Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
Pulling No Punches on Abortion
Reading the leaked draft opinion felt like a punch in the uterus (“Historic ‘Breach’ Puts Abortion Rights Supporters and Opponents on Alert for Upcoming Earthquake,” May 3). They’re basically saying the Constitution doesn’t grant people with uteruses the “liberty” to choose abortion for ourselves, meaning these justices believe the Constitution doesn’t grant us bodily autonomy. I’m not surprised since this seems to be the road conservatives have been paving. You don’t have to make abortion illegal if you make it totally inaccessible, as so many states have.
As a future reproductive health care provider, I’m ready to metaphorically punch back. I’m energized to find solutions that give access to abortion to all people. As we have seen with the pandemic, the people who will be most affected are low-income people of color, who have historically been medically disenfranchised.
We need collaboration from many different groups. We need pharmacists to help get medication for those who can’t easily access abortion care. We need providers who will travel or use telemedicine to provide abortion care for folks. We need attorneys to provide legal representation and advice to folks living in states with anti-abortion legislation. And, we need each other. This fight has just begun and, together, we will keep fighting; not just for our sake, but for our children’s, their children’s, and that of every future generation to come.
— Candy Ramirez-Hale, Oakland, California
It’s good to know that there are plans against the HEINOUS #ScotusVsWomen What we will NEVER FORGET is that THREE SCOTUS nominees LIED under oath.
— Peter Morley, New York City
Seniors Have Their Reasons for Not Getting Boosters
I read Liz Szabo’s article “Why Won’t More Older Americans Get Their Covid Booster?” (May 12) in the Chicago Tribune. I am in my 70s and clearly understand the dangers of covid-19. My primary care physician strongly recommended that I get the covid vaccine.
I had the Moderna vaccine. I did all right with the first vaccination. I had an extremely severe reaction to the second injection and I had a difficult time recovering from it.
When the booster shot was made available in fall 2021, I asked my primary care physician if I could get it. His answer was an emphatic no. Getting the booster shot would have put me in danger.
I am one person. Before you condemn seniors for not getting the covid booster, it would be good for you to consider that there may extenuating circumstances. Our bodies are older. It is a medically documented fact that older people react to medications differently than younger people. Please have some compassion and understanding.
— Arlene Lohrey, Wheaton, Illinois
To protect against #Omicron and subvariants, a booster is essential, but fewer than 30% of Americans have the necessary 3 doses.
…because Americans don’t WANT to get boosted, or because the CDC and media effectively messaging that the pandemic is over? https://t.co/gltv2qmViL— Lara Jirmanus, MD, MPH (@lzj961) May 12, 2022
— Dr. Lara Jirmanus, Revere, Massachusetts
I thought I’d answer the question your article assumes is critically important but does not attempt to answer: Why won’t more older American get their covid booster? Simple answer: no need for the booster, documented benefits are very small, risks are unknown, and costs are real.
I am not an anti-vaxxer; before retiring, I was an early leader in bringing nurses into my companies to give annual flu shots at no cost to all willing employees, which was nearly all of them. And my wife and I and all our extended family have had at least three shots at this point, except maybe a couple of the younger grandchildren. But if there’s evidence to support more shots for me now, it’s not obvious.
That there is a chorus of leading researchers and health officials dismayed about why I haven’t had another booster tells me more about how unqualified these researchers and health officials are to be writing the hymnals they’re singing from. My response to some of your particulars.
“People 65 and older account for about 75% of U.S. covid deaths.” Well, choir members, that’s lower than I thought it was and, by the way, did you note — as those of us 65 and older are acutely aware — that people 65 and older account for more than 75% of all health-related deaths? Heart, lung, and kidney disease; cancer; stroke; diabetes — not murders and accidents. But telling me 75% of people over 64 die of covid suggests I have no unusually big risk.“Among older people who died of covid in January, 31% had completed a first vaccination round but had not been boosted.” Later on, you tell us that “69% of … vaccinated older Americans have gotten their first booster shot.” Which means, I think, that those of us dying in January are typical of those of us not dying in January. So what’s the point of the booster?“A study of older veterans published in April found that those who received a third dose of an mRNA vaccine were as much as 79% less likely to die from covid than those who received only two shots.” Which means my likelihood of dying from covid decreases from 2.5/10,000 to 0.8/10,000 for the Moderna, and 5.0/10,000 to 1.2/10,000 people for the Pfizer-BioNTech vaccine. Not enough for this old fat guy to worry about, especially since the study doesn’t look at all-cause hospitalizations and deaths.“Overall, fewer than half of eligible Americans of all ages have received a booster.” Which means, dear reader, those 65 and over have a much higher boosted rate than our younger Americans. And the title of this article is …?
