Paving the Road

We all know where good intentions can lead. I thought about that while reading about Seattle’s new ban on plastic straws.

There is a growing global wave of bans on single use plastic products—straws, stirs, utensils – that aren’t often recycled. Policymakers want to fix the awful issue of plastic in the oceans, but there are people with physical disabilities who use plastic straws to drink because they can’t lift a cup or if they don’t use a straw, they run a significant risk of choking to death.

At least in Seattle, there is an exception for people with medical conditions who require straws, but it is not well publicized and suggested alternatives are not viable. The most likely situation is that restaurants and other watering holes just stop carrying them. Most of us with conditions have to carry supplies – medication, equipment, etc. – with us, but we all forget. I have run out of insulin often at work because I didn’t know I didn’t have enough to get me through the day, and keeping a medication on premises that expires in a month doesn’t work that well. For something as vital as getting a drink, this ban adds significantly to the burden we already have.

Difficult as the straw ban will be, it pales in comparison to the possible impact of new policies intended to address the opioid addiction crisis. I am not going to speculate about the intentions of the manufacturers who lied about how addictive opioids are or the doctors who took money to prescribe. Hopefully they will be held to account like cigarette manufacturers were when we discovered they had done something similar.

No, the problem we need to address is what states perceive as a solution. Many are instituting measures that would limit providers’ ability to prescribe. On the surface, it sounds like a logical solution. But the unintended consequences could be severe.

• Increased administrative burden: office and hospital administrative staff are already stretched thin because of the cost of doing business. This would stretch them even further.
• Stigma and restrictions: it’s all very well and good to be wary of a class of drugs that has caused so much misery, but there are plenty of patients who have a legitimate need for strong painkillers to treat severe pain. If the patients who need the medications can’t get them, they will be reduced to a state of existence, as opposed to living a life. And terminal patients, for whom palliative care is vital for maintaining dignity and comfort – addiction is not really an issue if you have weeks or months to live-- will wait in misery for death to come.
• An excuse for industry: insurers and pharmacy benefit managers (PBMs) hardly need another reason to delay or deny filling expensive prescriptions.

I have not heard a good solution to this one. Usually, I adhere to the theory behind our legal system (admittedly overly idealistic) called Blackstone’s Formulation, that it is better to let 10 guilty people go free than to imprison one innocent person. Translated for this situation, that would mean anything other than a solution that would punish the chronic pain sufferers for their conditions. I can’t make that work here since those addicted to opioids would be cast as the “guilty” ones. But they are victims, too, victims of a system that abdicated its purpose and its duty to put profits over patients.

So, what can we do? The only thing that comes to mind is increased patient engagement. We are headed in that direction, but slowly, too slowly to mitigate the negative effects of this latest slate of legislation.

I don’t think we as patients can wait for them to find us. At a few of the conferences I’ve attended, I’ve heard industry representatives speak about how difficult it is to find patients who want to be involved in research. This seems like an odd disconnect to me, as I am very aware of how vocal the online communities are. I bet nearly all of us, if given the opportunity to improve some part of the process/drug/system, would jump at the chance.

So, in the spirit of prevention and planning ahead, pick the entity (insurer, legislator, pharmaceutical company, etc.) you think is the biggest problem, and look up their public affairs office. Write or call or email or tweet with a message that if they ever decide to address X problem, you, as a user, would be happy to assist. Let’s see what happens!

Nothing to See Here

I’ve been planning a legislative update for a while. Little did I know just how bad June 2018 would be.

Before yesterday, I might have spent the whole post talking about the Trump administration’s new policy that allows insurance companies to offer plans that do not cover the 10 essential health benefits guaranteed by the Affordable Care Act. Of course, the ultimate target of the policy is to completely eliminate mandatory protections for those with pre-existing conditions, even though protecting that particular essential health benefit is “very important” to over 70% of Americans. Or perhaps the proposed cuts to the medical safety net – Medicare and Medicaid -- that would affect our most vulnerable, justified by a tax cut that was bad, but not that bad until you realize that they needed it to create a reason to gut Medicare and Medicaid.

