Category Archives: Health Care and Medicine

by | July 6, 2021 · 4:21 pm

Even with Recent Improvements, Obamacare’s Exchanges Don’t Cut It

“Health care should be a right, not a privilege, and Americans facing illness should never have to worry about how they are going to pay for their treatment.” Thus begins the Joe Biden White House’s description of the signature health care investment in their American Families Plan (AFP).

Unfortunately, that proposed $200 billion investment in no way matches the rhetoric. The AFP makes the expanded health care subsidies in the recently passed American Rescue Plan (ARP) permanent, but these expanded subsidies serve primarily to funnel money into insurance executives’ pockets while only making health care somewhat more affordable for millions of people in need. As policymakers debate their next steps forward on health care, it is essential that Democrats take a more critical look at one of Obamacare’s worst elements.

Health policy analysts typically focus on monthly health care premiums as the primary indicator of health plan affordability. In a February column excitedly touting the ARP’s temporary subsidy improvements, for example, New York Magazine’s Jonathan Chait included the graph below from my former colleagues at the Center on Budget and Policy Priorities (CBPP). It shows that the new subsidies should be saving people making between $30,000 and $60,000 roughly $100 per month on their premium payments.

Unfortunately, these types of graphs miss what’s really happening with health care affordability. On the most basic level, by plotting monthly premium amounts against annual income, they make it seem like premiums are much more affordable than they really are. $274 per month doesn’t sound nearly as bad as $3,288 per year, which is how much a typical 45-year-old individual making only $45,000 a year will continue to be expected to hand over to their insurance company if the AFP becomes law.

More importantly, these graphs omit the significant amount of additional money it takes for low- and moderate-income people to actually access the care their premiums are supposed to cover. Deductibles in particular are incredibly high on the Obamacare exchanges. The average deductible for a benchmark (Silver) plan on the exchanges is $4,800, meaning that, if the aforementioned 45-year-old got sick and needed $4,800 worth of care, the insurance company would not chip in at all. So that individual would end up paying $4,800 for their care in addition to $3,288 in premiums to the insurance company – or 18% of their income in total. If the individual’s health care costs exceed the amount of the deductible and the individual receives care from an in-network doctor – which is hardly a guarantee – the insurance company will begin to contribute. But even then, the individual will be on the hook for additional “co-pays” or a percentage of the additional costs due to “coinsurance.” Americans facing illness should never have to worry about how they are going to pay for their treatment, but if they have a new and improved Obamacare exchange plan they’d still be crazy not to worry. And they will continue to decline needed care because they cannot afford the deductibles and/or coinsurance.

In addition to ignoring the continuing health care accessibility problems faced by many individuals, common analyses of the increased subsidy approach fail to show the massive amounts of money being funneled from taxpayers to the insurance industry. Expanded subsidies mean individuals pay less to the insurance company but the government pays more.

The graph below addresses all of these problems. It shows health care spending and revenues for a 60-year-old individual making $30,000 who requires some medical care during the year – two doctors’ visits beyond the physical Obamacare covers, two lab tests, and a routine surgery, the combined price of which can be estimated at $5,583 – under five different coverage scenarios. The first three scenarios are coverage under an average Bronze, Silver, or Gold plan that this individual would have access to today (with the enhancements in the ARP that the AFP seeks to make permanent factored in). The fourth scenario is coverage under the Medicare program, which 17 senators and 156 House Democrats recently asked Biden to improve and extend to individuals below age 60. While Biden and Democratic leadership have yet to indicate they will actually do that, the White House does claim in both their AFP Fact Sheet and budget writeup that, in the words of the budget document, Biden “supports…giving people age 60 and older the option to enroll in the Medicare program.”

The fifth and final scenario is coverage under the Medicare for All proposal that was a centerpiece of Bernie Sanders’s presidential campaign. Medicare for All legislation in both the Senate and House of Representatives has numerous cosponsors. Biden and congressional Democratic leaders remain opposed to this policy, however.

Each bar in the graph has three potential components: individual spending (yellow), or how much the 60-year-old spends on health care taxes (they would have to pay the 1.45% Medicare payroll tax under each scenario, which would come out to $435 annually), premiums, and payments to their health care providers; net government spending (blue), or how much the government spends in payments to the individual’s insurance company and health care providers plus administrative expenses minus the fee the government charges the insurance company to sell insurance on the exchanges and the health care taxes and/or premiums the individual pays to the government; and insurance company spending (gray), or how much the insurance company ends up paying to the individual’s health care providers on the individual’s behalf.

The dotted lines show overall health care spending and who receives the revenue. The horizontal line shows what the health care providers receive in every scenario: $5,583, which is the cost of the care itself. The vertical lines show net insurance company revenue, or how much the insurance company takes in from the government and individual from premiums and subsidies minus the fee the company pays the government to sell on the exchanges and what the company actually contributes towards the individual’s care.

As the graph shows, the Obamacare plans are a disaster for both this relatively healthy 60-year-old and the government. The new subsidies in the ARP actually bring the average Bronze plan premium for this person down to $0 annually, but the average Bronze plan’s deductible of $6,900 means the individual must pay for the full cost of care themselves (assuming they do not forgo the needed care because of the cost), bringing their total health care expenses (including Medicare payroll taxes) to over 20% of their income. The government, meanwhile, pays the insurance company an annual premium of $8,160 through the Obamacare subsidies – far more than what the care itself costs and netting the insurance company $7,976 after subtracting their $184 user fee – in order for the insurance company to contribute nothing at all!

Silver plans are typically considered the best value on the exchanges, in part because lower-income individuals who buy Silver plans can qualify for some cost-sharing reductions. The amount of those reductions vary, but let’s assume this individual buys a plan with a sizable reduction that takes their deductible down $2,000 from the $4,800 average. Co-pays and coinsurance also vary plan to plan, but one of the better Silver plans might cover 80% of costs above the deductible. So once the $2,800 deductible is exceeded, the insurance company in this case would pay $2,226 of the remaining $2,783 the individual owes. Yet between the individual’s $1,020 annual premium payment to the insurance company, Medicare taxes, and $3,357 payment to their health care providers (due mainly to their still-large deductible), they would still be paying close to $5,000 towards health care – which someone making $30,000 a year obviously cannot afford. The government’s subsidy payment to the insurance company would be even larger than it was for the Bronze plan – $10,176 for the year – and the insurance company would pocket $8,718, which would once again be far more than the cost of care itself.