I think the reason we don’t have a higher vaccination rate — or, more importantly, why we have such a high death rate — is because the government botched this from the beginning, and in the last year or so made it even worse. Taking off a few weeks in March or April to dampen the curve and let the medical system prepare for what could be a catastrophe was understandable, but California Gov. Gavin Newsom and others like him issuing executive orders shutting down businesses and schools and beaches was just silly. I predicted this would do no good, and by reducing trust and confidence in politicians and government health ministers could make it much worse; two years later, I think I was right. With proper mask mandates from the beginning, we might have been in much better shape now and for the foreseeable future.
— Jim Call, San Diego
Very important article by @LizSzabo underscoring the need for a renewed public-private sector campaign to provide first booster shots to seniors. I’ve been talking about this for some time. #COVID19 https://t.co/iyrPRJCkQ7— Anand Parekh, MD (@AParekhBPC) May 12, 2022
— Dr. Anand Parekh, Washington, D.C.
Refilling the Nurse Pipeline
With the demand for travel nurses dropping, hospitals across the country are working hard to recruit and retain nursing staff (“Travel Nurses See Swift Change of Fortunes as Covid Money Runs Dry,” May 10). Amidst a historic nursing shortage, this is no easy task.
The U.S. Department of Health and Human Services recently released a new report highlighting the severe impact the pandemic has had on the nation’s health care workforce, including nurses. Burnout, trauma, and exhaustion have all exacerbated existing workforce challenges, and many hospitals have experienced critical nursing staff shortages over the past two years. Unfortunately, the problem is only expected to get worse, as research shows a third of nurses plan to quit their jobs by the end of this year. A large percentage of those (32%) will leave the field altogether, either switching careers or retiring.
These trends suggest that the United States will need to substantially grow the nursing workforce in the years ahead. While nursing education and training will be critical to meeting this challenge, many nursing schools lack the capacity to enroll more hardworking students, suggesting that it will be difficult to grow the nursing workforce in line with rising demand. At a time when America needs more nurses, the American Association of Colleges of Nursing (AACN) reports that over 90,000 nursing school applications were rejected in 2021 and enrollments in several key program areas including Ph.D.s — the backbone of the nursing education workforce — have declined.
To ensure a vibrant, safe, and resilient workforce for many years to come, the U.S. must invest in the nation’s nursing pipeline. This means supporting the efforts of nursing programs to attract and retain more nursing students at all program levels; addressing educational capacity issues by increasing faculty and clinical training opportunities; creating seamless nursing career pathways; and strengthening workforce readiness by ensuring students are prepared for licensure and to operate with good clinical judgment throughout their careers.
Over the past few weeks, I have met with countless nursing educators and students at conferences across the country, and these issues have all dominated the conversation. It’s clear, therefore, that the question isn’t “Is there a nursing workforce crisis?” — it’s “How do we train more — and better prepared — nurses?”
— Patty Knecht, chief nursing officer, ATI Nursing Education/Ascend Learning, Leawood, Kansas
Travel nurses raced to Covid hotspots. Now they’re facing canceled contracts.: How much does a travel nurse make a month? What exactly does a travel nurse do? As Covid funding dries up, travel nurses face canceled contracts. via NBCNews https://t.co/qqDqAVSdLC— Jeffrey Levin 🇺🇦 (@jilevin) May 9, 2022
— Jeffrey Levin, San Jose, California
Spreading the Wealth to Fix US Health
This family’s story of outrageous medical bills is relatable to many (“After Medical Bills Broke the Bank, This Family Headed to Mexico for Care,” April 27). Fortunately, the Fierro family’s innovative thinking saved them thousands in medical bills. After a series of unfortunate medical expenses during the pandemic, they ventured to Mexico to seek treatment for their son. The Fierros came up with an ingenious way to prevent themselves from falling deeper into medical debt, but not all families can do so. Therefore, the American health care system must develop a sustainable solution for patients.
