Aaron E. Carroll's Blog, page 20

Psilocybin, Depression, and Instagram Medical Advice

Recently, a big Instagram account posted some info about psilocybin mushrooms and depression, and we don’t think they represented the limited evidence very accurately. And generally, don’t make medical decisions based on Instagram posts.

 



The post Psilocybin, Depression, and Instagram Medical Advice first appeared on The Incidental Economist.

Health care is unaffordable, even for those who are insured

Health care costs continue to rise, making access to necessary care increasingly unaffordable, even for those who have insurance. On MedPageToday, Paul Shafer, assistant professor at Boston University School of Public Health, explains the growing issue of being underinsured and dives into a potential solution: monthly out-of-pocket caps. He discusses his recent JAMA Network Open study in which he employed a hypothetical monthly cap on out-of-pocket costs for in-network care of $250 or $500. Their analyses showed that nearly a quarter (24.1%) to more than a third (36.8%) of enrollees with commercial insurance would experience a reduction in annual out-of-pocket costs under those limits, respectively, with declines in annual out-of-pocket costs of nearly or more than half.  

Shafer notes that implementing this model would “not be a trivial effort”; it could be piloted, evaluated, and considered as an option in plan offerings. Nonetheless, Shafer’s MedPageToday article is a call for insurers, employers, and policymakers to shift how they view health insurance affordability. Read the full post here! 

Research for this piece was supported by Arnold Ventures. 

The post Health care is unaffordable, even for those who are insured first appeared on The Incidental Economist.

An Interview with Michael Stein

Author Michael Stein — a primary care physician, researcher, and chair of the Department of Health Law, Policy, and Management at Boston University School of Public Health — recently published two new books, Me vs. Us and Accidental Kindness: A Doctor’s Notes on Empathy. 

Me vs Us. explains why public health a lower priority than medical care, receiving less funding and resources. He argues that health should be recognized as a communal experience rather than a private one to adequately address our most pressing health crises.

In Accidental Kindness: A Doctor’s Notes on Empathy, Michael Stein examines the relationship between doctor and patient. Using his personal experience and knowledge of medical practice, Stein discusses why empathy is crucial in the doctor/patient relationship and why it may be lacking. I had the opportunity to interview Dr. Stein to gain more insight into the motivation behind these books.

Q: In Me vs. Us, you explore why the US is so invested in medical spending but spends comparatively very little on public health. What is it about your experience, professionally or personally, that motivated you to write this book?

A: I am a primary care physician who took a job in a public health school six years ago. That transition opened for me a new way of thinking about the world. I understood for the first time that paying attention to health or to health care require very different perspectives. Health care, the work I did in my medical office—interviewing, examining, testing, diagnosing, treating—involved taking care of patients one by one (what I call “Me” work). Creating health, on the other hand, involved more broadly thinking about populations (what I call “Us” work).

 Certain statistics that I learned before joining the public health world really bothered me. Why did the people living in the richest counties in the US live nearly twenty years longer, on average, than people living in the poorest counties? The combination of causes—poverty, bad water, bad air, poor food—could only be addressed by public health officials working at scale (if the political will was also there) in those places. It was clear that the life expectancy gap would never be filled by putting more money into health care systems, even if those systems addressed the inequities in care we also know exist in the poorest places.

So writing Me vs. Us was my way of saying: Reader, if you want to improve the health of all, and improve our sinking national life expectancy, then let’s turn the conversation away from doctor visits to public health and understand why we haven’t paid adequate attention to public health over the past fifty years, while pouring money into health care that now constitutes nearly one-fifth of our economy.

Q: Do you foresee global threats such as pandemics and climate change prompting greater public health funding because the American public can no longer pretend that public health initiatives are for “poor people”? Or are there still political forces that make this too optimistic?  

A: Me vs Us offer eight reasons why we underfund public health. That is this book’s pointed and I hope helpful contribution to the policy conversation in the U.S. If we don’t recognize these reasons and why they are potent and have taken hold in the public mind, we will not fund public health more except when we have to, when we are in the midst of a crisis, the next pandemic, and by then it is too late to produce optimal effects, as we now know. Public health initiatives do and will disproportionately aid low income people and they should because that is one way to address inequities in this country. Public health work is primarily government work and one of the functions of government should be to reduce the burden of the country’s leading causes of death, which too often fall on the poor.

Q: How do you address critics that say that the financial incentive in investing in youth and community takes too long to pay off, whereas we face pressing medical issues that need funding now? 