The average Gold plan, with a deductible of “only” $1,600 and coinsurance that might be 10%, is the best plan for an individual needing care. But with an annual premium of $1,848, the $1,600 deductible, and a $398 coinsurance payment above the deductible, our example 60-year-old making $30,000 a year would still need to pay over 14% of their income towards health care costs. The insurance company would contribute $3,585 towards care in this scenario but would still net a tidy $8,169 in revenue.

With government insurance the situation is radically different. Medicare Part B requires individuals at this income level to pay premiums comparable to those under the Gold plan, or $1,782 annually, and also has 20% coinsurance. But the deductible is only $203, saving our hypothetical 60-year-old $785 relative to the Gold plan. The biggest difference is that there is no massive subsidy for the government to pay to the insurance company in this scenario; administrative expenses are negligible (only $73) and American taxpayers collectively save thousands of dollars that would otherwise be wasted on insurance company executives’ outrageously high salaries. There’s really no justification for the Obamacare subsidies approach relative to the expansion of Medicare approach unless your goal is to pad insurance company profits.

Medicare for All would result in slightly-smaller-than-for-present-day-Medicare-but-still-major taxpayer savings relative to the Obamacare approach and, most importantly, is the best deal for the individual needing care. Our 60-year-old friend’s taxes would increase somewhat (by $704) under the income-based tax proposal Sanders released as one of a variety of potential Medicare for All financing options, but that tax increase would be more than offset by eliminating premiums, deductibles, and coinsurance. This individual would pay less than 4% of their income towards health care costs regardless of what care they needed. They would not “have to worry about how they are going to pay for their treatment,” which is why Medicare for All is the clear choice for everyone who truly believes that “health care should be a right, not a privilege.”

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by | April 21, 2020 · 8:46 pm

Resident Perspective: Volunteering at a Testing Site

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

 

With my office hours consolidated and no longer attending morning and noon teaching conferences, I find myself wanting to get back in the action. During my self-isolation I signed up for the Philadelphia Medical Reserve Corps. I signed up to be a “swabber” (obtaining samples from the back of the throat) at the South Philly screening site in the parking lot of Citizen’s Bank Park. I have Phillies tickets for a game that was supposed to take place this weekend. But instead I arrive at the stadium parking lot to see swathes of asphalt without cars. Instead they’re filled with tents, traffic cones, and people gowned from head to toe in PPE rather than tailgaters. This screening site is a joint venture between the Philly Department of Health, the Commonwealth of Pennsylvania, and the Federal Emergency Management Agency (FEMA). There is plenty of PPE to go around and I suspect this is due to FEMA’s presence because right now nobody seems to be overly concerned about limiting volunteer access to equipment.

Testing Site

I’m interested to see who comprises the volunteer corps because there is a wide variety of people in the Delaware Valley that suddenly have nothing to do. There are retired physicians, nurses, medical students (suddenly without any clinical duties), as well as people not at all involved in medicine who just want to help. Everyone is eager and energetic. You couldn’t tell there was a pandemic about to make its way to Philadelphia and the people that are most concerned they have an infection are driving to your current location.

There are multiple large white tents set up to receive cars to drive through. Each tent has the capacity to test about 100 people per day. The decision on how many tents to open each day is dictated by the number of volunteers available and the weather. On my first day it’s windy—very windy in South Philly. So windy in fact if you dropped a glove or a face shield you better start running because it would be 10 yards away before it hit the ground. Mornings start with huddles of teams where we begin the process of assigning volunteers to different stations and assign roles for the day. A woman in a vague military ensemble and standing up perfectly straight, presumably from FEMA, calls our medical director over after our huddle. There is a line of about 30 cars waiting for the entrance gate to the parking lot to be lifted to signal we’re ready to start testing. We typically start at 1pm on the dot but today things are dragging along. The Medical Director slowly walks back to the “swabbers” tent, facemask in hand, and dejectedly says that we have to close the operation today due to high winds which are anticipated to become worse as the day wears on. This is because the specimens may blow over and be scattered in the wind, putting Philly on the map as the first city to accidentally infect its own citizens with coronavirus. We have to go car by car to notify the inhabitants that if they are truly sick they should go to the nearest ED or come back at a future date. Demoralizing indeed.

Our positive rates with the nasal swab at the testing site are between 25% to 30%. If we had tested only 200 people that day, that’s still at least 50 people we would have identified as being COVID-19 positive. Who knows how many had to take off from work to come in or might not get the chance to come in tomorrow. The volunteers are pretty disappointed.

The screening site is a well-oiled machine by the time I arrive in late March. Through intake, data collection, verification, swabbing, etc. it takes about 8 to 10 volunteers to run one “lane” of cars. Ultimately the car completes its journey at our site in the swabbing tent where the specimen is collected. The more volunteers present, the more tents and lanes can be open,  which will greatly decrease wait time for the public to get screened—therefore enticing more people to receive testing. There are times when I volunteer and only two tents are open due to staffing issues. Additionally, I’m told by the Medical Director at the site that samples are now taking closer to 10 days to process, not the 5 to 7 that we had been telling the patients. Lastly, something that I find somewhat incomprehensible is that the FEMA guidelines for eligible patients to get tested do not align with those of the Philadelphia Department of Health. This leads to some people being taken out of line by FEMA representatives even though they’re eligible for testing according to the Department of Health. It never occurred to me that things like this can affect an overall city’s number of cases. Closing or decreasing screening capacity as well as delays in reporting can make numbers artificially lower.

I’m trying to find silver linings to come from the pandemic. Some are that the people being screened are overwhelmingly appreciative of our efforts. Local restaurants provide free lunch and dinner to the volunteers so it very much feels like a community coming together. I’m fortunate to observe the way people are supporting one another during these stressful times. Philadelphians are responding positively—for now. It likely won’t stay like this for the entirety of the pandemic as economic and other life-changes will exacerbate the anxiety that many people are feeling. I take comfort in knowing that there is potential for a lot to change in our society as we emerge from the pandemic.

It won’t be a surprise that our lives will be markedly different in the coming months and most likely years. For the foreseeable future,  society will no longer run as “business as usual” following the first wave of the pandemic. The way our healthcare system functions is something I’m most looking forward to seeing evolve as people realize that our employer-based model leaves millions behind is not equipped for delivering the most care to the most people. A new awareness of what we find important in life will also develop. This may entail rethinking the significance of the local community and each person’s role. We’ll be forced into introspection – things like where we get our food how we view work, and how we spend our free time will require reflection and evaluation – whether we like it or not.

