Four Years Later: What We Learned from the Ebola Crisis

By: Rebecca Desantis 

Introduction 

The increasing frequency of global health emergencies that affect multiple nations and regions necessitates a better understanding of the role global governance systems play in combatting public health crises. Much like the global nature of today’s international security situations, health emergencies demand a robust global management system that minimizes the damage of epidemics while maintaining economic and political stability in the face of crisis. In the past decade, governments have responded to multiple global health emergencies with limited staff, resources, and information. No crisis has exposed the deficiencies of the global health management system more than the recent Ebola outbreak in West Africa, beginning in 2013 and ending in 2015. Ebola is a rare and deadly virus that spreads by direct human contact, and is characterized by fever, weakness, vomiting and unexplained bleeding. This epidemic not only caused 28,000 cases of Ebola, and 11,000 lives lost, but also led increased distrust of the World Health Organization (WHO) and healthcare workers, worldwide hysteria and panic, and economic slowdown.

Looking back to this time four years ago, the Ebola crisis exposed significant gaps in global healthcare management in the developing world. Scholar David Fidler of the Council on Foreign Relations, explains that, “although unprecedented in international cooperation on health, the current regime complex for global health governance suffers from defects that many experts believe are responsible for suboptimal outcomes for individual and population health.” Knowing that there have been advances in global healthcare management, Fidler, like many in the field, believe that minimal change will occur if global leaders like the United States and the UN don’t focus attention on building up the capacity for international actors to address global health crises. Understanding the need for change begs the question: What policies do global health actors like the WHO and the Center for Disease Control (CDC) need to reform in order for our response to global health crises to improve?

The Case of the Ebola Outbreak

            In December 2013, the first Ebola virus infections of this outbreak occurred in the West African country of Guinea. Patient zero was a small boy in a village in Southern Guinea, who was documented as having symptoms of a mysterious disease. Local health workers first classified it as cholera-like diarrhea, then as hemorrhagic fever. Because Ebola had never been diagnosed in the region before, it was not on the radar. Over the course of the next year, the outbreak infected tens of thousands of people, spreading primarily through Guinea, Sierra Leone, and Liberia. The region was susceptible to the rapidly spreading disease because of the porousness of the national borders, which allowed people to freely move between countries. Furthermore, because the Kissi ethnic group lives in a region spread over all three countries’ borders, the disease spread with them, as seen in Figure 1.

Figure 1: Kissi Ethnic Group

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The Ebola epidemic hit a region that was moving towards economic and social stability after civil conflict had made the region unstable. Because of poor infrastructure and the inability for the region to diagnose and contain the first incidents of Ebola, the virus was able to quickly spread through the region. It was not until March of the following year that international Non-Governmental Organizations (NGOs) began setting up operations in the region to help deal with the spread of the disease. Most notably was Doctors without Borders, who stepped in to try to control the virus and grab the world’s attention.

By July of 2014, international attention grew and concern for the virus spreading to other countries became paramount. Some countries attempted to prevent spread of the virus by encouraging schools, universities, and other organizations to implement travel bans or quarantine travelers, which only increased the growing sense of fear in the international community. The number of new cases continued to grow, and the number of deaths steadily rose. This was when the most external funding came to try to deal with the virus, including $200 million coming from the World Bank. By the end of 2014, the virus had spread to neighboring countries; however, the number of cases began to decrease, and the spread was being contained.

During this global health crisis, a number of weaknesses and issues with how the WHO, CDC, and the health ministries dealt with the epidemic became apparent. The most detrimental issues included the process of reporting and documenting infections, the insufficient health infrastructure, and the general lack of accountability of the WHO and its regional partners.

Reporting Disease and Accountability

The length of time it took for the international community to recognize the crisis and respond hampered the containment efforts. Because there is no incentive for countries to report disease, the countries affected did not immediately report the virus to national representatives. This is in contrast to the process of reporting disease that is spelled out in the International Health Regulations (IHR), which are legally binding for all WHO member states. According to the WHO, the goal of the IHR is “to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide.” The IHR requires countries to report outbreaks to WHO, and subsequently explains the procedures for the response by the WHO and the reporting country. This process is important because it helps dispatch emergency response teams to the region and sets in motion security measures.

Kevin Sack of the New York Times reported on the political mess that was the reporting process in the Ebola crisis. Based in interviews with WHO staff, the representatives of the African Regional Office of the WHO were dispatched to gather information about the outbreak, but politics came before the needs of the people. Underfunded offices, unclear reporting lines, and incompetent representatives led to information not being transmitted to the WHO headquarters in Geneva. The WHO regional office also rejected help from the CDC because they wanted to handle the problem without help, which upset US officials. The CDC director at the time explained to Sacks that he was unsure who was leading the Ebola response, further showing the blurred reporting process, and ultimately caused delays in aid.

