It has been said that culture becomes biology. When exactly culture transforms into biology is subject to debate, and forms the basis of cultural evolutionary theory – the study of human cultures over thousands of years.
But biology also changes across shorter time horizons – changing in ways that are less cultural and more economic. To the point at which economy becomes biology – something we have witnessed for more than a century as our world grows increasingly dependent upon technology.
A premise first introduced by Nobel Laureate Robert W. Fogel, technophysio evolution is the theory that our use of technology affects our body, and overtime, initiates its own set of evolutionary changes onto our bodies in response.
Technology has become so pervasive that it dictates our lives, and has effectively become our economy. If we adopt Fogel’s theory into today’s technology driven economy, then we can surmise that economy is biology.
Hence the importance given to social determinants of health, exemplifying why food deserts matter – why inner city violence leads to a greater prevalence of hypertension among urban minorities – why unemployment leads to higher overdose rates – and why Medicaid expansion leads to better patient outcomes.
If economy is biology, then economic policy determines long term patient health, with some policies faring better for patient outcomes than others.
We observed how the Affordable Care Act (ACA) changed health care in complex, unforeseen ways. With many of the benefits coming from mostly economic improvements among patients enjoying the expanded Medicaid benefits.
Now with the passing of the recent $1.9 trillion American Rescue Plan Act (ARPA), healthcare is again set to change through another slew of economic reforms. And though the legislature was ostensibly designed to provide support for families during COVID-19, the long term economic shifts may come to dictate healthcare for the next decade. As the ARPA is an expansion of the ACA, building upon Obama era policies.
An analysis of the ARPA by Thompson Reuters finds that the ARPA expands ACA emergency care coverage, but eliminates any premium on emergency insurance (COBRA) coverage; increases the maximum amount of dependent care benefits that can be excluded from a person’s income tax; and offers greater tax credit while eliminating the upper income limits from participating in those credits.
All of which appears quite appealing, and may even incentivize states who previously chose not to participate in the ACA to expand their state’s Medicaid ACA program.
The think tank, Center on Budget and Policy Priorities, believes the ARPA would help upper income brackets deal with insurance premium burdens and would help lower income brackets retain certain insurance cost benefits while also retaining their unemployment benefits.
At first blush the expanded offerings and coverage would provide meaningful help to those suffering in an unprecedented time of economic hardship and uncertainty. But all that glitters is not gold.
Some consider this a short-term fix for a long-term crisis, as the only clear path to expanding health insurance is more government subsidies for commercial health plans, which are the most costly form of coverage.
And the cost of healthcare expansion becomes more costly to the tax payer over time.
In an interview with NPR, Paul Starr, a Princeton University professor and health care policy expert said, “the expansion of coverage is the path of least resistance”, and dubbed this dynamic of expansion a, “health policy trap.”
Starr went on to say, “insurers don’t have much to lose. Hospitals don’t have much to lose. Pharmaceutical companies don’t have much to lose, but the result is you end up adding on to an incredibly expensive system.” Insinuating that the added costs create their own externalities which compound onto the existing costs – which means as the healthcare system expands, the increase in cost expands at a faster rate.
The Congressional Budget Office estimates that by the end of 2021, taxpayers will shell out more than $8,500 for every American who gets a subsidized health plan through the ACA, which is an increase of 40% from the cost to taxpayers in 2020. An increase attributed to the expanded policy derived from the ARPA.
Proponents of this expansion argue that traditional Medicaid plans are still available, but the availability is becoming increasingly scarce as the healthcare industry shifts away from traditional Medicaid plans to now accepting a greater number of patients under the ACA.
Which is only logical since the healthcare industry stands to profit more per patient through insurance plans offered through the ACA than through traditional Medicaid programs.
According to the Health Care Cost Institute, health insurers in the Atlanta area pay primary care physicians $93 on average for a basic patient visit, but Georgia’s Medicaid program would pay the same physician seeing a patient covered by the government health plan just $41, according to the state’s fee schedule.
So why would a physician accept a Medicaid plan when it can accept an ACA plan?
So if an insurance company has to pay physicians more, then it will then charge the government more, and so too will the pharmaceutical company – and the medical device company – and the medical distribution company – and on it goes. And why not? The federal government is footing the bill.
Which explains the angst among many economists reluctant about the expansion of the ACA under the ARPA – how is the government going to finance this expansion? The simple answer is that they will continue to issue more debt and print more currency.
But healthcare operates differently in a debt-centric economy compared to a traditional capitalistic market. When debt fuels an economy, the separation among those who contribute to economic productivity and those who drive the economic cost widens. This means the social class which contributes to the economy, which finances the expanded healthcare system, grows more distinct from the social class which enjoys the benefit from the expanded system.
Soon there will be a distinct debtor class, which will grow accustomed to a perpetual debtor lifestyle, willingly taking on healthcare expense with little to no expectations of ever contributing to those expenses. Comfortably numb in the ever expanding sphere of healthcare coverage provided by the federal government.
And in turn, the healthcare industry will continue to charge more and more to this new debtor class, eagerly up-selling healthcare services to a class of patients willingly taking on more expensive insurance policies.
Soon we will begin to question the morality of medical debt, and whether it is ethical to continue to provide medical care to those who cannot actually afford to receive such care – creating a modern version of debtor’s prison based upon medical debt.
And as the disparity in healthcare economics increases, so will the disparity in healthcare outcomes.
