommended public health response.
In fact, there are legal mechanisms in place to address this situation – if only the Trump Administration will choose to use them.
Under such circumstances the Department of Health and Human Services (HHS), via the CDC, is the “payer of final resort”; the Director of the CDC can authorise payment for quarantine, care and treatment, although this is secondary to any state, local or private insurance obligations.
Of course, this assumes funds are available. The Trump Administration has consistently sought to cut CDC funding, but this has been resisted in the budgets passed by the Congress and then signed into law by the president.
Trump asked the Congress for $2.5 billion – or about $8 per person – with only half of this new money and the remainder to come from other health programs, including $535 million from the fight against Ebola, but the Congress, in a very unusual bipartisan mood, acted quickly and was much more generous. There was a push from the health care lobby (hospitals and insurers) to add in funds to cover the costs of housing, care and monitoring of patients who don’t require hospitalisation but need to be isolated.
Last Thursday the Senate approved (96-1) the $8.3 billion House-passed (415-2) emergency spending package which the President signed on 6 March. The bill includes a provision that will ensure funds cannot be raided by the Trump Administration for purposes other than addressing the coronavirus epidemic. You can read more about the provisions in the bill here, and also a related Croakey story on telehealth provisions. The legislative language is here.
In New York state, the Democrat Governor Andrew Cuomo has issued a directive requiring New York health insurers to waive cost sharing associated with testing for novel coronavirus including emergency room, urgent care and office visits. The Governor also announced New Yorkers receiving Medicaid coverage will not be expected to make a co-payment for any testing related to COVID-19. Sadly, these are no initiatives we are likely to see in Republican-controlled states.
You can read more about how inequalities in the US health care system are putting the fight against coronavirus at risk in this article in The Guardian.
From the Australian perspective, here is an article by Ben Roxas-Harris – along with some excellent references – based on lessons from the influenza pandemic.
This open letter from more than 450 public health and law experts to Vice President Mike Pence, as head of the Coronavirus Task Force sets out what a well-funded, evidence- and human rights- based approach to the outbreak looks like.
In an article first published in The Conversation, and reprinted in Croakey, English legal academic Morgan Shimwell looks at the clash of human rights and public health that arises from compulsory isolation in the fight against coronavirus and urges governments to be cautious in exercising their powers.
A few additional points
It is very early to be talking about a vaccine against this new coronavirus, although there has been some interesting news from Israel. But Trump and the Secretary of HHS, Alex Azar, have been talking this up, acting as if it is imminent (and having to be publicly corrected by experts).
At the same time, Secretary Azar this week refused to guarantee that the vaccine would be affordable to the general population, arguing that a profit-motive is necessary to incentivize private-sector investment in developing a vaccine.
Thanks to a provision in Obamacare, if the US Preventive Services Task Force recommended this vaccine, it would be required to be provided without deductibles or co-payments by all insurance policies regulated under the law. But who would make sure a vaccine was affordable for the poorest countries of the world?
An article in the most recent edition of The Lancet that looks at how increasingly restrictive migration policies that deny migrants and asylum seekers their right to health care generating a humanitarian crisis. The article refers particularly to situations of indefinite containment, such as on the Greek Islands, where people are living in facilities that are overcrowded and unhealthy.
What will happen if/when coronavirus gets into these camps – not just in Greece but in places like Bangladesh, Syria (see this article) and Turkey? (The issue of coronavirus is not specifically mentioned in the article.)
The same edition of The Lancet has an article about the looming threat of COVID-19 infection in Africa. Thirteen of Africa’s 54 countries have been identified by the World Health Organization as at risk of becoming centres for the disease on the basis of volume of traffic between China and weak health surveillance and treatment systems.
There is now an Africa CDC to help in this effort. It was created in response to the Ebola outbreak, and many countries have also established public health institutes. Health care leaders have learned a lot from Ebola, but resources are a continuing problem.
Yet another challenge to Obamacare
The US Supreme Court will hear, for the third time, a lawsuit to eviscerate the Affordable Care Act (ACA – also known as Obamacare). This lawsuit is two consolidated cases – California v. Texas and United States House of Representatives v. Texas – that were brought by a coalition of Republican-governed states, joined by the Trump Administration, and opposed by twenty Democrat-governed states.
The case centres on Congress’s decision to repeal Obamacare’s individual mandate. As originally enacted, the ACA requires most Americans to either obtain health insurance or pay higher taxes. The tax law President Donald Trump signed in 2017 reduced the amount of that tax to zero. The plaintiffs argue that the zeroed-out version of the mandate is unconstitutional (asking how can something be a tax if it raises no money?) and then go on to claim that the entire ACA law must fall if the deactivated mandate is unconstitutional.