The lack of accountability from the WHO, and its local and regional representatives is also prevalent in this crisis. The Harvard Global Health Institute and the London School of Hygiene and Tropical Medicine (LSHTM) Independent Panel on the Global Response to Ebola site this issue as one of the main reasons that the response to the Ebola outbreak was not quick.  The Panel explains that there is no incentive for local communities to report cases of disease to the appropriate WHO representatives. This stems from the distrust of healthcare officials because some villages viewed them as tools for the government to get more foreign aid funding. Others distrusted the health workers because they said they couldn’t follow their normal burial practices of washing the bodies, which was important to their culture, yet furthered the spread of disease. The delay in reporting caused the Ebola epidemic to spread more quickly and overwhelmed on-the-ground response teams.

Accountability doesn’t only apply to reporting the disease at the start, but also to the WHO’s response to the reports. The Harvard report states that the WHO was slow to send out the response teams, and quick to pull out their teams when the situation started improving. Sacks also mentions reports of healthcare workers who left the region only to see the situation worsen.

Insufficient Infrastructure

A second glaring weakness evident during the Ebola crisis is the missing infrastructure to deal with epidemics. As seen during the crisis, families struggled to get their sick to hospitals because of the lack of proper roads, and even if they reached a medical facility, they could be turned away due to the overcrowded conditions.

The slow response resulted from a lack of hospitals, doctors, nurses, and medical equipment in the developing world. Infrastructure overhaul and prioritizing emergency care requires appropriate funds, yet before the Ebola crisis, money was not being funneled into these types of programs. The lack of capacity at the local level to address and report cases of infectious disease makes it challenging for organizations like the WHO to mobilize a quick response specific to the needs of the situation.

Recommendations

The Harvard-LSHTM Independent Panel on the Global Response to Ebola provides a number of recommendations that urge the global governance system to make needed changes to their response to epidemics and call on political leaders to make those changes. Their recommendations focus specifically on the global response systems and their ability to build up global capacity.

Their recommendations are helpful, and the independent nature of this panel shows the critical nature of these recommendations. Their most crucial recommendation is their section on good governance reforms for the WHO, which recommends the WHO refocus on their core functions (providing leadership, shaping the research agenda, translation and dissemination of valuable knowledge, setting norms, articulating ethical and evidence-based policy options, providing technical support, catalyzing change, and monitoring the health situation and assessing health trends) and ask member states to demand a Director-General who will challenge government leaders who choose not to cooperate with reporting procedures. This will help ensure accountability at all levels of the WHO, and in their coordination with national governments.

Considering these recommendations, the WHO should go further by implementing the following reforms:

  1. Speed up the global response by creating a streamlined system for reporting cases of disease. This may involve incentivizing the reporting process or making it easier for local doctors and health administrators to report to national authorities and WHO representatives, which will then report to the WHO headquarters. It should be the role of the WHO to respond to every disease threat swiftly and appropriately.
  2. Increase funding to the African Regional Office of the WHO to re-implement their corps of anthropologists who work with villages on cultural practices to disease prevention and general healthcare practices. This was clearly a shortcoming of the regional office and re-implementing this office could help avoid distrust of healthcare workers in the future.
  3. Encouraging grassroots organizations and NGOs in the region to refocus efforts on local healthcare capacity building. The global response needs to be matched with infrastructure improvements on the ground. Infrastructure was a main issue in the spread of Ebola and increasing the capacity of villages to fight disease will help contain the spread. This would also help the WHO be able to act faster, because they will be able to work in better cooperation with local healthcare providers.

Image Source: Getty Images

Rebecca is in her last semester of American University’s Master’s of Public Administration program, concentrating in International Management. She hopes to use this degree to pursue her interest in education accessibility and access here and abroad, ideally working for an international organization. Her academic interests include higher education access, crisis management, and organization structure and management. 

Disability Insurance Skyrockets in the Last Two Decades

Political Pundits, public officials and the media often discuss the rising cost of entitlements and healthcare in the country. While Republicans and Democrats argue over how best to address these issues, few have acknowledged a key component to the rising cost of social security: an increase in individuals qualifying for disability insurance.

The federal government spent nearly $250 billion in 2011, paying more than 23 million people disability claims, 7 percent of the overall population and 16 percent of the workforce. This number accounts for nearly 4 percent of the federal budget, and is equivalent to 1 percent of the nation’s gross domestic product. There has been a 44 percent increase in disability claims by people who used to be in the workplace and a 28 percent increase in disability claims among veterans. A report by NPR also found that populations receiving disability insurance were higher in certain locations of the country. In Hale County, Alabama, nearly 1 in 4 working-age adults are on disability.

