Citizen Cartwright

Homeless seniors

The number of Americans 65 or older grew by more than a third from 2010 to 2020 — the fastest rate of any decade in 130 years, according to data from the 2020 census that was released Thursday.

 

And nearly a quarter of a million people 55 or older are estimated by the government to have been homeless during at least part of 2019, the most recent reliable federal count available. 

 

They represent a particularly vulnerable segment of the 70 million Americans born after World War II in the baby boom generation, the youngest of whom turn 59 this year, The Washington Post reports.

 

Advocates for the homeless in many big cities say they've seen a spike in the number of elderly homeless, who have unique health and housing needs. Some communities are racing to come up with novel solutions, including establishing senior shelters and hiring specially trained staff.

“It’s just a catastrophe. This is the fastest-growing group of people who are homeless,” says Margot Kushel, a professor of medicine and a vulnerable populations researcher at the University of California at San Francisco.

 

Dennis Culhane, a professor and social science researcher at the University of Pennsylvania, says the population of homeless seniors 65 and older will double or even triple 2017 levels in some places before peaking around 2030.

 

The largest shelter provider in Arizona, Central Arizona Shelter Services, is rushing to open an over-55 shelter in a former Phoenix hotel this summer with private rooms and medical and social services tailored for old people. The facility will open with 40 beds and eventually reach a capacity of 170, but that will barely begin to address the problem. CASS says it served 1,717 older adults in 2022, an increase of 43 percent in one year.

In Orange County, Calif., a Medicaid plan is creating a 119-bed, first-of-its-kind unit that essentially will serve as an assisted-living facility exclusively for homeless people, says Kelly Bruno-Nelson, executive director for the plan, CalOptima Health.

A combination of factors is to blame for the rising problem. People in the second half of the baby boom, who came of age during recessions in the 1970s and 1980s, face distinct economic disadvantages, Culhane says. Housing costs in many cities are soaring. The nation’s system of nursing homes and assisted-living facilities isn't equipped to handle the needs of homeless people, who suffer from high rates of substance abuse and mental illness.

And living on the street ravages the human body, street doctors and advocates say. Homeless people contract chronic diseases and other geriatric problems much earlier than average. Long waits for housing and a lack of specialized care expose them to a continued onslaught on their health.

After treatment for an acute illness, hospitals often discharge homeless patients, who wind up back in shelters or even back into their sidewalk tents and makeshift lean-tos, in what health practitioners in Phoenix call “treat-and-street.”

 

Medicaid, the health insurance program for the poor, will only pay for a long-term nursing home or assisted living bed if a person is unable to care for themselves. Many elderly homeless people aren't debilitated enough to meet that criteria.

“That’s where the gap in the system is,” says Regan Smith, long-term care ombudsman program director in Maricopa County, Ariz.

 

A pinball effect takes hold, according to health-care providers, shelter operators and advocates. Homeless people bounce from a homeless shelter to a hospital, then to a nursing home for a short-term recuperation stay. Once the short-term stay ends, nursing homes must decide if the person is infirm enough to qualify for long-term care. If the answer is no, they have to leave the nursing home, starting the cycle over again.

"Respite centers" now number about 150 around the nation, up from 80 in 2016, according to the National Health Care for the Homeless Council. They’re often funded at least in part by local hospitals that want to avoid discharging homeless people back onto the streets. They're designed to help homeless people recuperate for a few weeks after a health crisis. But with nowhere else to go, the elderly tend to stay far longer.

“Medical respite was not intended to be palliative care, hospice care, end-of-life care,” says Kushel, “yet some respite programs are starting to provide that service because there is nowhere else for these folks to go.”

 

Worrisome to Jeff Olivet, who leads the U.S. Interagency Council on Homelessness, is when the public responds to homelessness with “anger” and “vitriol” instead of seeking “thoughtful, compassionate solutions.”​

​To be part of the solution, he has four suggestions:​
1. Educate yourself on the the issue.​
2. Advocate at all government levels of government for “adequate resources to address this problem.”​
3. Donate to organizations “doing good workaround solutions to homelessness.”​
4. Volunteer for these groups.​​

Reining in pharmacy benefit managers (who?)

The Federal Trade Commission sued on May 16 to block the merger of drugmakers Amgen and Horizon Therapeutics, saying it would enable Amgen to leverage the monopoly power of two top Horizon drugs, reports KFF (formerly KHN).

In its suit, the FTC said if it allowed Amgen’s $27.8 billion purchase to go through, Amgen could pressure the companies that manage access to prescription drugs — pharmacy benefit managers, or PBMs — to boost the two extremely expensive Horizon products in a way that would inhibit competition.