The Republican legal arguments in this case are widely viewed as weak, yet the lawsuit has received very favourable treatment from Republican federal judges. A good explanation of how we got to this point is here.
The timing is exquisite: just as the election campaign gears up and just as coronavirus concerns have people worried about the adequacy of their health insurance coverage. The case will likely be argued before the general election in November, although the outcome will not be known until the spring of 2021.
Given the acknowledged weakness of the case, and hoping that the Court’s composition stays the same (Democrats are preoccupied with Ruth Bader Ginsberg’s health), there’s reason to hope for a good outcome; the Court has turned away two stronger challenges to Obamacare.
This should have Democrat strategists cheering as it gives them an excellent weapon with which to bludgeon Trump and Republicans in the election. Health care is the number one issue for most voters, regardless of political affiliation.
Trump and his party are very vulnerable on this issue. Last October, Trump said “we have a great Republican plan” to replace Obamacare. “Much less expensive. Deductibles will be much lower.” His statements came after a congressional hearing in which one of his top health officials said that the administration would do “everything we can” for Americans with pre-existing conditions. Under oath, she swore that the administration was aiming to help people find a pathway out of poverty.
Trump tweeted in January: “I was the person who saved Pre-Existing Conditions in your healthcare.” He has repeatedly sought to align himself with this issue, claiming, for example, he would “always protect patients with pre-existing conditions.”
But none of this is true. Republicans have no shortage of talking points and white papers endorsing controversial reform plans – the Republican Study Committee, a group of legislators, recently released another one – they’ve never been able to agree on a piece of actual legislation.
Instead the Trump Administration has thrown its weight behind the lawsuit described above that seeks to eliminate Obamacare and with it the requirements to cover pre-existing conditions. In court filings the Administration is clear about what it wants done to the law: “The proper course is to strike it down in its entirety.”
There’s a good explainer about the latest legal challenge to the ACA on the Kaiser Family Foundation website.
On wellbeing and budgets
Recently in Question Time, the Treasurer, Josh Frydenberg, spent some time mocking Labor’s push to consider including wellbeing indicators in the budget, calling it “laughable”. Shadow treasurer Jim Chalmers has floated including social and environmental outcomes alongside traditional financial indicators in the nation’s books, as New Zealand Prime Minister Jacinda Ardern has done.
But almost simultaneously, eminent Australian Professor Fiona Stanley, writing in The Guardian, was also making the case for why we must move beyond economic measures such as the Gross Domestic Product (GDP) as a measure of how well society (and government) is functioning.
Here’s what she said:
GDP gives the same value to sales of goods that are harmful to our health and wellbeing – such as alcohol, tobacco and guns – as to sales that are of benefit. It tells us nothing about standard of living, quality of our environment, our houses, our education system, our health or how our children and disabled are cared for. It does not take into account informal economic activity such as unpaid work which is significant in most countries.
It focuses on consumption rather than production and misses out on valuable interactions between innovative cooperative activities. And while GDP rises it does not show the costs to the environment or to income inequalities that may result from such activities.”
New Zealand is not the only country that does this: countries as diverse as Canada, Wales, Costa Rica and Bhutan have shown this approach is feasible (and read more in this Croakey article from last year).
Amplify Social Impact shows how this might be done with an Australian Social Progress Index. The index includes issues like personal safety, nutrition, sanitation, access to information and communications and inclusiveness. This is a very interesting website with data that will be increasingly informative over time.
It should be noted that a federal Treasury Wellbeing Framework, dating from 2011 but with origins back to the early 2000s, can still be found on the internet.
It talks about bringing “a whole-of-economy approach to providing advice to government based on an objective and thorough analysis of options”. Five dimensions that directly or indirectly have important implications for wellbeing and are particularly relevant to Treasury are identified:
- The set of opportunities available to people. This includes goods and services, good health and environmental amenity, leisure and intangibles such as personal and social activities, community participation and political rights and freedoms.
- The distribution of those opportunities across the Australian people. In particular, that all Australians have the opportunity to lead a fulfilling life and participate meaningfully in society.
- The sustainability of those opportunities available over time.
- The overall level and allocation of risk borne by individuals and the community and their ability to manage this.
- The complexity of the choices facing individuals and the community.
In those days, Treasury’s mission statement stated that its objective was “to improve the wellbeing of the Australian people by providing sound and timely advice to the Government, based on objective and thorough analysis of options, and by assisting the Treasury ministers in the administration of their responsibilities and the implementation of government decisions”.
