Aaron E. Carroll's Blog, page 44

What should Biden do about Medicaid work requirements?

I’ve got a new article out at The Atlantic digging into that surprisingly thorny question. At stake here is whether the Biden team can move quickly enough to forestall the Supreme Court from deciding two pending cases involving work requirements in Arkansas and New Hampshire. It’ll be tricky, in part because of some last-minute shenanigans to protect work requirements from reversal:

On January 4, … the Trump administration announced that it was changing the rules. In a seemingly innocuous letter to state Medicaid directors, the director of the Centers for Medicare and Medicaid Services, Seema Verma, offered “additional details of the process” for withdrawing waivers. One of those new details is that no withdrawal can take effect for at least nine months.

The change is a brazen, cynical attempt to protect work requirements long enough for the Supreme Court to rule on them. And while it’s dastardly, it’s also clever. When the states agree to the terms of Verma’s letter—and Republican-controlled states certainly will, if they haven’t already—its terms arguably become enforceable as a kind of intergovernmental contract. I say “arguably” because the letter itself may be legally defective, as two Democratic congressional leaders have already argued in an angry missive to Verma. But the possibility that the courts might treat it as binding means that it’d be risky for the Biden team to withdraw the waivers before nine months are up.

The Biden administration still has options, however—and here’s where the creative lawyering comes in.

Read the rest here. I’ll add that it speaks well of the The Atlantic that they were willing to run a piece digging into the nitty gritty of administrative law. It’s important stuff, but complicated.

@nicholas_bagley

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Does Vitamin D Influence Mood?

We’ve scoured the data for you when it comes to Vitamin D supplements, coming up empty-handed almost every time. We know it doesn’t help with a variety of conditions, including those related to the cardiovascular and musculoskeletal systems. But what about mood? Can a little Vitamin D supplementation stave off depression and/or the winter blues? We waded back into the data to find out.

 



@DrTiff_PhD

The post Does Vitamin D Influence Mood? first appeared on The Incidental Economist.

How Useful Are Temperature Screenings for Covid?

Temperature screening has become a common Covid mitigation practice in many settings. But as noted by one of our Healthcare Triage viewers, this practice doesn’t seem that effective at face value. So should we be relying on temperature checks to help curb the spread of Covid-19, or is it just medical theater that distracts from more useful efforts?

 

@DrTiff_PhD

The post How Useful Are Temperature Screenings for Covid? first appeared on The Incidental Economist.

Veterans Experience Differences Between VHA and Community Providers

Alex Woodruff is a Policy Analyst at Boston University School of Public Health. He tweets at @aewoodru.

The Veterans Access, Choice and Accountability Act (known as the 2014 Choice Act) expanded Veterans’ ability to seek medical care outside of Veterans Health Administration (VHA) if they met certain criteria. Prior to this legislation, concerns over wait times, especially for specialty care, showed long delays in Veterans’ access to VHA care. Since the implementation of the Choice Act, VHA wait times have decreased; at the same time, Veterans have increasingly taken advantage of their ability to utilize community-based care. Between 2014 and 2018, over 2 million Veterans received care from community providers — that’s roughly 25% of the Veteran enrollee population. This trend is likely to increase with further infrastructure developments and expansion of the program under the 2018 MISSION Act.

Little is known, however, about how VHA care compares to the care Veterans receive in the community through VA-purchased care. Understanding Veterans’ experience with community care is important. Health care experiences can drive patients’ care-seeking behavior; for example, positive experiences are often a marker for safe and effective health care services. New research has taken one of the first rigorous looks at patient experiences with both VHA and non-VHA care.

New Research on Veterans Experiences with Community Care versus VHA Care

Vanneman et al (2020) take a look over time at patients’ reported care experiences following implementation of the Choice Act. This study was conducted by researchers from the Department of Veterans Affairs, with affiliations to the University of Utah School of Medicine, Stanford University School of Medicine, and Boston University’s School of Medicine and Health, Policy, and Law Department.