My proposed solution is wealth distribution — alter progressive income taxation rates to tax people of lower incomes less and increase taxes for higher tax brackets, with a significant increase for those making over about $500,000 annually. The second part of my proposition is to use the additional money to create federal empowerment programs for those in lower tax brackets to build them up. Following an allotment to basic needs subsidies, I would create federally sponsored empowerment programs for youth in lower-income households — like tutoring, extracurriculars, professional development centers, etc. After ensuring that households are having their physiological and safety needs met, we can focus on growing toward the next level of opportunity rather than continuing the current cycles of poverty.
— Nitasha Sharma, San Francisco
all of it here. https://t.co/whan1lM3IT— Tung Fu Rue McLanahan (@VicMRodriguez) April 27, 2022
— Victor Rodriguez, Delaware County, Pennsylvania
An Urgent Piece of the Puzzle
Urgent care centers are a key part of this solution (“How the Test-to-Treat Pillar of the US Covid Strategy Is Failing Patients,” April 15). We have been working with the Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR) to better connect urgent care with state and regional gatekeepers to either test/prescribe/dispense themselves (where allowed) or be a pre-identified option for testing, prescribing, and assisting patients with finding a pharmacy with supply.
I’d love to see urgent care mentioned as an option in future stories on this topic.
— Lou Ellen Horwitz, Urgent Care Association, Batavia, Illinois
11/ The vaunted test-to-treat program announced by the Biden administration has largely been a dud:
* Not enough sites
* Too much reliance on pharmacies that don’t have licensed medical professionals on site
* A broken/confusing CVS booking flow https://t.co/sjZx4SgmwB— Myoung Cha (@cha_myoung) April 18, 2022
— Myoung Cha, San Francisco
In Managing Benefits, Patients Are Last in Line
Prescription discount coupons closely fit the definition of a bribe (“Is My Drug Copay Coupon a Form of Charity — Or a Bribe?” April 21). These prescription discount coupons, as mentioned, “cover up a drug’s true price, much of which our insurers pay” — although it is not particularly obvious how a discount affects insurance companies or insurance accessibility.
The U.S. pharmaceutical pricing process needs to be clarified for the public to understand this claim. Raw materials are sourced. Then raw materials are manufactured into finished products, packaged, and sent to distribution and dispensing centers, before making their way to patients. It sounds like a normal supply chain, but it is not. Manufacturers mark up prices and sell finished products to various players in the chain, and this is where there is a troubling lack of transparency. Each party — wholesalers, pharmacy benefit managers (PBMs), group purchasing organizations, and vendors — plays a role in the final price of the medication or cash price paid for a drug by increasing the price to the point of profit and offering or accepting rebates.
Rebates are off invoice and negotiated privately, with undisclosed price adjustments by the middlemen setting and negotiating their own profit and standing between patients and drugs patients need. The PBM determines the patient’s copay and the PBM determines in advance how much it will reimburse pharmacies or vendors for each medication covered under the drug plan. PBMs’ negotiated network rates have the effect of rebates and are generally far below the pharmacy’s list price, but PBMs typically require pharmacies to accept discount cards to remain in the pharmacy network.
That’s why a consumer without insurance saves money on prescription drugs by having access to a PBM’s network rate, which is lower than the list price. GoodRx provides discount coupons, but GoodRx is a PBM-backed program that collects a portion of the fee PBMs charge pharmacies when customers use discount coupons for these expensive drugs. Pharmacies lose the potential revenue from a cash-paying customer, who would have paid the pharmacies’ inflated cash price, and the pharmacies must pay a fee for the privilege of dispensing to a patient who may have used their pharmacy anyway. This results in the pharmacies increasing service fees and list prices often up to the maximum limit. This contributes to escalating insurance premiums and deductibles because insurance companies cover much of the list price for insured customers. Insurance companies do not take on the extra cost of these inflated cash prices and services. Insurance companies compensate for the rising amount they must pay out by charging more for premiums and increasing deductibles.