Vaccine Passports: what we need to know
The COVID-19 pandemic has killed more than half a million people in the US and has seriously impacted our daily lives. The granting of Emergency Use Authorizations for COVID-19 vaccines has been a game changer in helping to reverse the pandemic onslaught. Demand for the vaccines currently far exceeds supply nationwide. They have become the golden ticket that can transport us back to a time when routine activities, such as attending school or taking vacations, didn’t seem fraught with danger. What’s the best way to go about re-establishing these activities? One idea that’s getting discussed seriously is giving those who have been immunized a vaccination passport (VP).
What is a vaccination passport?
Let’s start by clarifying some terminology. VPs are documents that show that someone has been given a vaccine(s) and is therefore presumed to be immune from getting and sharing that disease. These are distinct from diagnostic tests to determine if a person is or is not infected with a particular virus (PCR and viral antigen tests) or has been exposed to a virus (antibody tests). VPs are the modern day equivalents of the “letters of transit” that played a key role in the film Casablanca. They’ll enable you to travel freely.
Why give vaccine passports?
Vaccinated people are unlikely to transmit the virus that causes COVID-19 with others, though this has yet to be definitely proven. So, what’s the primary rationale for giving vaccination passports? It seems the goal is to incentivize people to get vaccinated. Folks might be more likely to seek out the vaccine if it bestows upon them certain privileges, such as being able to travel freely. While the idea might sound appealing at one level, the road to vaccine passports is pockmarked with political potholes and littered with logistical land mines.
There are a lot of important questions that need to be answered before VPs can become widespread; it’s unlikely there will be a “one size fits all” solution. What might VPs look like? Pieces of paper (that could easily be lost or counterfeited), or a digital key or document you store on your smartphone (that many older folks still don’t have)? If you lost one, how would you get it replaced? Would your vaccination records be tied to your other medical records, and if so, what kind of privacy and security protections would be needed to safeguard your data? How would the passport administrator verify that you got vaccinated in the first place? Who is responsible for correcting any errors that crop up? Given how much we’ve struggled as a nation to simply solve the scheduling of vaccinations, VPs might be significantly more difficult to manage.
Who’s going to run the program?
A coalition of health tech leaders (including Epic, the Mayo Clinic, Microsoft and Salesforce) has started the Vaccination Credential Initiative to create an internationally accepted digital health card. Its vision – as stated on its website – is “to empower individuals to obtain an encrypted digital copy of their immunization credentials to store in a digital wallet of their choice. Those without smartphones could receive paper printed with QR codes containing World Wide Web Consortium (W3C) verifiable credentials.” Some European countries (e.g. Denmark) are working on developing their own immunization passports, and the President of the European Union Commission has voiced support for them.
We already have a hodgepodge system designed to keep folks with COVID-19 from traveling. Many airlines are requiring proof of non-infectivity to board a plane – these are distinct from VPs. The methods adopted vary from airline to airline: United uses Travel Ready Center, American uses VeriFly while others use Common Pass. Saga cruises are the first in the UK to demand proof of vaccination, but not everyone is on board with the concept. The World Travel and Tourism Council stated its opposition to allowing travel only by those who have been vaccinated, on the grounds that it is discriminatory.
The concept of gaining advantage from one’s immunological status is not a new one. In New Orleans in the mid 19th century, great economic value was attached to those who survived the onslaught of epidemic waves of yellow fever. A mix of structural racism and a system valuing “immunocapital” ranked men and women highly if they were yellow fever survivors. Those that had not had the disease yet found it difficult to obtain work or obtain credit and women could not marry. Slaves were similarly revalued, with larger assessments attached to survivors. This legacy of viral discrimination casts a long shadow over current discussions surrounding vaccination passports.
Also problematic is the fact that not everyone will be eligible for VPs. Some people can’t be vaccinated for medical reasons but would still like to participate in whatever activities the passports enable (such as travel opportunities). These individuals will likely file complaints if they are denied VPs, arguing that they’re discriminatory in nature. Vaccine opponents will no doubt also file lawsuits seeking to block the use of VPs, claiming they represent an attack on their freedoms and personal choice.
Others may be shut out of VP programs because they don’t have the computer skills to register online, a problem that’s turned out to be widespread with the vaccinations. Don’t have any ID? In some places this prevents the most vulnerable from getting the COVID-19 vaccine, and therefore VPs as well. Many Black and marginalized communities are already deeply suspicious of the medical establishment, and wary of receiving a COVID-19 vaccine. Restrictions that prevent these groups from participating in various societal activities because they don’t have VPs will echo the Jim Crow days of poll taxes and literacy tests that were required to vote.
VPs bring up a similar issue as mask mandates: who is going to enforce them? It is one thing for a cruise line to do so, since reservations are required and extensive paperwork needs to be filled out in advance. Who is going to keep non-vaccinated people out of restaurants or concerts that require proof of vaccination? We’ve already seen anti-maskers storm department stores, ignore requirements to wear masks on planes and even kill a security guard who confronted them.
Black market for vaccine passports
Many airlines are now requiring proof of a negative COVID-19 test before they will let their customers fly. This has led to a black market for fake negative COVID-19 test results for those who are looking to game the system. Similarly, bogus cards claiming that the cardholder was exempt– for medical reasons – from having to wear a mask, have been manufactured and distributed. It’s not hard to imagine that a similar market will emerge for VPs.
Overcoming vaccine hesitancy
Given the multitude of issues and concerns listed above, moving forward with issuing vaccination passports seems highly problematic. If the primary purpose of having VPs is to drive up immunization rates, that can be better accomplished by running public service announcements and ads illustrating how liberating it is to start doing normal activities once vaccinated. A nationwide campaign to do just that is already in the works. I personally can think of a better use for the time and money that will be spent on establishing VPs: use them to focus efforts on overcoming vaccine hesitancy in concert with combatting the high tide of online vaccine misinformation and disinformation.
Source: Technology Networks