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by | April 9, 2020 · 9:20 pm

Resident Perspective: Ready or not, time for telehealth

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Wednesday, April 1st

Medicine residents work in the hospital as well as the outpatient office. Cleared to go back to work, I’m scheduled to see some of my patients in the office. In an effort to limit the exposure to coronavirus for both the patients and the office staff, as many appointments as possible have been converted into telemedicine visits. These are essentially video-chat appointments using a HIPAA-compliant app where I can talk to a patient, ask about their symptoms and have them show me any relevant physical exam information, like using the camera on their phone to show me the back of their throat. I complete the online training modules that all providers have to pass and I think I’m as ready as I’ll ever be.

Something is off as I arrive at my clinic prior to my shift. First, it’s nearly empty, no front desk employees are there to wave to, and there are new standing hand sanitizer dispensers everywhere. Magazines from February populate the waiting room tables which may not be alarming for most businesses, but for my clinic, not having new editions of Philadelphia Magazine on display is shocking and noteworthy. No patients in the waiting room and doors to individual offices are closed, preventing natural light from gaining entry to the normally well-trafficked hallways. This place definitely feels more bunker-like than I remember. The few staff and attendings that are present are all wearing scrubs and face masks. Recognizable but unfamiliar, the pandemic has now officially warped and invaded every facet of my life and there is no sanctuary for normalcy.

Previously, only a small portion of physicians were utilizing telehealth visits. Fewer than 1% of Medicare beneficiaries used it prior to the pandemic.  Presumably because there is a learning curve on both the provider and the patient’s end, you have the opportunity to be more thorough during an in-person visit, and the big one: it wasn’t fully reimbursed by Medicare. Recently, under the Stafford Act and National Emergencies Act, Centers for Medicare & Medicaid Services (CMS) announced its beneficiaries will now be able to use telehealth to access their PCP for non-routine visits. Important to note, this is only temporary, as once the crisis is over (whatever that means), CMS will go back to its prior payment structure. Notably, other providers like social workers, psychologists, dieticians, etc. that are also integral to a person’s overall well-being will be covered.

Many of my appointments for the day involved patients interested in COVID testing. There’s an algorithm providers are to follow to determine who should be tested given the scarcity of tests. Mainly if the patient has symptoms, has other elevated risk factors such as coming into contact with a known COVID positive person, or recent travel to a coronavirus “hot spot”, they should be tested. This doesn’t cover a lot of other vulnerable people or others who should be tested, but the algorithm is designed to only catch the most likely positive cases at this point. The rapidity with things like which screening tests are performed and whom to test are just part of the equation in this constantly developing situation. Someone who is not eligible for testing one week, very well may be eligible the next.

I’d never performed a telehealth visit but the obvious problems that come to mind, like poor internet connection and not being able to get a gestalt on a patient that you can by an in-person exam, were apparent. In my first session I immediately encountered an  issue with a patient which our staff couldn’t get in touch with to see if they could convert their in-person appointment to telehealth. The patient’s partner had lost their job and couldn’t pay their cell phone bill so they were splitting the phone and the voicemail-box was full. The current economic crisis will of course exacerbate issues like this. Additionally, most commercial insurance as well as CMS will pay for audio/video calls but not necessarily only an audio (traditional telephone) call. My next patient actually was having difficulty accessing the proprietary HIPAA-compliant app on his phone, necessitating a phone call appointment which ultimately won’t be billable. Other appointments went smoothly and were unremarkable but already it’s clear there will be growing pains in moving patients to telehealth.

I’m a big believer in the future of telemedicine for many reasons but primarily because it provides a lower threshold for patients to access their providers, and this will be beneficial to delivering healthcare. These next few months will be telling if we can make it work nationally from a logistical standpoint. I’m not as convinced from a reimbursement standpoint as I’m sure there will be many kinks to work out. If my first foray into telehealth has shown me anything it’s that for my patients telehealth is a generally welcome idea in theory– many of whom did not grow up with cell phone technology– but in practice it’s a different story. Since the beginning of the quarantine, there’s been a surge in popularity of video and teleconferencing software connecting co-workers and friends alike. This current crisis will hasten the public’s comfort with interacting over the internet.  We’ll see how long it will take to successfully adopt and integrate into daily medical practice but the test has arrived regardless of whether insurance, the public, or providers are prepared.

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by | April 6, 2020 · 9:22 pm

Resident Perspective: waiting for test results

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Sunday, March 29th

Although I’m a resident and I’m able to access my own medical chart through the electronic medical record, I’m not allowed, per hospital policy. I’m relegated to waiting for my results once “released” to me. While waiting for results in self-isolation, at a certain point you don’t really care whether it’s positive or negative, you just want to know something. Unfortunately, we still don’t know if being coronavirus positive prevents you from getting infected again so I’m not at the point where I would prefer to be positive just to get it over with.

Finally, five days after having the back of my throat swabbed I get an email saying my results are back: SARS CoV-2—undetected. Whew, negative. I was able to isolate for 5 days while my wife worked and took care of our baby simultaneously. Many other households aren’t that fortunate and either the other parent would have to take unpaid time off from their job (if they are able) or the person in quarantine would have to watch the kids and therefore expose the entire family to coronavirus. This is problematic for many obvious reasons.

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A picture of me and Jack at the tail-end of my quarantine. I still smiled under the mask for some reason.

The responsiveness from the government to obtaining and manufacturing tests was bungled from the very beginning. Quick turnaround time for testing is beneficial for giving patients a diagnosis promptly and is beneficial for epidemiologic prediction models that guide how much a region will be impacted and which locations that will be hit hardest next.

There are two main testing locations. In-patient testing for those that are hospitalized, where the test is performed in the hospital’s own microbiology labs (“in-house”) which have continuously improving turnaround times. Once the tests became available to hospital labs across the country, waiting times went from 48 hours down to about 4 or 5 hours (and in some hospitals turnaround is under an hour). The other main testing sites are commercial labs (LabCorp, Quest Diagnostic, etc.), where your test would be performed if your outpatient doc sent in a referral or if you went to a screening center. Unfortunately wait times are getting much longer as the public demand goes up for testing, and along with it, any part of the supply chain that is lacking—from swabs to reagents to protective gear for the providers—will back up everything.

The answer to better prediction models and better care isn’t just faster turnaround time for tests. The media has really honed in on getting quick results as a major issue in the epidemic because the news can show a long queue waiting to be swabbed or interview people frustrated by the lack of knowing their status. Arguably just as important is the accuracy of these tests. Swabs of the nose and throat are analyzed by something called polymerase chain reaction (PCR), which is designed to multiply the virus genetic material—RNA in the case of coronavirus—and detect the presence of the virus itself. A couple of problems arise from PCR as there have been reports of high rates of false negatives—meaning getting an inaccurate “undetected” reading when in fact, one is coronavirus positive. This is called low sensitivity in a test.