I would have encouraged you to vote if you felt threatened by these policies. I would have given you a link to make sure you were registered (and to register if you weren’t), tell you where to go on election day, and how to vote early, as well as one to help you evaluate the candidates by their voting records.

And I would have steered clear of anything political beyond healthcare policy.

In good conscience, I can’t do that anymore. I will always encourage you to vote, but the Supreme Court has handed down three decisions in the last three weeks that will make that more difficult.

• Decision #1: Gerrymandering is a way to draw (or re-draw) Congressional districts in a way that discriminates against members of a specific race/ethnicity or political party. Racial gerrymandering has been illegal for a long time. Until recently, political gerrymandering was not egregious enough to require laws to prevent it. Now it is. A couple of weeks ago, The justices decided that they weren’t going to rule on whether partisan gerrymandering is unconstitutional. It’s hard, but not impossible, to measure, and it’s gotten to the point where it is demonstrably creating an unlevel playing field. This would have been the time to act. Solution: Get your state legislature to put gerrymandering on the ballot. Several states are proposing plans for the courts or bipartisan commissions to redraw the districts. Twenty-four states allow citizens to propose policy to the legislature or directly to their fellow voters.
• Decision #2: They upheld a decision to continue letting Ohio to purge voter rolls after missing one vote. Currently, if you miss a presidential or mid-term vote, the state will send you a notice informing you that you are about to be purged from the voter rolls. On paper. Through the mail. If you do not respond, you will be taken off the voter rolls after another four years. Do you know who actually checks the mail and reads random communiques from the state? No one under the age of 60. The Voter Registration Act says purging voter rolls for not voting is illegal. However, the majority (strictly along party lines) ruled that because the purge wasn’t aimed at a single individual, it didn’t violate the law. Do not let yourself believe that this behavior will be confined to Ohio. Solution: Nothing for the moment.
• Decision #3: They reversed a lower court decision that Texas districts were racially gerrymandered against Latinos. This decision was also made along party lines, and comes five years after they gutted the Voting Rights Act. Solution: Nothing for the moment.

All of these things put together with states closing polling places in minority neighborhoods, voter ID laws, and limiting polling hours and early voting options conspire to make voting by certain groups impossible. And who are these groups? Minorities, low-income earners, the elderly, and the disabled. All we ever wanted was a level playing field, and each of these things is another obstacle to overcome for the people who have the most to lose.

I am an optimist. I do not like being the doomsayer, but today it feels like there is no other choice. Today, Supreme Court Justice Anthony Kennedy, the only swing vote on the Court, announced that he will retire at the end of July. I can tell you right now that the Trump administration will nominate another Neal Gorsuch, who believes that racial gerrymandering is not illegal and has indicated through his judicial record that he does not believe in legal protections for the disabled. The Supreme Court protected the ACA only because the individual mandate was a tax. Now that the individual mandate is gone, so is the reason the Supreme Court protected it. What do you think will happen when the Trump administration brings another case saying that the Affordable Care Act is unconstitutional now that the individual mandate is gone. Nothing good, I assure you.

Supreme Court appointments are for life. Whoever comes in after Kennedy will be there for decades. The only way to stop it is to flip the Senate from red to blue – another very difficult but not impossible task. This means we have to protect Democratic Senators in Florida, Indiana, Missouri, North Dakota, and West Virginia, and flip two in Nevada, Arizona, or Tennessee.

I can tell you right now: this is the most important vote you will ever cast. If you have to miss an hour or two of wages you can hardly afford, or bring your kids to the polling place with you, or beg a ride to get to your polling place, PLEASE VOTE, especially if you live in one of the states I mentioned above. If you ever felt powerless in politics, now is your time. We have the power to protect ourselves, if only there are enough of us. I do not want to see our rights, so dearly won, steadily walked back for the next 30 years, and neither do you.

P.S. I do not consider the current administration to be conservatives. They are not the respected adversaries I have always known.