In 2020 there is no such language. The Treasury corporate plan now says that the Department’s purpose is: “To support and implement informed decisions on policies for the good of the Australian people, consistent with achieving strong, sustainable economic growth and fiscal settings.”
Ross Gittins has written well on this issue. You might enjoy reading this recent article about the Australian worship of GDP which he calls “the great god of mammon”.
In a May 2019 article Gittins wrote about how, in 2018, Australia’s wellbeing index (as measured by the Herald/Age-Lateral Economics index of wellbeing) grew by just 0.3 percent, compared to growth in real GDP of 2.4 percent.
The survey found that setbacks in the nation’s health – a jump in obesity and worsening mental health – and a surprising decrease in the population’s post-school qualifications countered gains in other aspects of Australians’ lives, including increased life expectancy, better early childhood education and care, and less long-term unemployment.
(Details updated after publication): Meanwhile, Croakey editor Jennifer Doggett was due to address related matters in a presentation to a Victorian Healthcare Association event in Melbourne this week; however, the event has been postponed for reasons related to COVID-19.
Alarming levels of obesity
The impact of obesity on wellbeing is the perfect segue into a brief discussion around the issues on the table for World Obesity Day (March 4) and Obesity Care Week (March 1-7).
If current trends continue, one in five adults around the world will be obese in the next five years. In fact, according to the new report by the World Obesity Federation, all countries around the world are unlikely to meet the 2025 obesity targets set by the World Health Organisation.
In Australia, the picture is increasingly worrying.
In 2017-18, the Australian Bureau of Statistics’ National Health Survey showed that two-thirds (67.0 percent of Australian adults were overweight or obese (12.5 million people), an increase from 63.4 percent in 2014-15. The National Health Survey also indicated that almost one quarter (24.9 percent) of children aged 5-17 years were overweight or obese in 2017-18 (17 percent overweight and 8.1 percent obese).
The Obesity Policy Coalition (OPC) has issued a report entitled Obesity in Australia: a decade of inaction and has slammed the failure of successive governments to tackle Australia’s obesity problem. It is calling for robust actions to be clearly outlined in the COAG upcoming National Obesity Strategy.
The OPC report assesses the progress made in the decade since the Commonwealth Government published its response to the National Preventative Health Taskforce’s report Australia: The Healthiest Country by 2020 – National Preventative Health Strategy – The roadmap for action. (Admittedly that report was released in what we might now see as the glory days of the Rudd-Gillard Government when prevention was an actionable government agenda item.)
The actions set out in the original roadmap included:
- driving environmental changes to increase physical activity levels;
- motivating healthier eating and activity through social marketing;
- reducing people’s exposure to unhealthy marketing;
- developing effective interventions among indigenous communities; and
- building the evidence base, monitoring and evaluating the effectiveness of actions.
Of the 27 recommended actions made in the original roadmap to reduce and control obesity in Australia, the OPC found that only one had been fully completed.
Many (20) have made limited progress, while six have not been progressed at all.
“Our analysis found that the focus tended to be on individuals simply changing their behaviour, however with around 12 million Australian adults above a healthy weight it is clear that fundamental changes need to be made in our society more broadly to support healthy eating and active living,” said Jane Martin, Executive Manager of the OPC.
Australian of the Year Dr James Muecke has called for a “multi-pronged approach” to tackle the obesity crisis, including measures to address the consumption of sugary products.
Without the necessary immediate, multi-pronged, sustainable approach to tackling obesity, Australia will soon find itself in competition with the United States for the fattest and most unhealthy nation on earth.
New data from the US CDC indicate that in 2017-18, 42.4 percent of American adults were obese (defined as a BMI of greater than or equal to 30) and nearly one in ten was severely obesity (defined as BMI equal to or greater than 40). The prevalence of obesity was highest among African-Americans (49.6 percent), compared to non-Hispanic whites (42.2 percent), Hispanics (44.8 percent) and Asians (17.4 percent).
This indicates that the prevalence of obesity among adults has moved further away from the Healthy People 2020 goal of 30.5 percent (the level in 2000).
Research shows there are differences by socioeconomic status and region. In 2018, for example, adult obesity prevalence was highest in Mississippi and West Virginia and lowest in Colorado.
Social prescribing
A recently-released report from a November 2019 round table on social prescribing (defined as “a means of enabling GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services”) offers some possibilities for better approaches to improving wellbeing and obesity.
I commend this report to you and urge you to find time to read it.
The good news story
This week’s good news story highlights how respect for culture and efforts to keep alive an Aboriginal language have transformed a school. You can read about it here.
There should be, there must be, more of this!
And if you want to learn some words of the Kuku Yalanji language of Far North Queensland, you can start here.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