Using data from the VA Survey of Health Experiences of Patients, they evaluated Veterans’ experiences with both VHA and non-VHA care. This routine survey captures patients’ overall rating of their provider and experiences with access to care, communication with their provider, and care coordination. Using a score for provider rating and composite scores across access, communication, and coordination domains, the researchers assessed each type of outpatient care — specialty care (i.e. cardiology, orthopedics), primary care, and mental health care. Completed surveys administered between 2016 and 2017 were included, totaling over 412,000 responses for specialty care, 430,000 for primary care, and 29,000 for mental health care. The researchers examined multiple covariates in their models including education level, perceived health status, and perceived mental health status.

This study tested four hypotheses:

VHA outpatient care would rank higher than community-based care in patients’ reported experiences.
VHA would score better in mental health and primary care access than community-based care, but worse in specialty care access.
Over time, Veterans’ experiences with outpatient care would improve for both VHA and community-based care due to increased focus on patient-centered care.
Differences in Veterans’ experience between VHA and community-based care would lessen over time as the Choice program was more firmly established and community providers gained experience treating Veterans.

Previous studies attempted to draw conclusions between VHA and non-VHA data, but these studies either did not compare results over time or were limited by single-measure designs or comparisons to non-Veteran populations. This is the first study to directly compare VHA and non-VHA Veteran care experiences over time and to be conducted after the community care program has seen a significant uptake.

Findings

Using a series of multivariate regression models to adjust for covariates, researchers found that scores on provider ratings, communication, and coordination of care were all better for VHA care compared to non-VHA care, confirming their first hypothesis. There are multiple possible reasons for this, including that patients familiar with the VHA may find community-based care challenging to access and that providers at VHA facilities are better in tune with the social and medical challenges Veterans face. Additionally, providing care to veterans in both the community and VHA systems has substantial challenges in terms of communication and care coordination that may impact patient satisfaction.

The second hypothesis was also supported, with patients reporting a better experience accessing specialty care in the community than in VHA and no difference between primary and mental health access experience. Only specialty care experience scores increased across all four experience domains, which is a mixed result for the third hypothesis that speculated all outpatient care would increase. And finally, the fourth hypothesis was unsupported as the gaps between VHA and non-VHA care experiences remained stable over the study period.

Discussion

This study gives valuable insight into the success and future of VHA’s efforts to expand care options for Veterans to community-based providers. Understanding care experiences among Veterans is an important factor in both care and policy decisions. Vanneman et al (2020) provide strong evidence to support the quality of VHA care when compared to community-based care. Overall, patients found outpatient care at VHA facilities to be high quality. Specialty care access was the only domain in which Veterans reported a better experience in the community, aligning with the study’s hypotheses as well as the driving forces behind offering community care to Veterans in the first place. These results provide context for Veterans, policymakers, and VHA providers around when it is best to facilitate community care.

The study also calls attention to the need to accurately track Veterans’ experiences regardless of where they receive care, whether within VHA or in the community. For example, VHA facilities that have large numbers of patients receiving community care may choose to study why and what modifications could be made to improve Veterans’ VHA experiences. As community-based care utilization increases, VHA has the opportunity to expand its infrastructure to measure patient experiences in response to these changes. This knowledge will improve how VHA cares for its Veterans, ensuring a patient-centered experience in the most appropriate setting possible.

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The Health Of The People Should Be The Supreme Law

In a bitterly contested ruling in November, the Supreme Court sided with religious groups challenging restrictions on in-person worship in New York State. In doing so, the justices in the majority signaled a dangerous retreat from the long-established legal principle of deferring to the public health powers and judgments of state governments.