A: I’m not sure what pressing medical issues need funding now that at their core do not have underlying social causes and therefore policy solutions. Obesity seems to me the driver of tremendous disability, premature death, lost employment; it is the pressing medical issue. And the ultimate lessening of obesity in America, affecting 50% of the population, are related to food and economic policies. But for return on investment policies that affect children like the Earned Income Tax Credit, are notably effective, and critical if you believe like I do that poverty is the major driver of poor health in America. But taking on large societal problems will always be slow work. And let’s not forget vaccinations, under attack in the US, but an investment in children that saves lives even in the short run.

Q: In Accidental Kindness, you discuss how the medical environment may be improved by increased empathy and humility between doctors and patients. What led you to exploring the interpersonal aspect of medical care? 

A: Empathy is one of those words that has increasingly entered our vocabulary in the past few decades. Why? I believe because we want it so badly and see it so little. That’s why we talk about it so much more than we used to. I don’t know what it’s like inside you and you don’t know what it’s like inside me, and to be part of a deep significant conversation with another consciousness, another person, we feel human and unalone, and I get to do this work at my medical office and wanted to put down on the page for others to engage. I’ve always thought that any great book allows a reader to leap over that wall of feeling alone. My book relates stories about how I and other doctors I’ve met have been kind and also unkind, and how and why that happens, and how patients react. Remember, I am an internist who still works in a system of reimbursement which explicitly values surgical procedures more than talking to someone about what matters to them most.

Q: What do you think is the first crucial step in fostering the empathy and humility you advocate?

A: Kindness must always built on top of competence, knowledge, skill. This is what patients expect and what we expect from ourselves as doctors. To provide poor care is to be unkind. Kindness means giving talk and time and being open to the patient experience. It requires attention to patients and their suffering, curiosity—we have to keep asking questions—tolerance, as well as self-reflection, understanding the sources of our unkindness, our negative or positive response to certain patients. We can’t provide all patient needs, but a warm and wholehearted presence can bring comfort. Patients need to know their providers are concerned.  Humility is necessary when there’s no obvious or immediate solution.

The post An Interview with Michael Stein first appeared on The Incidental Economist.

Accidental Kindness

Another new book, Accidental Kindness: A Doctor’s Notes on Empathy by Michael Stein — a primary care physician, researcher, and chair of the Department of Health Law, Policy, and Management at Boston University School of Public Health — is part memoir and part critique of medical training and practice. Drawing on his work, Stein examines the often conflicting goals of patients and their doctors.

No doctor enters the medical profession expecting to be unkind or to make mistakes. But because of the complexity of our medical system and because doctors are human, they often find themselves acting much less kindly than they would like to.

Meanwhile, patients don’t intend to beat themselves up. Yet, they often look to the medical system not just for relief not only from physical symptoms but also from self-blame. Doctors and patients are often in need of forgiveness, including from themselves. Patients can be given permission by their doctors to take a risks with their lives; doctors can be given permission by their patients not to feel sad and distressed after a mistake.

The book’s essays touch on poverty, racism, class inequality and leave the reader with new knowledge of and insights into what we might hope for, and what might go wrong, or right, in the most intimate clinical moments.

The post Accidental Kindness first appeared on The Incidental Economist.

ME vs. US

In a new book, ME vs. US, author Michael Stein — a primary care physician, researcher, and chair of the Department of Health Law, Policy, and Management at Boston University School of Public Health — explains why public health constantly loses out to medical care for attention and resources. Yet, public health holds the solutions to our most concerning health crises, from Covid-19 to obesity to climate change.

The US spends on average $11,000 per citizen per year on health care, but only $286 per person on public health. Stein offers eight reasons why. These include that public health often offers few opportunities for private entities to make money; its successes are incorrectly framed as cases prevented rather than as saving lives; and that it is often thought of as government work on behalf of only low income families. 

In the end, he argues, health has to be recognized as a communal experience, not merely a private one. Medical systems, still dominant, need to embed public health thinking and practice in their functions. At the individual level, doctors need to help patients to think of their environments as drivers of health.

At the policy level, investments in our youngest children yield large value. There is an enormous “bang for the buck” associated with a range of programs for children, from early education to child health insurance and college expenditures. Additionally, Federal funding might move some of the dollars going to genomics (ME programs) to a new emphasis on implementation of effective prevention programs (US Programs). Health requires government to act as an authority that balances the ME and US perspectives for there to be any chance of success in a shared future. Health needs to be thought of as a common good.

The post ME vs. US first appeared on The Incidental Economist.

Can Daily Multivitamins Improve Cognition?