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According to the Social Security Administration, a disability is defined as a situation where someone cannot do the work they did before and cannot adjust to other work because of a medical condition that has lasted or is expected to last more than one year or result in death. If an applicant is making more than $1,130 per month, they cannot qualify. With the rise in recipients, it is important to recognize the reasons why individuals are applying for disability insurance and how these reasons have changed. In 1960, the two largest reasons why an individual received disability insurance were due to issues with the circulatory system (26.9 percent) and the nervous system and sense organs (15.4 percent). In 2014, the two major reasons for receiving disability insurance were due to issues with the musculo-skeletal system and connective tissue (36.1 percent) and the circulatory system (10.0 percent). The three main causes that have led to the increase in disability insurance applications are the recessions in 2001 and 2008, an aging population, and a decade of war.

Studies have demonstrated the impact of economic conditions on the fraction of individuals receiving disability insurance benefits. During the recession of 1989 to 1993, the number of disability applications increased by 45 percent; between 1999 and 2003 disability insurance increased by 58 percent. Due to the great recession of 2008, by the end of 2014 the number of recipients of disability insurance had increased by 21 percent. These statistics are important for they demonstrate how many individuals are applying for disability insurance after economic distress. However, economic distress should not allow someone to classify as disabled.

An aging population has also led to an increase in those applying for disability insurance. The likelihood that a fifty to sixty-four-year old man receives disability benefits is 50 times greater than the probability that a man between twenty and forty-nine will receive insurance. Workers in their fifties are about 20 percent less likely than workers age 25 to 34 to become re-employed. Studies show that the aging populations has led to a 15 percent increase in the disability insurance among men and a four percent increase among women. Along with age, war has had a huge effect on individuals receiving disability payments. Between 2000 and 2013, the number of veterans receiving payments rose by almost 55 percent, from 2.3 million to 3.5 million. In 2000, 9 percent of all veterans received disability insurance, by 2013, that number rose to 16 percent. Average disability payments to veterans also rose by nearly 60 percent over this time period, from $8,100 in 2000 to $12,900 in 2013.

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Image source: Congressional Budget Office

All of these reasons and the significant impact of the recession on revenues led the Disability Insurance Trust fund to take on financial strain – at the end of 2014, the disability insurance trust fund was 152 billion less than what was projected in 2008 – with 60 billion in assets. With the increase in funding, the social security administration has projected that funding for the Social Security Disability trust fund will last until 2023. The funding was originally expected to run out in 2016, but due to the Bipartisan Budget Act of 2015 and a reallocation of the payroll tax rate, the depletion date was extended. However, when the same problem comes around in a decade, reallocating the payroll tax rate should not be used again – it is an easy short-term fix, but does not address the problem that with technology, people are living longer and costs are constantly rising.

In order to secure disability insurance and social security as a whole, there must be a way to make the trust fund solvent. In order to save money, public officials should eliminate what is known as the carried interest exemption. This exemption allows managers to count earnings as capital gains instead of ordinary income – capital gains are taxed at 23.8 percent, while labor income is taxed at 39.6 percent. Closing the loophole would generate $17 billion in tax revenue over the next 10 years that could be used towards the solvency of social security. The federal government should also consider capping itemized deductions for households to $50,000 dollars which would save roughly $749 billion in the next decade. These savings would ensure that disability insurance remains solvent and adequately funded. Finally, the federal government should re-evaluate the review process for those receiving disability benefits. Currently, the Social Security Administration reviews cases that are expected to improve once a year, cases where improvement is not likely once every three years, and cases where someone is permanently disabled every seven years. Reviews should happen more frequently in order to ensure that fraud is avoided and that those receiving benefits truly qualify. Someone applying for disability insurance after an economic recession, not beforehand, may be more qualified for welfare and fall outside of the qualifications of disability insurance.

Social Security, specifically the disability fund, was designed to ensure protections for those who need it the most and cannot work to take care of themselves. Global conflicts, recessions and innovations in health and medicine have led society to change. The government must remain vigilant against fraud and adapt to the change in demographics, age, and the economy. The disability fund cannot be allowed to fail and our government must rise to the challenge of making necessary fixes so that our most vulnerable populations have the protections they need to live a good life.

Image source: Amerigroup

When Self-Regulation is not Enough: A Look at Food Marketing to Children

Childhood obesity is a problem that has received a growing amount of national attention, largely due to Michelle Obama’s health initiatives as First Lady. One area related to child well-being that has yet to see a lot of policy development is food marketing to children. Currently, food marketing is self-regulated by the advertising industry through programs like the Children’s Food and Beverage Advertising Initiative (CFBAI). Recent analysis suggests that this type of regulation does not adequately protect children or hold companies accountable for their marketing practices.