The FTC also announced an expansion of a yearlong investigation of PBMs, saying it was looking at two giant drug-purchasing companies, Ascent Health Services and Zinc Health Services. Critics say the PBMs set up these companies to conceal profits.

The week before, the Senate Health Committee approved on May 11 bipartisan legislation sponsored by Chairman Bernie Sanders, D-Vt., and Sen. Bill Cassidy, R-La., a physician and the panel’s top Republican. The legislation (S 1339) is intended to increase transparency of PBMs, among other things.

Background
In a separate article titled "PBMs, the brokers who control drug prices, finally get Washington’s attention,” KFF discusses the role and relevance of PBMs (there’s a helpful four-minute video).

"Drug manufacturers claim that exorbitant PBM demands for rebates force them to set high list prices to earn a profit,” says KFF. "Independent pharmacists say PBMs are driving them out of business. Physicians blame them for unpredictable, clinically invalid prescribing decisions. And patients complain that PBMs’ choices drain their pocketbooks.”

"With PBMs driving prices, competition has had the opposite effect from what economic theory predicted Medicare patients would spend out-of-pocket on drugs, one large study showed. Over a five-year period, patients were paying 50 percent more for branded drugs that had competitors than for those that didn’t."

"All this makes the PBMs ripe targets for politicians of both parties," KFF says. "Yet the complexity and obscurity of their role in the drug marketplace have skeptics wondering whether legislation advancing in the House and Senate will actually help patients or lower prices at the pharmacy counter.”

The role of PBMs certainly IS complex and obscure. If you’re interested in diving deeper, I refer you to the KFF articles and to this Vox article.

AP: Racial health disparities harming African Americans

"From birth to death, Black Americans fare worse in measures of health compared to their white counterparts. They have higher rates of infant and maternal mortality, higher incidence of asthma during childhood, more difficulty treating mental illness as teens, and higher rates of high blood pressure, Alzheimer’s disease and other illness as adults,” says The Associated Press, which spent a year examining the issue.

 

Key takeaways:

 

— African American women have the highest maternal mortality rate in the United States, almost three times the rate for white women, according to the Centers for Disease Control and Prevention. And African American babies are more likely to die, and far more likely to be born prematurely, setting the stage for health issues that can follow them throughout their lives.

 

Multiple factors contribute to these disparities, according to the CDC and advocacy groups, such as underlying health conditions. But more doctors and experts point to the role of structural racism that's created inequitable access to health care, implicit bias and discriminatory care.

 

— More than 12 percent of African American children nationwide have asthma, compared with 5 percent of white children.

 

With asthma, especially for children, where you live makes all the difference, says AP. And where you live often depends on your race. 

 

Across America, nearly 4 in 10 African American children live in areas with poor environmental and health conditions compared to 1 in 10 white children, AP says.

 

– The United States has a shortage of mental health providers who understand the roles that racial identity and racism play in shaping young African Americans' mental health. Between 1991 and 2019, African American adolescents had the highest increase of any group in suicide attempts, at nearly 80 percent.

 

— About 56 percent of African American adults have high blood pressure, compared to 48 percent of white adults. 

 

Only 32 percent of white adults with high blood pressure have their condition under control with medication, but the level for African Americans is even lower, at 25 percent.

 

Among white people, the prevalence of cardiovascular risk factors and disease is projected to decrease over time, says AP. Yet significant increases are projected among people of color, especially African Americans and Latinos.

 

— About 14 percent of African Americans over the age of 65 have Alzheimer’s, compared with 10 percent of white Americans, according to the CDC. The trauma of experiencing racism is believed to be a contributing factor, AP says.

Drug shortages

Thousands of patients are facing delays in getting treatments for cancer and other life-threatening diseases as drug shortages in the United States approach record levels, says The New York Times.

There are 238 items on the drug shortages list of the American Society of Health-System Pharmacists. 

 

“This is, in my opinion, a public health emergency,” says Dr. Amanda Fader, a professor at the Johns Hopkins School of Medicine and a president-elect of the Society of Gynecologic Oncology, “because of the breadth of the individuals it affects and the number of chemotherapy agents that are in shortage right now.”

White House officials and members of Congress are grappling with an opaque and sometimes interrupted supply chain and quality and financial issues that are leading to manufacturing shutdowns, the Times says. They’re examining the underlying causes of the faltering generic drug market, which accounts for about 90 percent of domestic prescriptions.

 

Some shortages, like those of weight-loss drugs, are the result of high demand, while others have been attributed to overprescribing, including for antibiotics, or a lack of investment in potential alternatives.

The Biden administration has assembled a team to find long-term solutions for shoring up the pharmaceutical supply chain as the United States remains heavily reliant on medicines and drug ingredients from India and China. 