Because PCR looks for the virus itself from the swab, there have been studies in which essentially, if you go lower down the trachea (“wind pipe”) and obtain a sample closer to the lungs there are higher concentrations of virus located there so you will get a better sample and potentially provide more RNA material to amplify and detect with PCR. The issue with going down the trachea, in addition to being very unpleasant, can cause more of the virus to be coughed up during the procedure potentially infecting more people. So it seems not only possible, but likely that the swab going to the back of the throat either by way of mouth or nose just doesn’t pick up enough virus to be amenable to detection in many instances.

A blood test was recently approved by the FDA under Emergency Use Authorization which will test for antibodies (our own immune system response to the virus). These tests are already in use in China and other countries and can return results in under an hour. The benefit is that these tests aren’t dependent on obtaining an adequate swab and they could potentially tell us if someone’s been exposed in the past. It will also lead to more data regarding immunity to future infections with SARS CoV-2. The downside is that the test may not be accurate either and potentially detect non-COVID-causing coronavirus like CoV-1. There also arises questions like: is it better to know with 80% accuracy with one method vs 70% accuracy with another but it takes half the time to get the results back? There are no clear-cut answers because there are pros and cons to both.

The good news amongst all of this is that there is high “specificity” with these tests, meaning that if you get a positive result then you almost certainly have COVID, however comforting that may be. Keep in mind, for the time being these only apply to people that are having symptoms. I haven’t even touched upon the messed up screening guidelines and how they’ve morphed over the past few weeks. All of this is really to say we don’t know how many people are SARS CoV-2 positive currently for lots of reasons, and looking at the current positive cases on the news only tells part of the story.

At our institution there have been patients that we’ve been so sure are COVID positive that we’ve performed multiple PCR tests yet have all returned negative. Unfortunately, the answer to those that are so sure they are positive with coronavirus but have received negative testing is to assume the test is wrong. Given the rapidity with which this is all developing there just isn’t enough data regarding how accurate these tests are and how they should be employed.

I finally received a call from occupational health telling me the test results and to go back to work. Typically I’d be starting on outpatient weeks at this time, meaning I would be seeing patients in the office and go to morning and afternoon conferences with other residents. The pandemic has disfigured outpatient life for a resident, so now I start with telemedicine appointments and we’re given strict instructions to stay away from the hospital until it is our turn again—I’ll gladly oblige.

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by | April 5, 2020 · 5:12 pm

Resident Perspective: Who is “Essential”?

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Friday, March 27th

I’m not having any symptoms at all at this point, really itching to get back to work. All residents have been instructed to check their temperatures before and after every shift since last week, in the hopes of catching any early signs of infection. We were not supplied any thermometers by the program, local drug stores are all sold out, and checking online the cheapest thermometers that will arrive in fewer than 4 days are all over $50. Luckily, I have my son’s infant forehead thermometer but I’m pretty sure doesn’t really work—I use it anyway and consistently have a temperature below 95 degrees, whatever that’s worth. I hadn’t felt feverish so I continued to go in to work at the hospital.

I’ve been reading a lot of self-congratulatory posts on social media from those in healthcare, selfies with a mask on, a team posing for a picture in all their protective gear, etc. For the most part it’s pretty benign but important stuff—reminding people to wash hands and stay home. The other intention is to self-promote and remind others they’re putting themselves at risk for the greater good. A troubling type of post I’ve been seeing is from providers (often not directly taking care of any COVID patients) excited and proud at the prospect for the medical community to come together to defeat this invisible foe. Maybe these sentiments are posted because morale is low and physician burnout is even higher than typical at this time? Bully for those that go into the fight ready, willing, and able. This mentality seems to say that as healthcare providers we should all rush to the frontlines as it’s a commendable action. I suspect many people not working in healthcare may not realize that residents are not really given a choice whether to participate or engage with high-risk coronavirus patients.

Residents are at an even higher risk of burning out at this time because all “non-essential” employees are not permitted in the hospital and they are limiting the number of employees for the essential roles as a way to decrease overall exposure. Medical students typically make discharge appointments, obtain outside hospital records, and other vital tasks—but medical students are no longer permitted in the hospitals because in many ways they’re paying for the privilege of being there. That topic in and of itself could be another blog post.  Gone or restricted hours also apply to many case managers, social workers, patient transporters, nutritionists, physical therapists, drug or alcohol rehab representatives, etc. The burden of caring for patients and providing a safe discharge now falls more squarely on the remaining, smaller medical teams, which includes residents (and more specifically the interns—first year residents). This is time-consuming and no doubt will hasten burnout. In our program we’ve been fortunate enough to be able to take certain measures to mitigate this, like shorter duration spent on COVID teams for residents, but we may not have that luxury in the coming weeks.

Is this what we signed up for as trainees? My institution for now has been remarkable in being able to accommodate residents that are particularly vulnerable or have vulnerable household members; others may not be so lucky. Hospital administrations have to make the decision as to who to put in harm’s way. It’s not always cut-and-dry—should we protect older attendings or younger trainees? Is the duty to provide the best care for these current patients or to minimize exposure of budding physicians who will be practicing for decades to come? We have no idea if there are any long-term repercussions to the lungs or any other organ systems in people with asymptomatic coronavirus, and they may confer a higher rate of complications not seen for years or decades—we just don’t know. The vast majority of residents and clinicians in Internal Medicine are very hesitant to jump right in, and understandably so. Initially no med students, interns, or residents were to take care of COVID patients. As the epidemic grew into a pandemic more and more hands needed to be on deck. But still, the decision regarding which specialties will be taking care of these patients is growing. The public may not realize it either, but some residents and even attendings from subspecialties that don’t have much clinical patient exposure (e.g. Radiology) may have to dust off their stethoscope and start taking care of loved ones in your hospital.

Similarly to reports about physicians having to decide which patients get a ventilator, we are also making the decision as to which providers get greater amounts of exposure, which is a morbid endeavor. In Philadelphia, we’re fortunate enough that we haven’t had the same patient burden as New York so it hasn’t been all-hands-on-deck, but we may have to start asking which residents can handle more exposure than others, sooner rather than later.  Does taking care of an elderly family member, or a child at home come into consideration? What about providers with immune system issues? Where does my duty to provide for my patients trump my duty to keep my family’s risk of exposure at a minimum? Is it moral to ask a young, healthy, single resident to have repeated exposure or is it better to spread it out over several residents but lessen their daily exposure?