Food Marketing’s Link to Childhood Obesity

Legislation introduced in Baltimore in early January would require businesses that sell or advertise sugary drinks to warn kids (and parents) about the risk of obesity associated with those products. These warnings are already in place in San Francisco. Policies like banning the sale of jumbo-sized drinks in New York and taxes on sugary drinks have been overturned or failed in other ways. Other countries are considering policies on this issue as well. In the UK, a tax on sugary drinks has been proposed by several health organizations, including the British Medical Association. This recommendation is significant because Prime Minister David Cameron is currently working on a strategy to combat childhood obesity in UK.

Food marketing to children has been contributing to childhood obesity. The chairwoman of the Health Committee in the UK (who also supports the tax on sugary drinks) said that additional action on the issue of advertising campaigns is needed to curb childhood obesity. Recent analysis completed by the University of Liverpool in the UK analyzed 22 studies on food marketing and found that the practice increases food consumption in children, but not for adults. A study completed in the Netherlands also showed that children playing a candy advergame online ate more candy than those playing a toy advergame.

How industry self-regulation works

Currently, much of food marketing to children is self-regulated by the advertising industry. The Children’s Food and Beverage Advertising Initiative (CFBAI) is an organization formed by several food and beverage companies alongside the Better Business Bureau in 2006. Companies that are members of CFBAI (including McDonald’s, General Mills, and Coca-Cola) pledge to use CFBAI’s uniform nutrition criteria to determine those foods that can and cannot be advertised to children under 12. The nutrition criteria require a specific amount of saturated fat, trans- fat, sodium, and total sugars allowed in food advertised to children. The criteria also include a nutrition component, advocating the inclusion of fruit, vegetables, non-or low fat dairy, whole grains, and other essential nutrients in a healthy diet. This applies to all advertising platforms including television and internet sites. Companies also pledge not to advertise to children younger than 6. To ensure that these commitments are kept, CFBAI staff monitor ads and report their findings to the public. Each company also submits an annual compliance report to CFBAI.

Is self-regulation sufficient? 

Food marketing toward children was recently analyzed by the UCONN Rudd Center for Food Policy and Obesity and published in their Snack F.a.c.t.s. report. Some compliance issues with CFBAI standards were noted in the report. Of the 10 brands advertised mostly to children on TV, four were manufactured by CFBAI companies but CFBAI had not approved these brands for children’s advertising. Additionally, the Snack f.a.c.t.s report discovered advertising that was directed towards children under 6, and recommended that companies follow their CFBAI pledge and not advertise to this age group.

CFBAI guidelines have several shortcomings. One limitation is that the guidelines only apply to children under the age of 12. The Snack F.a.c.t.s report recommends that the guidelines should apply to children up to the age of 14. They also recommend that the CFBAI should close loopholes in their definitions of media directed at children, and use additional measures to identify ads and ensure that products meet nutritional standards. Another suggestion is for the CFBAI adopt the Smart Snacks nutrition standards (what schools use) so products that cannot be sold to children in schools will not be advertised to children. Nearly 75% of the brands advertised to children did not meet the Smart Snacks nutrition standards.

There are also racial disparities in food marketing. The Snack F.a.c.t.s found both Hispanic and black children were targeted in ads more frequently than white children. 90% of the advertising on Spanish language TV was for sweet and savory snack brands. Between 2010 and 2014, advertising for sweet snacks and savory snacks increased by 30% and 551%, respectively, while advertising for yogurt (a healthier product) fell by 93%. Black children saw 64% more snack food ads than white children. Black teens saw more than twice as many ads as white teens. Among black teens, there were 129% more ads for savory snacks compared to white teens, an increase of 71% more ads since 2010.

More protection needed for children

The main purpose of advertising is to sell products. While self-regulation certainly provides positive press for those companies promoting Corporate Social Responsibility, it does not adequately protect children from potentially harmful advertisements. In effort to curb the obesity crisis, taking action against food advertising to children will eventually become a necessary step.

Image source: US Right to Know

Why is the Budget Deal All Bad for Obamacare?

While the cable networks wrapped up their most recent Republican debate coverage, House Speaker Paul Ryan released the details on legislation that would keep the lights on in the federal government through 2016. The late-night release of what is supposed to be the first major legislative accomplishment under the newly minted speaker may have been motivated by an unexpectedly steep price tag: $680 billion.