A recent study looked at whether taking cocoa as a supplement or taking a multivitamin could improve cognitive function (or at least slow cognitive decline) in older adults. Well, according to the study, the cocoa wasn’t doing anything, but the multivitamins did seem to have an influence on cognition. But, as we so often have to, we’re going to take a close look at the study and say “hold on a minute.” Let’s take a close look at how the study was conducted and get a sense of just how much credence we should lend these findings.

 



The post Can Daily Multivitamins Improve Cognition? first appeared on The Incidental Economist.

Some Good News in Alzheimer’s Treatments

The surprising approval of the extremely expensive and maybe not that effective drug Aduhelm has been dominating the conversation around Alzheimer’s treatments in recent memory. Today, we’re getting positive and talking about a very promising drug that’s making its way through the research and approval pipeline.

 



The post Some Good News in Alzheimer’s Treatments first appeared on The Incidental Economist.

It’s time we talk to the guys about pregnancy

With the midterm elections last week and the recent Supreme Court decision to overturn Roe v. Wade, the abortion debate is front and center. But what seems to be missing from the conversation is the men.

The short of it is that sex leads to pregnancy. Discussions often emphasize what a woman should do — to not get pregnant and if she does get pregnant. But it takes two to tango. It’s time we emphasize the man’s responsibility, both in pregnancy and in preventing it. After all, they are equally responsible and equally capable.

Guys who aren’t ready to risk becoming fathers should consider not having sex. Abstinence is the only sure-fire way to prevent pregnancy. No other birth control option is 100 percent effective. If a guy is not ready to be a father, he should not risk getting his partner pregnant at all. To do so would be irresponsible.

Guys should initiate conversations about safe sex. Men who do choose to have sex should do so safely. But safe sex first starts with learning about it and talking about it. An abstinence-only approach to sex education will not prevent pregnancies, so parents and educators must teach about consent and the mental and emotional impacts of sex outside of committed relationships and how to prevent pregnancy and sexually transmitted infections.

Armed with that knowledge, couples then need to talk about safe sex. The guy should initiate this conversation. He should assure his partner that he understands the risks of sex, will always engage safely, and will accept responsibility if they do get pregnant.

Guys should always use condoms. They should also provide them. Condoms are only available form of male birth control (excluding vasectomies). But they are sold almost everywhere and are very affordable, sometimes even free.

Of course, women who are not ready to be mothers should also use birth control. But, as the consequences of unprotected sex fall disproportionately to the woman, it’s only fair that the man do his part to prevent pregnancy in the first place.

Guys should consider that condoms don’t always work. Condoms are good at preventing pregnancy, but they are not fool-proof. If used perfectly, every single time, condoms are 98 percent effective. With typical use though — accounting for human error and other factors — they only work 87 percent of the time. In other words, two to 13 percent of men who use condoms will still get their partners pregnant.

Guys who become fathers should take responsibility for their children. Most importantly, this means the man acknowledges his role in procreation. But it also means he’s involved in what comes next.

I don’t believe abortion is the answer, nor do I minimize the impact that carrying a baby to term and raising a child will have on a woman’s life. All post-conception options are only possible with significant social and financial safety nets. But before the mother’s community steps in, the father must.

If the parents choose adoption, the father should support the mother during pregnancy and delivery. This may look like financial support, transportation to appointments, and taking the lead on the adoption paperwork.

If adoption isn’t an option, and whether the parents stay together or not, the father should be an equal partner, ensuring that parenting doesn’t fall solely to the mother. This means getting connected to resources, seeking joint custody, contributing financially, and helping carry the emotional weight of parenting.

All of this is easier said than done, especially when culture shies from personal responsibility. So, we need to flip the script. Responsible men — and good fathers — don’t need to be the exception; they can be the rule.

We must teach young men about cause and effect, risk and benefit, and accepting consequences. We must also include guys in conversations about reproductive rights and birth control. Every time we ask a woman what she’s doing to not get pregnant, it’s imperative we turn to her partner and ask him what he’s doing, too.

Plus, we need to dismantle parenting double standards. When a woman parents, we say she’s just doing her job. When a man parents, we lavish him with praise. But fathers don’t babysit. Without challenging these stereotypes head on, we continue to endorse the idea that guys can get their partners pregnant with no consequence to themselves.

Pregnancy isn’t just a “women’s health” issue. We owe it to women everywhere to teach guys how to prevent pregnancy. There should be just as much expectation on men to responsibly engage in sex as there is on women to deal with the consequences.

The post It’s time we talk to the guys about pregnancy first appeared on The Incidental Economist.