Although I personally hope to continue to be at or near the front lines, I understand those that are in a compromised position, and they shouldn’t feel bad for wanting to protect themselves or their family. There is no portion of the Hippocratic oath that implicitly or explicitly states that physicians have a duty to patients above their own safety. This is a nuanced situation that doesn’t have a blueprint in place. There are many features that as a society we’re having to figure out in real-time, which is just adding to our collective anxiety.

Healthcare workers are put in an awkward situation in these times. We need to be discussing this openly, with transparency about the treatment of healthcare workers, especially nurses and residents. How to improve the healthcare system is an important topic that hopefully will not be able to be ignored after we pass the emergency of the pandemic. It will not be easy to address this because the goals of the industry are not aligned with the goals of the public or those providing care. Even though we’re in the midst of the pandemic it’s a beneficial practice to reflect and think about the way we can improve the safety and efficacy of those delivering care.

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by | April 4, 2020 · 9:26 am

Resident Perspective: It Begins

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Wednesday, March 25th

Today was my first day of quarantine and now I feel like I’m a part of society. In the prior weeks, working on the general hospital floor I was constrained by daily ritual –nothing said on the news or by the government about isolating or “staying home” applied to healthcare workers, or residents, more specifically. Those working in hospitals are in the thick of it, but we have a completely different experience because we have to continue to go to work and do our jobs while everyone else has just had drastic changes dictated for their daily lives. I was working long hours every day so I didn’t observe any special social distancing; my daily routine recently had been to come home and only have about an hour before turning in for the night so I wasn’t doing much socializing. Now home and quarantined, I found out quickly how fast things could change as I spend most of the day sequestered in our bedroom away from my family and where they typically are during the day.

My wife’s mother watches our son but we’ve collectively decided that while I might feel fine, because of my high risk exposures it would just be best for her to not come until things cool off. We’re lucky that we have the opportunity to actually have this option as many families in our situation would either have to choose exposing a loved one to potential coronavirus or have the parent take time from work to watch their kid. I fully appreciate we’re privileged enough to even have that possibility.

I look out my closed bedroom window and think it’s a shame that the weather’s so nice as I’m sure everyone is itching to be outside. Spring is in full swing even on our street, as the trees are approaching full bloom, and I’m pretty sure a bird’s nest is being built in our gutter as I hear constant chirping with rustling of leaves and tin behind the upper corner of my bedroom. I can hear neighborhood kids outside playing. I look down and see groups of 4 or 5 parents awkwardly try to stay 6 feet apart on our narrow street. I’d like to kindly remind them to keep their distance, but like Jimmy Stewart in Rear Window, I just gaze at them from the safety of my newly shuttered life.

Hearing the kids play, I wondered, what are they thinking is going on? How much have their parents told them? I don’t know what age you go from being elated you’re off from school to being worried about whether or not you and your family will survive. Do they think this is a normal occurrence and something they’ll have to deal with frequently in their lives? This must have a major impact in many different ways on kids of varying ages. I remember getting talks at school about fire safety and going home every night and practicing an escape plan with my family because I was so terrified. I don’t know what 8 year old me would be feeling about the invisible yet much more real confrontation with a virus. I couldn’t imagine having a 2 or 3-year-old that doesn’t understand that they can’t go outside to play with friends and then have to keep them entertained throughout the day. Then do it again the following day indefinitely.

I’m now realizing there will be so many unforeseen consequences, namely impacting those on the lower socioeconomic scale. When you work in healthcare during a crisis all you care about is how it impacts you and your patients. When suddenly removed, I’m forced to take a step back and come to grips with how this affects literally everything and everyone else in society. Maybe it’s because I now have my own child to look out for, but children have been on the forefront of my thoughts related to the pandemic. They may not be medically the most vulnerable in this case but they are in terms of long-lasting impact. Every facet of their lives are being disrupted—psychologically, educationally, nutritionally, and overall developmentally. Many families rely on food provided for kids at school. Expansion of SNAP benefits under Families First Coronavirus Response Act, which recently passed, may lead to unhealthier food choices for children as well, as this isn’t regulated like nutrition guidelines for school lunches. I’d also have to assume that kids aren’t getting the same quality of education if it’s all strictly remote, let alone the meaningful and necessary bonding that takes place at school. No doubt there will be a wealth of data to supply research to tell us what we intuitively know, which is when society stops functioning as usual the most vulnerable among us are impacted the greatest.

This time away from the hospital is allowing me to reflect on the many facets of life that are touched by this pandemic, so I’ll treat it like sabbatical.

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by | April 1, 2020 · 7:58 am

Resident Perspective

I was encouraged by my wife to keep a journal for thoughts and feelings surrounding the developing coronavirus pandemic because I may be able to offer a unique perspective as a resident in medicine who is also a new parent and attempting to overcome fear of the unknown and what’s to come. I will try to update as frequently as I am able.

Monday March 23rd 2020

I found out that the Attending Physician I had been working with all last week and who was coughing during rounds was getting tested for coronavirus last night in the emergency department. I can convince myself I’m having symptoms of fatigue, sore throat and maybe a headache but I’ve also been working in the hospital for almost four weeks straight and this could just be general exhaustion mixed with a touch of seasonal allergies. I try not to think about it too much.

I haven’t been wearing any masks or other personal protective equipment around the hospital yet. At this point I feel like we are still in the nascent stages of the impending unknown so wearing a mask right now seems premature. The practice isn’t mandatory but I see more and more random staff in the hallways with facemasks on, many of whom aren’t clinicians which is a greater indication that I should probably get on board. Every now and then I’ll check a supply closet or outside a patient’s room to see what the surgical mask inventory is like. There are constant rumors floating around that, like the N95 facemasks, other equipment will be locked up and parsed out by a charge nurse on an “as needed basis”. If a run-on-the-banks situation were to occur, I want to make sure I hit the sweet spot where I don’t contribute too much to the hysteria but ensure I’ve got a mask without having to fight for scraps. I’ll continue to assess the situation.

Meanwhile, I observe more PAPRs (Powered Air-Purifying Respirator—special protective equipment) next to rooms on the wards, awaiting their donning by newly trained hands. They’ll be used for all COVID patients but since there aren’t any confirmed as of yet in our hospital, the purpose is to be used by all COVID “rule-outs” for now–those that are being tested and don’t have results back. We have a three to five day turnaround for test results right now, meaning we simply don’t know if the virus is already in our presence. The increasing numbers of PAPRs seen daily act as a surrogate for the proximity of the disease to Philadelphia and as a gauge for the level of concern amongst residents.