At first glance, the consequences of the New York case appear limited: officials even revised the state’s restrictions before the Court issued its injunction. The five conservative justices in the majority granted relief for the challengers regardless, on the basis that Governor Cuomo’s directives “single[d] out houses of worship for especially harsh treatment” compared to essential businesses. The governor had mandated that certain areas of the state with high rates of community spread limit attendance at religious services, whereas secular settings like grocery stores were not subject to such constraints.

The evidence did not bear out the idea that houses of worship had faced discrimination, however. For example, a brief submitted by the American Medical Association noted that “the Governor’s Executive Order has singled out religious services for more lenient treatment than similarly risky activities.”

Beyond the narrow (and currently moot) specifics of the New York case, the ramifications of the conservative majority’s ruling undermine the viability of critical public health measures like restrictions on high-risk activities and mask requirements. The upshot of the unsigned November ruling could be severe — both during this pandemic and the next.

Judges, as the majority that overruled restrictions in the New York case pointed out, are not public health experts. That’s precisely why the age-old principle of salus populi suprema lex esto, meaning the welfare of the people is the supreme law, calls for the courts to give state officials substantial latitude in their efforts to limit the spread of deadly pathogens like SARS-CoV-2.

The majority in Roman Catholic Diocese of Brooklyn v. Cuomo claimed, in the face of overwhelming evidence and expert consensus to the contrary, that “it has not been shown that granting the applications will harm the public” and that “the State has not shown that public health would be imperiled if less restrictive measures were imposed.”

In a concurrence, Justice Neil Gorsuch brushed aside the weight of salus populi, referring to the landmark Supreme Court precedent of Jacobson v. Massachusetts as a “modest decision.” Though no one would seriously argue with Justice Gorsuch’s assertion that “even in a pandemic, the Constitution cannot be put away and forgotten,” this is a straw man. In fact, New York State was striving to balance states’ public health powers with other constitutional liberties. (See this recent post for more on balancing religious freedom and public health.)

As states try to strike this balance, the fact that this pandemic has led to the deaths of hundreds of thousands of people in this country should urge strongly in favor of leaving public health measures intact. The carnage that Covid-19 has wrought seems to represent an emphatic call for federal judges to defer to epidemiologically-informed executive actions.

Until we reach vaccine-induced herd immunity, policies that leverage public health tools such as mask-wearing and physical distancing continue to be the most effective tools at state and local officials’ disposal to combat the spread of the novel coronavirus. When necessary, mask mandates and temporary shutdowns of non-essential businesses are not panaceas, but they’re far from useless.

Recognizing the authority of state officials to implement life-saving measures is not tantamount to casting aside the Constitution. Instead, recognizing states’ prerogative to safeguard the health and welfare of the people is exactly what the Court’s precedents, a proper weighing of constitutional interests, and the dire reality of this pandemic require.

@liambendicksen

The post The Health Of The People Should Be The Supreme Law first appeared on The Incidental Economist.

What Can Be Learned From Differing Rates of Suicide Among Groups

The following originally appeared on The Upshot (copyright 2020, The New York Times Company). 

U.S. suicide rates vary widely across racial and ethnic groups in ways that can upend expectations. The explanations may suggest avenues for prevention.

Suicide in America has been rising for two decades, with rates for white Americans consistently well above those for Asian-Americans, Black Americans and Hispanics.

In data released in 2017, the rate for white Americans was around 19 per 100,000, and it was about 7.1 for both Hispanics and Asian-Americans/Pacific Islanders, and 6.6 for Black Americans, according to the Centers for Disease Control and Prevention.

Emotional and social stress is associated with suicide. From this, a puzzle emerges.

‘Whether through family, church or another community’

Because of pervasive racism, Black Americans experience substantial stress, fewer opportunities for advancement and more threats to well-being. These negative experiences can degrade mental and physical health, as well as limit education, employment and income — all of which can increase suicide risk. Unemployment, which is higher for Black Americans than white Americans, is itself a source of stress.

Yet the Black suicide rate is about one-third that of whites.