 

Officials have been debating possible measures including tax incentives for generic drugmakers and greater transparency around generic drug quality. The current incentives favor drugmakers with the lowest prices, which includes those that might cut corners — leading to disruptive plant shutdowns if the FDA requires a fix. 

 

The FDA, which employs a team of about 10 people who do the day-to-day work of mitigating and reporting drug shortages, has said it's seeking authority from Congress to get additional information about the drug manufacturing and supply chain.

 

Four Senate bills with bipartisan sponsorship could help get generic drugs to market more quickly by addressing tactics or loopholes causing delays, the Times says.

Researchers release ‘pangenome’ showing human diversity

The genome being used to determine your chance of getting heart disease or the cancer treatment you would respond to has been put together from bits and pieces of genetic material from a few people of mostly European and African ancestry.

 

Now, the first “pangenome,” representing individuals with ancestry from across the globe, could improve the genetic testing for various diseases and even provide new insights into human evolution and biology, says Science. 

 

And researchers are aiming to sequence new genomes from other regions that have been historically underrepresented, such as the Middle East.

 

Sarah Tishkoff, a human geneticist at the University of Pennsylvania who was not involved in the new study in the journal Nature, says there’s a lot more diversity out there. “But this is a great start.”

What’s the status of the coronavirus as the emergency designation ends?

Nearly everybody in the United States has some form of immunity as the emergency designation ends Thursday, whether from vaccines, a previous infection or both, says The New York Times. And medications like Paxlovid have significantly reduced the risk of serious illness.

 

"But we must also remember that there is a substantial group of Americans who are still very worried about contracting Covid, in particular the older and the sicker,” says Dr. Sanjay Gupta of CNN.

 

"The CDC estimates that the risk of hospitalization for those 75 or older is between 9 and 15 times higher than for those who are 18 to 29, and here in the United States, nearly 25 million people are older than 75,” Gupta says.

 

"When it comes to our general health, a study published in the journal Clinical Infectious Diseases found that people with asthma had a 1.4 times higher risk of hospitalization than a healthy person, hypertension bumped up the risk to 2.8 times higher, chronic kidney disease to four times higher and severe obesity to 4.4 times higher,” Gupta says. "Someone with three or more health conditions had a five times higher risk. Forty percent of Americans are obese, and nearly 70 percent of the country has at least one of the conditions that greatly increases their risk.”

 

One of the greatest lessons of the pandemic for the United States, Gupta says, is that “while we had tremendous resources to combat this pandemic, our collective poor health put us at a tremendous disadvantage. We must do all we can to focus on the basics, because no amount of wealth can buy good health.”

 

Dr. Robert Wachter, chair of the department of medicine at the University of California, San Francisco, says he continues to wear a mask in most crowded indoor settings, like on a plane or in a museum but not if he needs to go into a store quickly. He says his main motivation is to avoid long Covid.

 

Gupta says: "During the past three years, I would often speak with public health and other experts to try to work out exactly when we would move out of the pandemic phase and into the endemic stage of this health emergency. There were few hard answers. Instead, many told me that it came down to the number of Covid deaths we could stomach as a society, in exchange for an end to having our lives disrupted.”

 

And, as individuals, it comes down to our own personal risk assessment.

 

Here are 23 pandemic decisions that went right, from The Atlantic.

The corporatization of medicine

The shortage of primary care doctors is getting worse, says The New York Times. These doctors practice in one of medicine’s lowest paid and least glamorous fields, and most are overworked.

 

Yet “despite their lowly status, primary care doctors oversee vast numbers of patients, who bring business and profits to a hospital system, a health insurer or a pharmacy outfit eyeing expansion,” the Times says.

 

So multibillion-dollar corporations, particularly giant health insurers, are buying up primary care practices. For example, CVS Health, with its pharmacy business and ownership of the major insurer Aetna, paid about $11 billion to buy Oak Street Health, a chain of primary care centers that employs doctors in 21 states. Amazon bought One Medical, another large doctors’ group, for nearly $4 billion.

 

The increasing privatization of Medicare, the federal health insurance program for older Americans, means that more than half of its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government now is paying those insurers $400 billion a year.

 

“That’s the big pot of money everyone is aiming at,” says Erin Fuse Brown, director of the Center for Law, Health & Society at Georgia State University and an author of a New England Journal of Medicine article about corporate investment in primary care. “It’s a one-stop shop for all your health care dollars.”

 

The absorption of doctor practices is part of an accelerating consolidation of medical care, putting patients in the hands of a shrinking number of giant companies or hospital groups, says the Times. Many of those companies already were the patients’ insurers and controlled the distribution of medications through ownership of drugstore chains or pharmacy benefit managers. 

 

Nearly seven in 10 of all doctors now either are employed by a hospital or a corporation, according to a recent analysis from the Physicians Advocacy Institute.