Over the last several days quite literally every discussion between residents in the hospital is about the coronavirus. Either discussing potential treatments; rumors as to what’s going on in China, Italy, or New York; sending memes or chatting about our trepidation and general anxiety that has gripped the entire hospital. Even when seeing my patients, every TV seems to be tuned into the news, all of which are giving up-to-the-minute global figures alternating between death tolls and economic indices. Patients ask questions for which I don’t have answers. No families or visitors are allowed in the premises. No students or “non-essential personnel” permitted to the hospital. Residents are instructed to follow social distancing protocols and there are to be no gatherings of more than five.

I went to a stroke alert today at a patient’s room for a patient that I wasn’t directly taking care of, I just happened to be nearby. The patient was in a designated “rule-out” room meaning all personnel involved need to treat the patient with extreme caution, and to limit those in contact with the patient to only those “essential.” Two nurses and a tech were in the cramped room already while the neurology resident was outside the room, not wanting to unnecessarily expose herself, miming the actions for a neurologic exam to one of the nurses. She gave instructions through the patient’s door window and into a speakerphone in a patient’s room a mere 4 or 5 feet away. The nurse and the tech cautiously proceeded to ask the patient to perform the maneuvers coached by the neurologist. It was an odd scene as clearly the patient could hear the instructions from the hallway through the door as well as the speakerphone but was polite enough to not mention that to the nurse directly in front of him. The nurse dutifully relayed the commands, “can you follow my finger with your eyes and keep your head still?” and the patient dutifully followed them. It would be funny if it weren’t so bizarre. Turns out he wasn’t having a stroke but it was good to have the opportunity to work out kinks regarding the protocol for patient emergencies. Residents are instructed to make note of instances in which normal protocols can’t be followed given the extra necessary precautions we now have to take. No doubt there will be plenty.

The hospital is both quiet but buzzing lately. Most of the services only have a few patients on each team and I walk down the wards and can find four-five-six! rooms in a row without any occupants. I’ve never seen more than two consecutive empty beds during my years here. The hospital policy is to discharge as many patients as possible with the impending influx of COVID cases to come. No elective surgeries and if you don’t absolutely need to be hospitalized you’d be safer at home. The atmosphere was akin to the episode of Game of Thrones just prior to the final battle in the last season. Nervous and anxious, we have no overflowing wine to keep us preoccupied and stumbling about. The morale is low and the silence in the hallways and in the former resident-gathering areas from our lounge to the cafeteria forces it to reverberate. Philadelphia has the temporary advantage of being able to watch from the shore as the tidal wave from China picks up steam as it makes its way across Europe, to New York City and crashing down I-95.

That night at home I continued to mentally scan my body for any possible symptoms. I hardly ever get sick so I don’t know if I’m short of breath at the top of the stairs because I’m out of shape or because I have a deadly infection. Best to push it to the back of my mind as there’s nothing I can do about it at this moment.

Bedtime routine completed. I get a text message at 10:00pm from a co-worker saying that the Attending I had been working with came back positive for coronavirus.

Image from Getty Images.

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by | March 31, 2020 · 12:01 am

Governor Wolf and the Courts Must Act Now to Mitigate Public Health Threat

On Monday morning, the ACLU of Pennsylvania filed an emergency request to the state Supreme Court to order county courts to release vulnerable populations from city jails. Philadelphia activists amplified the call to action through an organized social distancing caravan targeted at key decisionmakers. These actions follow the first confirmed cases of COVID-19 in Philadelphia prisons and jails, which were reported last Friday.

For weeks, the ACLU, local activists, community organizations, the Defender Association of Philadelphia, and the Philadelphia District Attorney’s office have been urging the release of vulnerable populations from conditions where social distancing is impossible. The First Judicial District (FJD) courts and Governor Wolf, however, still refuse to step up to inhibit the rapid and fatal spread of COVID-19. Two weeks into the alarm being raised on coronavirus in Philadelphia, the FJD has released minimal numbers of immunocompromised and elderly individuals, far fewer than the hundreds or thousands that have been released in other jurisdictions across the country and world. The courts have also rejected emergency release petitions based on public health concerns for those detained on probation or parole violations, barring many youth and adults who pose no threat to society from returning safely home.

Despite a foreboding history of communicable disease outbreaks inside detention centers, Governor Wolf has also declined to proactively save lives by closing inhumane facilities and exercising his gubernatorial powers of compassionate release. People awaiting immigration cases in York County Prison are on hunger strike to protest insufficient measures for their safety. The Berks County Immigration Detention Facility in Leesport, PA, one of the nation’s three immigration detention centers for families seeking asylum, lost its state license to operate in 2016 due to dangerous conditions and ongoing human rights abuses of residents, including infants. Yet Governor Wolf’s administration reiterated last week that they would not issue an emergency removal order unless there is a serious threat to public health inside the walls, an irony not lost on advocates and immigrant families currently fearing for their lives at the prospect of COVID-19 entering the unsanitary facility.

Jails and prisons as institutions pose a greater public safety risk than any individual they cage. This was true before the pandemic began and is an even more urgent truth as the virus enters jails, prisons, and detention centers. These overcrowded facilities lack access to soap, sinks, paper towels, and hand sanitizer and put both those who are incarcerated and those who enter these facilities for their work at risk, as recently seen on a large scale in New York City’s infamous Rikers Island Jail. The FJD and Governor Wolf could immediately reduce overcrowding and mitigate this risk without any threat to public safety. Governor Wolf could enact massive compassionate release with just the stroke of a pen, which would free any elderly or immunocompromised person at increased risk for contracting and dying from the disease. He could also order the release of community members detained by Immigration and Customs Enforcement (ICE) who are held for no crime other than lacking documentation while they otherwise contribute robustly to our communities. The FJD could supplement these efforts by releasing all those charged on low-level offenses from county jails and discontinuing arbitrary bail amounts. There’s no good justification for wealth-based detention in general and it is particularly indefensible during a pandemic. The courts and the governor also have the power to extend compassionate release to individuals who are up for parole review, individuals within six months of their release date, pregnant individuals, and youth in county and state detention facilities – many of whom are medically vulnerable and in conditions violating the federal ban on solitary confinement of youth because of facilities’ attempts to follow social distancing.