“Social stressors — lower socioeconomic status and racism among them — are more prevalent and severe for the Black population than the white one,” said Joshua Breslau, a senior behavioral and social scientist at RAND. “But suicide and some risk factors for it, like mental health conditions, are less prevalent in the Black population. This is puzzling.”

One explanation may be a racial disparity in suicide data. Ian Rockett, an epidemiologist with West Virginia University, studies mortality data. “Because suicides can be difficult to prove, many may be misclassified as undetermined intent or accidents,” he said. “This problem is greater for Black Americans than white Americans.”

His work, and that of others, shows that deaths of Black Americans are far more likely to be coded as undetermined than those of white Americans, in part because Black Americans dying by suicide are less likely than whites to leave a note and to have a record of mental disorders. (Lower rates of mental health diagnoses reflect at least in part poorer access to health care and treatment that stems from racism.)

But misclassification cannot fully explain the racial difference in suicide. Other factors may help protect Black Americans from suicide, despite conditions that would seem to place them at higher risk. Dawne Mouzon, a sociologist and associate professor at Rutgers University, suggested that religious involvement is one source of protection. Black Americans overwhelmingly identify as Christian. “Because of their faith, Black Americans are more likely to believe suicide precludes reaching heaven after death,” she said.

Although church membership has trended downward over the last two decades, it has been lower and fallen faster for white Americans than Black Americans. According to a national survey by the Pew Research Center, by almost any measure of religiosity, Black Americans are more religious than whites. Emotional and social support from a church congregation may also confer mental health benefits, Professor Mouzon added.

It’s a much debated connection. A recent systematic review of studies found that attending religious service is not especially protective against suicidal ideation (thinking about or planning suicide), but it does protect against suicide attempts, and possibly protects against suicide.

Other types of group activities may confer a similar sense of belonging. Volunteers with caregiving responsibility maintain a significantly reduced suicide risk, a 2019 study found. As a 1976 study put it, social support is anything that leads someone “to believe that he/she is cared for and loved, esteemed, and a member of a network of mutual obligations.”

Jonathan Lee Walton, dean of the School of Divinity at Wake Forest University, sees another angle to Black religiosity that could reduce suicide rates. “It’s in the Black theological tradition that in this life you will experience trouble and hardship,” he said. “Unfortunately, this is born of tragic experiences in this nation. This prepares one for paths of despair, for traveling the lonely road of heartbreak, perhaps in a way that white Americans don’t learn to the same degree or from a young and formative age.”

Single parenthood is another possible explanation. Black women are more likely to be single parents than white women, and they have the lowest suicide rates across any race/gender group. (Suicide is less common among women than men in general.)

“For single parents, being the sole financial, instrumental and/or emotional support provider for children can deter suicide, even in times of extreme distress,” Professor Mouzon said. Another way single parenthood may reduce suicide risk is through the coalescing of extended family and community support for the care of the child. It’s possible this support, once in place, also confers mental health benefits that reduce suicide risk for the mother.

Experts say some reasons for the relatively low suicide rate among Latinos — who also tend to be poorer and face discrimination — are close social and family networks, which can build and maintain resilience, as well as moral objection to suicide based on religion. A study published in 2014 in the Journal of Clinical Psychiatry suggested that immigrant families can lose some of that protection when they assimilate and lose ties to Latino culture.

Though it’s impossible to predict who will attempt or complete suicide, the broad risk factors that contribute to suicide in all racial and ethnic groups are widely documented. They include mental health challenges and psychiatric disorders, exposure to suicide by others, being bullied, substance use, loneliness and social isolation, and exposure to stressful life events.

In the last two decades, there has been a sharp rise in so-called deaths of despair — suicides, drug overdoses or alcohol abuse — among middle-aged white Americans without a college degree. In their research on the subject, the Princeton economists Anne Case and Angus Deaton pointed to, among other factors, loss of community and loss of status.