One of the surprising focal points of the spending bill was the Affordable Care Act. The proposal makes four key changes to the existing law:

  1. It delays the “Cadillac Tax”, a 40 percent tax on the most expensive health insurance plans provided by employers, until 2020.
  2. It pauses the tax for not purchasing health insurance as required by the ACA’s individual mandate until the end of 2017.
  3. It pauses a tax on medical device manufacturers until the end of 2016.
  4. It prevents Congress from using general funds to provide payments to health insurers who took on higher numbers of unhealthy customers in the ACA’s Marketplaces (a hit to a program known as risk corridors).

These changes led Politico to label the ACA as the number one loser from the budget deal. Vox reporter Sarah Kliff didn’t go that far, but she did note that the changes make the ACA much more expensive for the federal government and open it to possible attacks from fiscal conservatives.   

But is the alarm over increased spending generally and the changes to Obamacare specifically justified? 

The budget deficit is already very low

Federal data show that the budget deficit (the difference between tax revenue and government spending in a single fiscal year) will drop to 2.5 percent of GDP in 2015. The White House praised the numbers, and the spending deal shows that even conservative legislators feel they have some room for more red ink (likely because it includes substantial tax cuts).

Fiscal hawks strongly disagreed with this assessment. The head of one of Washington’s prominent fiscal watchdogs tweeted:

While fiscal responsibility is generally a good virtue, it isn’t clear that the government is no longer capable of taking on more debt. In fact, deficit spending may help the economy.

The Federal Reserve just increased interest rates. Time for fiscal policy to step up.

One reason that deficit spending might actually help the economy is that the Federal Reserve just increased interest rates. Since the start of the financial crisis, the nation’s central bank has held interest rates at zero to help stimulate economic growth. Now that the unemployment level has fallen to 5 percent, the nation’s central bankers felt that the economy was strong enough to withstand the Fed taking their foot off the gas. This week, the Fed announced that an increase in interest rates was needed to combat the potential for rising inflation, a process that occurs somewhat naturally when the economy is strengthening.

But one byproduct of increased interest rates is slower economic growth. Raising interest rates makes it more expensive to borrow money. Individuals would likely respond by borrowing less to finance large purchases like homes and cars. Businesses will also respond by borrowing less to finance new projects and growth. And while the unemployment rate has dropped, some still see weaknesses in the labor market that would have been helped by keeping interest rates at zero.

But the adjustment of interest rates (and other actions by the central bank that make up monetary policy) is just one of two tools that can be used to stimulate the economy. The other is fiscal policy, and it can come in the form of decreases in taxes or increases in government spending. The budget deal does just that by extending tax cuts and pausing tax increases, particularly the increases slated to occur as prescribed by the Affordable Care Act.  

The changes to Obamacare delay unpopular parts of the law, but popular parts are left in tact

Since the 2014 midterm elections, President Obama has faced a Congress fully in the control of Republicans. Many of these Republicans campaigned on repealing (and sometimes replacing) the ACA. The overthrow of former House Speaker John Boehner came in part because of little movement on conservative priorities like an ACA repeal. A new speaker amenable to the most conservative members of the House may have seen the first budget clash as an opportunity to pursue conservative goals.

But that isn’t what happened. Instead, the changes to the ACA actually placate groups that had some reasons to oppose the law but others to support it.

Principal among these are labor unions which lobbied heavily against the Cadillac Tax. The opposed the tax because one of the long-time perks of union membership has been lavish benefit plans, including expensive health insurance. The tax on high-priced health plans limited the compensation that unions could extract from employers. But members of labor unions are mostly Democrats, and removing the Cadillac Tax eliminates the one barrier members likely have to supporting the signature legislative achievement of the sitting Democratic president.

Another group with split loyalties is the medical device industry. Expanded coverage under the ACA allows more patients to access the devices and products manufactured and sold by the industry. That, in part, was enough of a rationale to ask the industry to pay a higher tax on their products. With the delay (and possible eventual repeal) of the medical device tax, the industry can now accept the new business without the added taxes.

Given the important role interest group politics play in Congressional policymaking, limiting the objections of key groups clears the path for broader political support for the ACA.

All this occurs while no harm is done to the existing mechanisms for providing health insurance coverage under Obamacare. Both Medicaid expansion and the health insurance marketplaces are still functioning, despite conservative objections. And funding for both of these is protected within general revenue.

Lessening the political pressure on Obamacare may even result in coverage gains through Medicaid expansion in conservative states previously reluctant to embrace the ACA.

It’s not all roses either

To be clear, there are parts of the deal that aren’t great for the ACA. The delay of the health insurance tax pauses the most direct policy tool the law has for encouraging people to sign up for health insurance. The delay may limit the number of healthier people who find insurance to be worth its cost and lower the overall health status of those who do purchase insurance.