Community members are anxious to welcome children, parents, siblings, aunts, uncles, grandchildren, grandparents, partners, and friends home, people they have often traveled thousands of miles and spent thousands of dollars in travel expenses and private prison phone company bills to stay connected to during the months, years, or decades of their incarceration. Precautionary measures for COVID-19 now forbid most visits to jails and prisons. Most facilities have not replaced those visits with video conferencing alternatives or lowered costs per phone call minutes to talk with lawyers and families. This strains already obstacle-ridden bonds between those behind barbed wire and those in the outside world. If and when our loved ones are connected to the basic resources and support systems they need to survive, they are less likely to commit crime and more likely to contribute positively to society when they come home, as so many returning citizens do. In the midst of this deadly pandemic, allowing them to sustain those bonds through early release also grants them access to health-sustaining resources and the ability to social distance, preventative measures mandated by the governor himself to ward off and slow the spread of the novel coronavirus.

Governor Wolf and the FJD must take immediate action before they risk condoning hundreds if not thousands of preventable deaths in the state. Government inaction on continued overcrowding of carceral facilities has already resulted in chaos and deaths in places such as Italy and Colombia. Our city and state have an opportunity to instead follow the example of neighboring states, to embrace humanity and public health common sense in mitigating the disastrous effects mass incarceration will lend to COVID-19’s rapid spread.

Hannah

About the Author: Hannah Prativa Spielberg is currently pursuing a Master of Social Work at the University of Pennsylvania. She worked for four years as a social service advocate for the Defender Association of Philadelphia. Hannah is inspired by the leadership and love-based activism of community members and friends who have experienced life from the inside of prisons, jails, and detention facilities, who moved her to write this piece.

Hannah recommends following @YASP2, @aclupa, @powerinterfaith, @DecarceratePA, @Closethecreek, @Phillybailout, @phillybailfund, @mediamobilizing, @BBworkers, @BLMPhilly, @LILACPhilly, @JustLeadersUSA, @AmistadLaw, and/or @reclaimphila for updates and ways to get involved in the fight.

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by | March 8, 2020 · 7:03 am

Pro-Choice? Bernie Sanders is the Clear Choice.

On reproductive rights, the records of Bernie Sanders and Joe Biden are about as different as Democratic candidates’ records can be. “Biden over 36 years in Congress staked out a reputation as one of the Democratic Party’s most conservative voices on abortion,” as Politico summarized last year. According to the Planned Parenthood Action Fund’s 2016 review, on the other hand, “There’s no question: Senator Bernie Sanders has a strong record on reproductive rights.”

Here’s how Politico elaborates on Joe Biden’s record:

For decades, [Joe Biden] opposed late-term and so-called partial birth abortions, lamenting that one ban enacted in the 1990s did not go far enough. He supported Republican presidents’ prohibitions on funding for groups that promote abortions overseas, and backed legislation that would have allowed states to overturn Roe v. Wade. He even fought unsuccessfully to widen religious groups’ exemptions from the Affordable Care Act’s mandate for birth control coverage…

In public statements, interviews and recently resurfaced videos, Biden said he believed that “abortion is wrong from the moment of conception,” and said he doesn’t “view abortion as a choice and a right” but rather “always a tragedy.” He also said he did not believe that “a woman has the sole right to say what should happen to her body.”

Biden voted for the adoption of the Hyde Amendment in the 1970s and later opposed efforts to make exemptions and fund abortions for women who were victims of rape or incest.

He held that position until [the late spring of 2019, after he began his 2020 presidential campaign.]

Here’s how the Planned Parenthood Action Fund elaborates on Bernie Sanders’s record:

Sanders Has a 100% Voting Record on the Action Fund Scorecard
When the Action Fund started scoring congressional votes in 1995 (a few years after Sanders began his tenure in Congress), one of the first votes we scored was an amendment to allow over $190 million for family planning projects under Title X. Then-Representative Sanders was a key vote in moving that amendment forward. Throughout his career, he has continued to vote to protect access to safe and legal abortion, as well as federal funding for family planning and health care provided at Planned Parenthood health centers.

Sanders Supports Expanded Access to Birth Control
To this day, Sanders also has reliably and consistently voted to ensure women’s access to the full range of birth control options. During the fight over the Blunt Amendment, which would have allowed employers to opt out of providing insurance coverage of birth control, Sanders gave a speech on the Senate floor voicing his opposition:

“…there is growing anger that members of Congress, mostly men I should add, are trying to roll back the clock on women’s rights… Let me add my strong belief that if the United States Senate had 83 women and 17 men rather than 83 men and 17 women that a bill like this would never even make it to the floor.”

What’s more, he supports the Affordable Care Act, including its mandated coverage for birth control, and co-sponsored a bill that would protect women from bosses who want to block this coverage from them…

Sanders [also] signed onto a friend-of-the-court brief to the Supreme Court advocating against the Hobby Lobby’s decision to deny insurance coverage for contraception to their employees…

Sanders Supports Access to Abortion
To sum-up Sanders’ stance on abortion, just read what he had to say in a 2012 op-ed:

“We are not returning to the days of back-room abortions, when countless women died or were maimed. The decision about abortion must remain a decision for the woman, her family and physician to make, not the government.”

His strong position that we, as a nation, will never go backwards when it comes to access to abortion care is a major reason why Sanders is in our corner.

Sanders has also been a cosponsor of one of the most proactive pieces of legislation that would prevent states from chipping away at abortion access: The Women’s Health Protection Act, introduced in 2015 and 2013. This act would prevent politicians from passing laws aimed at shutting down health centers by imposing unnecessary building regulations and medical procedures such as mandatory ultrasounds — which have the sole intent of shaming women and making it harder for them to access safe, legal abortion…

On the campaign trail, Sanders boldly defended abortion access at the Christian institution Liberty University despite the fact that the university is so conservative that Ted Cruz announced his run for president there…

Sanders Has Stood With Planned Parenthood
The PPAF thanks Sanders for being an unwavering ally of Planned Parenthood patients and consistently voting in favor of protecting patients who rely on federal funds to access birth control, cancer screenings, and other basic health care at Planned Parenthood health centers.

If Bernie Sanders is elected, pro-choice women can feel confident he’ll have their backs. If Joe Biden is elected, regardless of what he says during campaign season, pro-choice women will have a lot of reasons to worry.