 

The companies say these new arrangements will bring better, more coordinated care for patients, but some experts say the consolidation will lead to higher prices and systems driven by the quest for profits, not patient welfare.

 

The experts say these big acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to dictate limits on services.

 

Sen. Elizabeth Warren, D-Mass., is urging the Federal Trade Commission to take a closer look at some of the large deals, which regulators so far haven't blocked on antitrust grounds. “I fear that the acquisition of thousands of independent providers by a few massive health care mega-conglomerates could reduce competition on a local or national basis, hurting patients and increasing health care costs,” she wrote to regulators in March.

 

This consolidation of medical care also may run afoul of state laws that prohibit corporate medicine, says the Times. Such laws prevent a company that employs doctors from interfering with patient treatment.

The millions of people at risk of being kicked off Medicaid

Media have been reporting for months that millions of people are expected to be left without health insurance after a three-year reprieve during the coronavirus pandemic, when the federal government prohibited states from removing anybody who was deemed ineligible.

 

The nationwide review of the 84 million Medicaid enrollees over the next year will require states to remove people whose incomes now are too high for the federal-state program for the poorest Americans. 

 

And the start of Medicaid disenrollments comes as the federal government puts an end to a boost in payments for the tens of millions of Americans who receive food stamps, and as benefits like free coronavirus vaccines and tests associated with the public health emergency that's to expire May 11 are in limbo, says The Washington Post.

 

State-based health insurance marketplaces created by the Affordable Care Act are the only places people can buy individual insurance with help from an income-based subsidy, says a March Associated Press article on how people who lose Medicaid coverage can shop for new insurance.

 

Advocacy groups have said for months that confusion and errors will wrongly leave some of the country’s poorest people suddenly without health insurance and unable to pay for necessary medical care.

 

And Medicaid enrollees are reporting that they’ve been erroneously kicked off in states that have begun removing people, including Arizona, Arkansas, Florida, Idaho, Iowa, New Hampshire and South Dakota, according to data gathered by AP.

 

Some people have been mailed pre-populated application forms that have inaccurate income or household information but leave Medicaid enrollees no space to fix the state’s errors. Others have received documents that say Medicaid recipients will lose their coverage before they’ve even had an opportunity to re-apply, says Trevor Hawkins, who works for Legal Aid of Arkansas. 

 

The federal government requires states to tell people only 10 days in advance that they’ll be kicked off Medicaid, AP says.

 

Advocates for health care access say they're most worried about the 7 million people who will still be eligible for Medicaid but unable to surmount administrative hurdles; won’t receive renewal letters because they've moved, will face a language barrier filling out forms; or will be victims of clerical errors. 

 

Note to readers in metropolitan Washington: Virginia is one of 14 states disenrolling people from Medicaid starting May 1; Maryland and D.C. join 22 states starting in June.

'Why America isn’t that awful'

That’s the subheadline of this week’s edition of Australia’s “good news” newsletter Future Crunch.

 

Ha, ha, ha. To quote a friend of mine from India, that subhed “cracks me down.”

 

It reminds me of the Dutch fiancé of another friend. When I asked her if she and her husband might at some point live in the United States, she said, “Oh, no, you can’t raise children there!”

 

Future Crunch's item on us says: "Yes, everything in America is awful, except for the fact that inequality is falling; unemployment is at its lowest since WW2 (and so is racial disparity in hiring); it's still the world’s richest, most productive and most innovative economy; poverty and uninsured rates are at their lowest levels in history; Millennials are back on track, and GenZ are blowing past other generations in saving for retirement.”

 

Enjoy your weekend, my fellow Americans, in our livable unlivable conditions!

GOP efforts to keep abortion rights off state ballots

Last year, voters approved ballot measures that established or upheld abortion rights in all six states where they appeared, says The New York Times.

 

Now, with abortion rights groups pushing for similar citizen-led ballot initiatives in at least six other states, GOP-controlled legislatures and anti-abortion groups are trying to make it harder to pass the measures — or to get them on the ballot at all, the Times says.

 

While some legislators have targeted citizen-led initiatives on redistricting, voting rights for felons and legalized marijuana, abortion opponents and supporters agree that the Supreme Court’s decision overturning Roe v. Wade has supercharged the push for citizen ballot measures and GOP efforts to deter them, the Times says.

 

The biggest and most immediate fight is in Ohio, where Republicans in the state legislature are advancing a ballot amendment that would raise the percentage of votes required to pass future abortion rights measures to a 60 percent supermajority, says the Times. The measure has passed the state Senate and is expected to pass the House this week.

 

The GOP measure — which would require support from 50 percent of voters to pass — would go before voters in a special election this August.