This problem could be exacerbated by the provisions on risk corridors. Funding from the risk corridor program is meant to shield health insurance companies from the risks of insuring a new customer group by compensating them for higher than expected costs. Limits in the program have already led to the closures of many health insurance co-ops and could push out a major health insurer from the marketplace next year.

But given that Obama faces a Republican Congress made up of emboldened conservatives, a package of tax decreases, concessions to interest groups, and deficit spending may actually mean a mixed outcome for the ACA. In this environment, a mixed bag might be a win.

How Policy Will Trip Up Outsiders Like Carson and Trump

Policy wonks often grumble about the negligible role policy plays in the election process. Events like debates and speeches do little to encourage candidates to talk in detail about their policy proposals or give voters the tools to judge which proposals are most effective.

The 2016 Republican primary may signify the low point of policy’s influence on elections. Ben Carson has called for repealing the Affordable Care Act because it is the worst thing to happen to Americans since slavery. Donald Trump has campaigned on solving the U.S. immigration crisis by building a wall on the Mexican border and insists that the Mexican government will pay for it because he can make great deals.

But while voters have yet to punish Carson or Trump for these outlandish proposals, policy is beginning to impact the race in more subtle ways. As the top two outsiders maintain their lead in the primary polls, journalists are beginning to question Carson and Trump’s policy positions in greater detail.

Both have struggled in describing how to implement their policy objectives, revealing their weakness as political outsiders with no experience in elected office. While not yet evident in the polls, these weaknesses are hurting the outsider’s fortunes in terms of electability as measured by party endorsements and prediction markets.

October’s Republican debate on CNBC focused extensively on economic issues which left the candidates vulnerable to criticism of their tax proposals. Trump and Carson were questioned about the mathematical difficulties in both lowering tax rates and lowering the federal deficit.

As scored, Trumps plan would increase the deficit by $10 – $12 trillion over the next decade (see here and here for different estimates). Carson’s proposal for a 10% flat tax is less detailed, but is estimated to increase the deficit by $3 trillion in the first year.

Trump responded to criticism of his tax plan in typical Trump fashion.

Carson answered by denying that that the rate would be 10% and offered vague nods to “strategically cutting”, “getting rid of all deductions and loopholes”, and stimulating the economy as ways to make up the funds lost by implementing the flat tax. When pressed by moderator Becky Quick that he’d have to cut 40% of government spending to make his plan budget neutral, he replied simply, “That’s not true”.

Carson has also struggled on the specifics of domestic and foreign policy. In one notable exchange about his health care proposals on Fox News Sunday, Carson said he had discarded a previous proposal that would have ended Medicare and Medicaid, two federal health programs for the elderly and the poor. He also stumbled in describing the funding mechanisms for his new proposal, leaving moderator Chris Wallace (and health wonks) thoroughly confused.

Policy fluency matters because it demonstrates how prepared and well-executed a campaign is. Effective campaigns employ policy as a weapon by proposing clear solutions and wrapping these solutions into the larger narrative of the campaign. When asked about his lack of executive experience during the 2008 election, surrogates for Barack Obama repeatedly cited the success of his campaign as evidence of his preparation for the White House. In turn, his campaign effectively pinned Hillary Clinton down on her vote for the Iraq war.

This plays itself out in primaries through the debates. Candidates use high profile events like these to build a perception of electability by outlining solutions that speak to the concerns of the primary electorate.

Research by Alan Abramowitz shows that voters judged 1988 primary candidates in part by their chance to win the general election. As the early primaries passed, voters judged candidate electability on their performance in states like Iowa and New Hampshire. Since campaigns now begin well before the first primary states vote, candidates will seek out debates as an opportunity to build this perception of electability.

Voters aren’t the only group that supports candidates that are perceived to be more electable. Primary elections are often prefaced by the “invisible primary”, which occurs when party elites endorse and raise money for their preferred candidates. This stage, where “the party decides, has typically favored insider candidates with extensive fundraising connections in the party. Outsider candidates, like Trump and Carson, struggle to compete in this phase of the campaign as shown by FiveThirtyEight’s endorsement tracker.

Frequent poll watchers might note that Donald Trump and Ben Carson have dominated the polls in the early primary season and have garnered support from over half of Republican voters. While this is true, polls are not the most accurate judge of a candidate’s chances this early in the primary season.

The prediction market is another method that can be used to judge the electability of primary candidates. Unlike polls, participants in prediction markets wager about what they think will happen as opposed to their preference. This encourages betters to be realistic about the chances of each candidate and consider issues like electability. These measures move more reliably in response to major events like a presidential debate. After the CNBC debate, prediction markets favored Marco Rubio, who had a strong response to his rival Jeb Bush and more substantive answers to policy questions.