A Polio Case in the United States. What Does it Mean?

A vaccine-derived polio case was reported in the United States recently, despite the fact that the polio vaccine effectively eradicated polio in the US decades ago. What is polio exactly? How did a polio case crop up in the US and what is vaccine-derived polio? What does this mean for future community spread?

 



The post A Polio Case in the United States. What Does it Mean? first appeared on The Incidental Economist.

Analyzing LGBTQ+ Health Outcomes from Health Care Discrimination

Health care discrimination is not new, and the negative health impacts are well documented  for some minority groups in the United States, especially Black, Indigenous and People of Color communities. While health care discrimination is also common against lesbian, gay, bisexual, transgender, queer/questioning, and other identified (LGBTQ+) individuals, the consequences are less clear.

Expectedly, there is significant evidence of health care discrimination against the LGBTQ+ community. A national study found that, in the past year, 47% of LGBTQ+ respondents were refused care from a provider and more than 20% were denied insurance coverage on gender-affirming care (e.g., hormone therapy, reconstructive surgeries).

What’s more, different states have different protections for LGBTQ+ individuals against health care discrimination. Given the diversity, I was curious to see if health outcomes also differed from state to state. Below is the research I found. Surprisingly, there isn’t much available.

Tennessee (TN): Minimal Protections

Laws
TN remains one of 27 states where there are no LGBTQ+ inclusive insurance protections. Additionally, state Medicaid policy and state employee benefits have explicitly excluded gender-affirming care and coverage since at least 2014. There also exists a recent for pre-pubescent minors, and State Senate and House leaders plan to expand it to include pubescent minors in their first bill of 2023.

Evidence of Health Outcomes
One study from 2021 found that LGBTQ+ Nashvillians were more likely to report unmet medical needs and repeated mental distress than their non-LGBTQ+ peers, due in large part to high prescription costs from being uninsured.

Nebraska (NE): Partial Protections

Laws
44% of Americans live in states without nondiscrimination protections and NE is one of them. While NE does not ban hormone treatment for minors, it has explicitly excluded it and gender-affirming surgery for state employees and those eligible for Medicaid since at least 2014.

Evidence of Health Outcomes
A 2016 study of over 400 Nebraskans found reduced rates of depression and suicide in transgender and gender non-conforming patients who had trans-inclusive health care providers. This mirrors national trends as well.

California (CA): Full Protections

Laws
Having the most legal protections, CA explicitly prohibits insurance discrimination, covers gender-affirming surgery and hormone therapy, and is the only sanctuary state for minors seeking gender-affirming medical care.

Evidence of Health Outcomes
This year, the UCLA Center for Health Policy Research found that although LGBTQ+ Californians are now insured as much as or more than their non-LGBTQ+ peers, there are still delays in accessing prescriptions and care.

Implications

Surprisingly, the data above is all I could find on health care discrimination and health outcomes for LGBTQ+ individuals. Given the significant research on barriers to health care and the resulting physical and mental health disparities among other minority groups (e.g., higher rates of illness and death across various conditions), I expected to find more.

Even more surprising, there were no studies to report on health outcomes in the most restrictive states (e.g. Arkansas, Arizona), nor in Alabama where gender-affirming medical care for minors is considered a felony crime.

Despite the minimal data available on impact, we do have enough evidence that health care discrimination exists within the LGBTQ+ community and that is enough to try to stop it.

At the federal level, the Department of Health and Human Services is currently trying to update the Affordable Care Act to include nondiscrimination protections for sexual orientation and gender identity. It’s not finalized yet though, as public comment in the upcoming months will determine whether this revision is adopted.

At the state level, the midterm elections will present another opportunity to address LGBTQ+ inclusive health care, as several candidates are running based on their opposition to it.

In Florida, the Governor seeking reelection is currently working with the Florida Board of Medicine to ban puberty blockers, hormone therapy and gender-affirming surgery for minors.In Texas, the Governor seeking reelection has directed the state to conduct child-abuse investigations on parents providing gender-affirming care to their LGBTQ+ children.In Pennsylvania, some Governor and Senate candidates have platforms that incorporate openly supporting conversion therapy.

Plus, on the ballot in Nevada is a question asking voters whether or not their state should guarantee equal rights based on sexual orientation and gender .

While evidence is still thin on the health outcomes associated with health care discrimination against LGBTQ+ patients, there’s plenty to indicate that health care discrimination is happening. And plenty to vote on at the polls tomorrow.

The post Analyzing LGBTQ+ Health Outcomes from Health Care Discrimination first appeared on The Incidental Economist.