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by | January 8, 2020 · 8:28 pm

On Both Politics and Policy, “For All” Beats “For Some”

Medicare for All or Medicare for All Who Want It? Free college for all or free college for just the non-rich? The debate between universal (available to everyone) and means-tested (available only to those who meet certain criteria) programs has defined the Democratic primary. Bernie Sanders, often joined by Elizabeth Warren, argues for universalism, declaring education and health care to be basic human rights. Amy Klobuchar, Pete Buttigieg, and Joe Biden argue against, contending that government resources must be targeted only to those in need, rather than wasted on the rich and/or on those who ostensibly don’t want them.

On the most commonly cited rationale for each position – sustainability for universalists and resource constraints for means testers – proponents of universalism have the upper hand. Medicare and Social Security, two of the United States’s largest, most successful, and most popular programs, are as close to universal as we’ve got. By giving everyone a stake in these programs, proponents argue, their near-universality has insulated them from attack. Bob Greenstein (the President of the Center on Budget and Policy Priorities, where I used to work) points out both that these programs have been cut and that their popularity could conceivably be due to the perception that they’re tied to work rather than to their quasi-universal nature, but the Alaska Permanent Fund, a state-level universal program not tied to work, also enjoys overwhelming public support. So do universal programs that aren’t tied to work in other countries – other countries’ universal health care systems, for instance, are way more popular than our means-tested approach. It’s reasonable to expect a universal program to be more sustainable than a means-tested alternative over time.

The Buttigieges of the world counter that universal programs are too expensive; in December, for instance, Buttigieg said they would require “the kind of taxation that economists tell us could hurt the economy.” But even if you reject the notion that government spending can be substantially increased without raising taxes, concerns about higher taxes are entirely without merit. Research has consistently (and predictably) failed to support such concerns, the United States has significantly lower taxes than the rest of the developed world, and scores of reputable economists support tax proposals, like those Sanders and Warren have released, that can fund the universal programs on offer. When Buttigieg says he’d prefer to “save those dollars [that would otherwise be spent on free college] for something else,” he is presenting a false choice. It is only his and others’ political preferences, not actual resource constraints, that stand between us and full funding of all the priorities he listed: education, infrastructure, child care, housing, and health care.

Still, the most compelling case for universal programs isn’t political. It is, ironically, that they’re better at achieving two of means testing’s major goals: helping people in need and doing so efficiently. They reduce stigma, arbitrariness, usage barriers, and administrative costs.

Universal programs help people in need by reducing stigma

Most low-income people work incredibly hard to put roofs over their heads and food on their tables. Yet they’re constantly accused of being unskilled, lazy, good-for-nothing loafers in search of government handouts. Afraid of being perceived that way and/or ashamed of their economic situation, many people who are struggling to get by decide not to access the means-tested benefits to which they’re entitled. They’d rather go hungry than risk someone catching them using food stamps in the checkout line.

Correcting false stereotypes is a top priority, with universal programs a useful complement for improving the experience of people in need. If everyone received SNAP benefits (SNAP, which stands for Supplemental Nutrition Assistance Program, is the contemporary name for the food stamp program), for example, using them would no longer identify someone as low-income. We would thus expect higher rates of SNAP usage among low-income people.

That’s exactly what we’ve seen with the school meals program following the introduction of a program called “community eligibility,” which enables schools and school districts with a certain percentage of low-income students to offer free school meals to all students – regardless of their income levels – free of charge. Research suggests that reduced stigma is at least part of the reason students at schools that have adopted this program are more likely to take advantage of school breakfast and lunch programs.

Universal programs help people in need by eliminating arbitrary cutoffs

For SNAP, the income eligibility threshold is 130% of the poverty line, or about $27,700 annually for a family of three. People who make less than that amount (provided they meet other requirements – SNAP also has an asset test and restrictive eligibility rules for various groups of people including immigrants, individuals aged 18 to 49 who don’t have children, and students) can access benefits; people who make more than that amount cannot. Under Buttigieg’s higher education plan, college is free only for families making less than $100,000 a year (and discounted for families making between $100,000 and $150,000).

Means-tested benefits typically phase out slowly – that is, benefits get gradually smaller as beneficiary income gets higher – to ensure that the sum of pay plus benefits continues to increase when people pass eligibility thresholds. But why shouldn’t a family of three making $30,000 a year get food assistance? Why should $100,001 be the level at which a family starts having to pay for college? Eligibility thresholds in means-tested programs are arbitrary and inevitably create strange, difficult-to-justify divides between people right above and right below them. Universal programs avoid this problem completely by providing the same benefit to everyone.

Universal programs help people in need by reducing usage barriers

Means testing requires some form of testing, as the name implies, to determine whether or not someone is eligible for benefits. Depending on the complexity of a program’s eligibility rules, that testing might require a form of identification, proof of residence, proof of income, or any number of other things. Eligible beneficiaries may need to mail, hand-deliver, or electronically submit one or more forms, which, as Sanders accurately observed during the December debate, “people are sick and tired of filling out.

Filling out forms and proving eligibility is much more than an annoyance for many eligible people in need. Some may not know how to read or write. Some may move and/or change jobs frequently. Some may lack an official ID. The more hoops people have to jump through to access benefits, the fewer eligible people will actually end up receiving benefits.

Government agencies can mitigate this problem with outreach efforts and assistance programs, of course. But even well-administered means-tested programs like SNAP that continue to improve in these areas don’t catch everyone they should, in part because of the access barriers means testing inherently creates – in 2016, the most recent year for which we have data, about 15% of people eligible for SNAP did not participate in the program.

Universal programs improve efficiency by reducing administrative costs

In addition to creating an obstacle for eligible beneficiaries, the complexity introduced by means testing presents a challenge for efficient government. Every form that needs to be filled out has to be processed. Eligibility has to be verified. Complex rules have to be actively managed. Means-tested programs spend a larger share of their money on administrative overhead than universal programs do.

Administrative costs for Social Security, for example, are only 0.7% of total expenses. For SNAP, one of the most efficient and effective means-tested government programs, administrative spending comprises 7.7% of its total budget. Over three-quarters of those administrative costs are “certification-related,” meaning they’re “associated with determining household eligibility.”

To be clear, the overall cost of SNAP and other means-tested programs would be many times higher, even with substantially reduced overhead costs, if they were more universal. Increased overall cost is the only real potential downside of universality. And if one were forced to choose between increasing benefits for people in need and extending benefits to higher-income people who don’t currently receive them, increasing benefits for people in need would be the clearly correct choice.

But as noted above, that choice is a false one. There is no question that the US government has the money to offer increased benefits through universal programs. The only question is whether we will choose to spend it on the worthy goals of helping people in need and improving government efficiency for everyone.

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