Over all, the C.D.C. report found higher suicide rates in rural America than in medium/small and large metropolitan counties. Most gun deaths in America are suicides, not murders, and white men are more likely to own a gun. The C.D.C. report said rates of suicide by gun in rural counties were “almost two times that of rates in larger metropolitan counties.”

Among Asian-Americans, one study suggests that collectivist cultures among immigrants that promote care for others could be a protective factor. Another points to close family relationships. But what holds for one group may not for another. Aparna Kalbag, a mental health research psychologist and advocate, works with South Asian-Americans. “Their relatively higher education also plays a role,” she said. “It influences how they perceive and react to mental health symptoms. They view them as something they can change, and they have the resources to do so.”

This is not the case with other, lower-income groups whose access to mental health care is more circumscribed.

The group with the highest suicide rate

Suicide rates are highest among Native American and Alaska Native populations: 21.8 per 100,000 people.

One study found that American Indian youth in southeastern Montana are more likely than white youth to report feeling sad or hopeless — one predictor of suicide risk. Greater alcohol and drug use among Native American populations is also associated with higher suicide rates. Another study documented high rates of psychological distress among Indigenous populations.

According to scholars of suicide in Indigenous populations, these are all byproducts of colonization.

“Colonization is not only in the past,” said Desi Rodriguez-Lonebear, an assistant professor at U.C.L.A. and a citizen of the Northern Cheyenne Nation. “It’s an ongoing system, a series of structures that continue to disenfranchise, erase and traumatize Indigenous peoples.”

One of the most obvious and tangible effects of colonization on those populations is their forced segregation into reservations and the intergenerational trauma that ensued from severing ancestral relationships to their lands, cultures, languages and ways of life. “The psychological, social, and economic harms this causes cannot be overstated,” Professor Rodriguez-Lonebear said.

Explanations for variation in suicide rates across racial and ethnic groups point to ways to reduce it. “Whether through family, church or another community, emotional and social support is key to suicide prevention,” said Lillian Polanco-Roman, an assistant professor of psychology at The New School. “Beyond that support, these groups can also serve as bridges to mental health services.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at  SpeakingOfSuicide.com/resources

@afrakt

The post What Can Be Learned From Differing Rates of Suicide Among Groups first appeared on The Incidental Economist.

At-Home Testing for Covid

Experts have long been calling for quicker, cheaper, and more accessible ways of testing for Covid-19. Though such tests would be less accurate than the predominant PCR test, speed matters more than accuracy when it comes to curbing a pandemic. The FDA just issued an Emergency Use Authorization for a fairly affordable, at-home Covid test that renders results in 15 minutes, providing a useful mitigation resource as vaccine distribution rolls out.

 

@DrTiff_PhD

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Bias In, Bias Out

Melissa Garrido, PhD (@GarridoMelissa) is the Associate Director of the Partnered Evidence-based Policy Resource Center (PEPReC) at the Boston VA Healthcare System, U.S. Department of Veterans Affairs, and a Research Associate Professor with the Department of Health Law, Policy, and Management at Boston University School of Public Health.

**This is a research notebook entry — I’ve summarized a few recent articles on racial bias in predictive algorithms. The links below are a useful starting point if you are interested in learning more about this topic.

The saying “garbage in, garbage out” is used to urge investigators to carefully consider the variables and data being fed into a statistical model. The same applies to racial bias. Without considering how structural racism contributes to and is reflected by data, modeling strategies, and interpretation, we risk perpetuating or worsening inequalities.

Two articles about racial bias in clinical decision-making and predictive algorithms highlight their potential to reinforce and worsen racial disparities in health care access, quality, and outcomes:

In Reconsidering the Use of Race Correction in Clinical Algorithms, Darshali Vyas, Leo Eisenstein, and David Jones provide examples of the unintended effects of including measures of race and ethnicity in clinical decision-making algorithms. For each example, they highlight an attendant concern about equity — many of the algorithms systematically produce different risk estimates for people of color or underrepresented groups than for white patients. Differences in risk estimates can lead to systematic differences in further diagnostic testing or treatment. For instance, the Vaginal Birth after Cesarean (VBAC) risk calculator assigns a lower probability of success with VBAC for African American and Hispanic women than for white women — increasing the likelihood that African American and Hispanic women undergo unnecessary Cesarean deliveries.