As the primary election heads towards the first votes in Iowa and New Hampshire, watch for candidates to differentiate themselves further on policy issues. The wonkier the debate gets, the more it disadvantages Trump and Carson.

See more on the debates from Vox:

End of Life Care in the US: Towards a Patient-Centered Approach

 

Within the past few weeks, the Obama administration issued a final rule which allows Medicare to reimburse physicians for engaging in consultations with patients on end of life care. Receiving widespread support from both the American Hospital Association and American Medical Association, the final rule will be effective starting in January 2016, nearly six years after the enactment of the Affordable Care Act (ACA).

End of life care is a difficult subject for discussion between physicians and patients, but it provides the opportunity for advance planning that reflects the patients’ best interests. This final rulemaking action by the Centers for Medicare and Medicaid (CMS) illustrates a firm step in the direction of a more patient-centered approach to end of life care, showing the benefits of hospice and other palliative care measures for patients nearing the end of life. Pursuing these alternatives has the potential to better direct Medicare savings and reflect the patients’ best wishes.

A Paradigm Shift

Incentivizing doctors to have these pertinent discussions reflects a larger shift in the approach to healthcare, where a more patient-centered approach is stressing quality of care over the quantity of treatments given. Through the ACA, alternative payment and reimbursement models have been pursued by CMS to improve the delivery of care. Some of these models like accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) emphasize communication among different care providers, the coordination of care to the patients, and as a result a more efficient cost structure. The paradigm shift away from ‘more treatment’ to ‘better quality’ is an important distinction to make in the delivery of care, especially at the final stages of life.

This approach has been difficult to communicate, and during the early stages of the ACA there was plenty of backlash against the government-sponsored ‘death panels,’ the misconception that a patient’s care or lack thereof would be determined by CMS bureaucrats. Instead, as the new rule clarifies, advance care planning is a step that can be taken at the discretion of the patient to determine their best options.

Cost of Care

The 2014 total expenditures for Medicare were $613.3 billion, which included funding for Medicare Parts A (hospital stays, skilled nursing, and hospice care), B (physician, outpatient, and other services for the aged and disabled), and D (prescription drug insurance coverage). According to the Kaiser Family Foundation, seniors who passed away in 2011 while receiving traditional Medicare coverage (Parts A, B, and D) averaged about $33,486 per beneficiary, nearly four times more than beneficiaries who did not die that year. The Foundation also reported that on average about half of the total Medicare expenses for people who passed away in a given year went toward hospital inpatient care. The Kaiser Foundation’s report also highlighted that only 10 percent of the Medicare expenses within a beneficiaries’ final year were spent on hospice and other non-invasive care options. Focusing on patient comfort, hospice care is a less costly alternative because it does not involve the surgical procedures, hospital stays, and medication costs that typically accompany aggressive treatment. Pursuing this care option would help beneficiaries, insurance companies, and Medicare avoid excessive medical costs.

Focus on Quality

More affordable care is a major benefit of alternative and less-invasive treatments, but perhaps the best advantage of these options is the focus on quality. Palliative care, which focuses on managing care for patients who are experiencing chronic illness, is an alternative to the more aggressive and painful options that patients may not want to pursue. Hospice care is usually performed within the patients’ own home, where nursing services, palliative medications, and counseling is provided. Medicare can cover hospice care for patients with a life expectancy of six months, and if patients live longer than this timeframe a hospice doctor can re-certify the patients’ terminal illness and extend treatment.

In 2004, Aetna performed a study on their policyholders with less than a year of life expectancy by giving them access to hospice care without foregoing other care options to combat their life-threatening symptoms. Over two years, the study found that despite having access to both options, patients were more likely to rely solely on hospice care, with many making fewer trips to the emergency room and I.C.U. The study reflected the comfort that patients felt when receiving counseling and in-home care as opposed to within a hospital, and it further reflects cost savings on behalf of Medicare, private insurance companies, and patients as well.

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Atul Gawande, surgeon and acclaimed writer on the topic of end of life care points out that nowadays, “death comes only after long medical struggle with an incurable condition…or the multiple debilities of very old age.” Life expectancy in the United States has grown significantly, a trend that should cause us to think about what advance planning patients should be talking with their doctors and what course of action they would like to pursue. Options like hospice and palliative care remain vital paths for patients with short life expectancy to manage symptoms and live somewhat peacefully within the comfort of their own homes while saving out-of-pocket expenses and Medicare expenditures.