— Shinice Pace, Douglas, Georgia
Followup question: Is high consumer cost sharing for drugs about efficient utilization management or lowering premiums for healthy patients?
I’m happy to discuss problems with copay assistance but we must consider current equilibrium and how we got here.https://t.co/ZCkzsd3Jch— Craig Garthwaite (@C_Garthwaite) April 25, 2022
— Craig Garthwaite, Chicago
Elisabeth Rosenthal raises important points about the impact of manufacturer copay assistance on prescription drug costs, but many people living with rheumatic diseases don’t have any other options to help them afford the medications they need. Lower-cost generic and biosimilar versions of these drugs simply don’t exist.
I’ve lost count of how many difficult conversations I’ve had with my patients about affording their medication. And hanging over these discussions is the ever-present fear that one day the copay assistance will run out and my patient will have to abandon treatment.
So, recent efforts on the part of insurance companies to limit manufacturer copay assistance through policies like copay accumulators will only hurt patients who need the most help. Congress must pass the Help Ensure Lower Patient (HELP) Copays Act to put an end to this practice, and require health plans to count all copay assistance toward patients’ cost-sharing requirements.
— Dr. Howard Yang, Los Angeles
It’s a bribe. It should be made illegal across the board.
— Harry Sit, Midway, Utah
‘Building on Quicksand’
Are you kidding? Massachusetts has the highest health care costs in the world (“States Watching as Massachusetts Takes Aim at Hospital Building Boom and Costs,” May 3).
Our private health insurance payments to hospitals are the highest in the nation, almost four times the prices Medicare pays.
The original 1994 merger of Massachusetts General Hospital and Brigham and Women’s Hospital was approved without one public hearing. Some people are finally gagging on consolidations that would raise our high costs even higher — so Mass General Brigham’s acquisition of South Shore and MelroseWakefield hospitals was blocked. And its expansion in western suburbs is probably blocked, at least for now.
But no effective cost controls exist, even on paper.
The Health Policy Commission is toothless.
And state House Speaker Ron Mariano has publicly declared that the tool to rein in high prices is “competition.”
In summary, competitive forces are evaporating as hospitals consolidate and close. Behind the Potemkin village facade of regulation, we find neither substantial regulation nor any measurable competition. The result is financial anarchy, with high costs and higher premiums.
No one in Massachusetts health care is accountable for anything outside the building where they work.
I could guess about the benign motives for writing and publishing this happy-news story. But you’re building on quicksand, I fear.
— Alan Sager, professor of health policy and management at the Boston University School of Public Health, Boston
Fascinating story by @Meyer_HM, but a confluence of highly unusual forces. “States Watching as Massachusetts Takes Aim at Hospital Building Boom and Costs” #healthcarecost #masshealth https://t.co/747P0Eu1IU via @khnews— Michael Millenson (@MLMillenson) May 3, 2022
— Michael Millenson, Chicago
CDC’s Power Is an Overreach
Seriously, even if there is a really scary disease, more scary than all the diseases we now have, it won’t matter if we mask up or not — the next disease could be different and get through the pores or enter the ears and eyes! That’s when the Centers for Disease Control and Prevention will decide who lives and who dies, and that is not the kind of power I want any agency to have over me or my loved ones (“Judge’s Ruling on the CDC Mask Mandate Highlights the Limits of the Agency’s Power,” April 21). Every single person on this planet has a right to be here because we were all born into it; no other person or entity has the right to take that from any of us. I’ve already told my children, if I ever get cancer, I am refusing treatment — and, no, I am not religious. It is a waste of time and money, and my children will inherit that debt, in addition to losing me. I’m not trying to do that to anyone. Just as with most of the diseases we do not have cures for, we need to learn how to live with them. For Pete’s sake, there’s no cure for chickenpox, and you don’t have to get vaccinated if you have had chickenpox. Say no to giving the CDC more power and for sure say no to giving the feds more power!
— Katrina Green, Aloha, Oregon