In Dissecting Racial Bias in an Algorithm Used to Manage the Health of Populations, Ziad Obermeyer, Brian Powers, Christine Vogeli, and Sendhil Mullainathan demonstrate the ways in which racial bias can arise from models that do not include race as a variable. They use health system data that include components of an algorithm that is used by a large academic hospital to predict need for a care management plan, the predicted risk score, and outcomes. In an algorithm that does not include race as a predictor, the authors find evidence of calibration bias — Black and white patients have different risk scores despite having an identical set of other covariates. White patients with fewer health concerns were scored as higher risk than Black patients with more severe health needs, meaning that Black patients would be less likely than white patients to be referred to care management programs when appropriate.

In this case, the bias arises from the fact that health care costs were used as the outcome with an assumption that health care costs are a valid marker of health care need. However, the Black patients in this sample had lower health care costs than white patients with similar levels of health needs — reflecting racial inequities in access to health care.

Removal of race from a model may lead to improvements in some outcomes but declines in others. For instance, models to predict estimated glomerular filtration rates (eGFR), a measure of kidney function, systematically estimate that Black patients have better kidney function than white patients. This can lead to systematic delays in referral to specialty care among Black patients. Removing race from the model may improve specialty care access but lead to decreases in eligibility for certain medications among Black patients and decreases in the number of Black adults who are eligible to be kidney donors. Creators and users of predictive models and clinical decision-making tools need to carefully think through unintended consequences of modeling decisions. In the case of eGFR, a joint National Kidney Foundation – American Society of Nephrology task force will be issuing recommendations on potential changes to kidney function estimation in early 2021.

The choice to include or exclude race as a covariate in a model is just one of many modeling choices that can influence the degree to which bias is included or perpetuated in a model. Predictive models that are developed using data on a non-representative patient population are unlikely to produce accurate or meaningful estimates for broader groups of patients.  In models developed with electronic health record data, inequities in regular access to care may mean there is less data available for patients at risk of adverse outcomes. Where possible, it may be better to incorporate data that occurs early on in an illness and that is less dependent on patients’ access to regular follow-up visits. Directed acyclic graphs (DAGs) may be helpful for carefully thinking through the ways in which structural inequality influences relationships among variables (such as access to health care and rates of health care use) in a model and the inferences that can be made from the model.

In addition, the goals of the model should be considered when determining whether it is fair. If developers seek to create a statistical model that performs similarly across different groups of patients, the choice of performance metric may lead to unintended consequences. Improved calibration of predicted and observed outcomes across groups may come at the price of increased false negatives or false positives in one group of patients.

Predictive models play a large role in guiding decisions about treatment and resource allocation — close attention to their development and use is needed to guard against inequities in health care access and outcomes.

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Come work with me (and colleagues you’ve read here)

Colleagues you’ve read here (including Melissa Garrido, Elsa Pearson, Cecille Avila, and Alex Woodruff, among others) and I are advertising for a policy analyst. If that’s you, this is an opportunity to work with us at the Partnered Evidence-based Policy Resource Center (PEPReC). Though PEPReC is a center in the Veterans Health Administration, the position will be filled through Boston University.

Apply here.

@afrakt

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Covid Vaccine Facts with the WHO’s Dr. Kate O’Brien

We recently spoke with Dr. Kate O’Brien, director of the Department of Immunization, Vaccines and Biologicals at the World Health Organization. We spoke with Dr. O’Brien about how the Covid vaccine works, safety questions and concerns, and issues of distribution – including how we plan to distribute it equitably.

 

@DrTiff_PhD

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