 

Image source: Delta In-Home Care

How Carly Fiorina’s Super PAC Made Her the Feminist Candidate

Last week’s GOP debate again reshaped the field of candidates vying for the Republican nomination. Political pundits and polls largely agreed that Carly Fiorina is on the rise while Jeb Bush is fading as voters look towards outsider candidates.

But beneath the headlines, Carly Fiorina made a subtle shift in how she defines herself as the only female candidate in the field for the GOP nomination. It was a shift that may have been forced by supporters outside of her campaign.

CNN made a point of highlighting both personal and political differences between the candidates during the debate. The most prominent personal conflict was the spat between Donald Trump and Fiorina.

The feud began after Trump, the real estate billionaire turned outsider political candidate who is known for his brand of political incorrectness, criticized Fiorina’s looks in an interview with Rolling Stone:

Look at that face! Would anyone vote for that? Can you imagine that, the face of our next president?! I mean, she’s a woman, and I’m not s’posedta say bad things, but really, folks, come on. Are we serious?

Before the debate, Fiorina brushed off Trump’s insult. When asked by Megyn Kelly to respond, Fiorina simply acknowledged that the voters helping her rise in the polls really were serious. Pressed further about Trump’s criticism of her looks, Fiorina sidestepped again and asserted that her rise in the polls is what is getting under the skin of The Donald.

But supporters of Fiorina took a different approach. After the political commentariat derided Trump’s comments as sexist, Fiorina’s Super PAC responded to Trump with an ad entitled “Faces”,

The political class applauded Team Fiorina for standing in the face of Trump’s sexism with headlines like “This Carly Fiorina ad is the perfect comeback to Donald Trump’s sexist insults” and “In Your Face! Carly Fiorina Responds to Donald Trump’s Insults About her Looks in a New Campaign Ad”.

Reports also glossed over the fact that the ad came from a Super PAC instead of Fiorina’s campaign, assuming that the divide between outside groups and campaigns is so small as to be nonexistent.

This teed up the most prominent contrast CNN sought from the candidates. Shortly after the debate began, Jake Tapper threw Fiorina the pitch, asking for her direct response to Trump’s comments.

Clips from the post-debate analysis and reports in the following days would only show the moment when Fiorina laid the hammer on Trump. Without directly condemning Trump, Carly dismissed his comments from the perspective of all women.

“I think women all over this country heard very clearly what Mr. Trump said.”

But watching the debate live led me to question Carly’s enthusiasm for taking on Trump. For a candidate who won on style all night and whose convictions showed in every response, she hesitated when given the Trump softball question.

She touched her lip, looked down, and first pivoted to how “Mr. Trump said that he heard Mr. Bush very clearly,” as if she needed a moment to grab her hammer. Then when the moment passed, she paused and stared emptily into the crowd, displaying the gap between what she wanted to say and what the crowd wanted to hear.

In predictable fashion, Fiorina was again praised from the left for taking down Trump. Emily Bazelon said on the Slate Political Gabfest that she experienced a “feminist moment” with Fiorina. Huffington Post praised the heels that Fiorina wore while she “put Donald Trump in his place.”

But Carly hasn’t always been a feminist political champion. In fact, she’s largely been critical of using gender as a strategy to win votes. Her website states that it’s time to end identity politics. She’s argued that Democrats treat women like an interest group and pit them against men in the pursuit of winning elections.

From a policy perspective, she opposes proposals seen as particularly beneficial to women. She’s against a federal mandate for paid family leave. She would repeal the Affordable Care Act. And in her most impassioned moment in the second Republican debate, she claimed that the recently released videos targeting Planned Parenthood’s role in fetal tissue research included footage of a live fetus kicking while a doctor discusses a procedural change meant to “harvest the brain”.

Fiorina’s momentary hesitation to slam Trump may be reflective of her hesitancy to carry the feminist banner as the first woman to become president of the United States.

But it also reveals the potential downside for candidates supported by outside money. While coordination between campaigns and their supportive Super PACs is legally prohibited, its is generally assumed that the actions of a PAC represent the interests of the candidate. In this case, it appears plausible that Carly for America may have gone out front of Carly for President, boxing the candidate into being more aggressive in her female-focused messaging than she otherwise would have been.

As the field thins and supporters of vanquished candidates look for someone new, how the Fiorina campaign frames her gender in this race will tell us what the campaign understands about the Republican primary electorate. Would a gender-based rationale help her gain the marginal support from Republican women she needs to secure the nomination? Or will an older and majority male primary electorate deter Fiorina from being the “woman’s candidate”?

Fiorina’s speech kicking off her campaign made this seem like an irrelevant question. But because of her Super PAC and Donald Trump, her answer may determine the fate of her candidacy.