The backlash against using race to allocate Paxlovid is in full swing
This drives me crazy. From Alice Miranda Ollstein and Megan Messerly in Politico:
Republicans are accusing the Biden administration of racism — against white people.
The administration’s recommendation that race and ethnicity be considered when deciding who gets the limited supply of new Covid drugs is the latest political talking points with which Republicans are hammering Democrats, looking to energize their base ahead of the midterm elections.
The issue is gaining steam in both the establishment and MAGA activist wings of the party. Sen. Marco Rubio is among several lawmakers pushing the Food and Drug Administration to rescind the recommendation, calling it “racist and un-American.” Former President Donald Trump during his rally in Arizona earlier this month claimed that the Biden administration is “denigrating white people to determine who lives and who dies.” The Wall Street Journal recently ran an editorial blasting New York’s version of the policy as “unfair and possibly illegal” and warned that “Democrats could pay a lasting political price” for it. Former White House policy adviser Stephen Miller, who is suing New York over the policy and threatened legal action against Minnesota and Utah, railed against the efforts as “unconstitutional, immoral, and tyrannical.”
Minnesota and Utah have withdrawn their guidelines in the face of protest and threats of lawsuits. New York State is sticking with its guns. How do you think this will go over at the Supreme Court? Yes, that’s a rhetorical question.
As I emphasized in my earlier post, treating race/ethnicity as a risk factor could potentially be justified. If Blacks/Hispanics with COVID are at greater risk of dying than otherwise similar Whites, it is entirely appropriate to take race/ethnicity into account in allocating limited supplies of Paxlovid. The problem is that it’s not clear this is true.
Ollstein and Messerly cite a study that finds that Blacks/Hispanics/Native people have higher age-adjusted overall death rates than White people, relative to their share of the population. I have no reason to doubt this, but it seems likely that much of this gap is due to greater exposure, not a higher likelihood of dying once you get sick. Are public health officials saying that we should take scarce, life-saving medication from higher-risk Whites and give it to lower risk Blacks/Hispanics because Blacks and Hispanics have a higher risk of getting sick in the first place? You can make this argument in a moral philosophy seminar, but it will not convince many people at the Supreme Court or in the court of public opinion.
Ollstein and Messerly also point to a new CDC study that finds significant racial differences in treatment for COVID, especially among outpatients. This is hardly surprising (as I discussed here), and it is a serious problem. But if this is the problem that regulators are trying to solve they should 1) say so explicitly and 2) choose policies that are reasonably related to the problem. Instead, we get this:
“People think that if we don’t take race into account things will be distributed equally. That’s not true,” Bell stressed. As an example, he cited the Biden administration’s early vaccine distribution program that relied on local pharmacies, which left many communities of color without access during the rollout’s first few months. “A policy like that on its face seems equitable, but it isn’t really.”
It makes good sense to ensure that vaccines are available where disadvantaged people live. A policy that made sure vaccines were available in Black neighborhoods would have been justified morally and probably legally, and it would have been relatively uncontroversial. I made a similar argument about distributing Paxlovid. But no one would argue that eligibility for vaccination should have been based on race, rather than risk factors (including the risk of exposure, which is relevant for vaccines, but not for treatments).
Then there’s this:
Those in charge of implementing the recommendation at the local level say this is rarely an issue clinicians confront and that no one is being denied Covid pills based on their race.
. . .
“Is there a situation where a person would not qualify but only for the additional risk factor or consideration of race or ethnicity? Certainly, that could be a situation. In the thousands of patients that we’ve treated have we seen that particular criterion be the only criterion for a patient? It would be incredibly small,” Liebl said.
I am not sure what the argument is here. Paxlovid and monoclonal anti-bodies are in incredibly short supply. If one person gets treated, another person will not. Perhaps the effect of race/ethnicity on allocation is not evident to a practitioner given how the allocation system works, but my guess is that Supreme Court Justices will figure this out. Or perhaps the guidelines simply get physicians to reflect on how they treat Black/Hispanic patients (whether they are missing undiagnosed risk factors, etc.), but race/ethnicity are not treated as independent risk factors. That’s totally fine (as I said here), but if so it would help a lot if the guidelines said this. Or maybe race/ethnicity really has no effect on treatment decisions, and the policy is simply ineffective, so why bother?
Finally, there’s this:
“This policy is trying to combat racial and ethnic disparities that are already happening,” explained Taison Bell, a doctor and assistant professor of medicine at the University of Virginia’s division of infectious diseases. “But it’s perceived as an attack. Well, I can’t think of any victory for racial equality that didn’t upset some folks.”
Yes, you have to break eggs to make an omelet, and sometimes you need to do things that are controversial in the name of justice. But this policy will not make an omelet. It will just break a lot of eggs. Remember Hans von Spakovsky? He’s doing the happy dance about this.
Racial disparities in health are a big problem and they demand our attention, but there is no justification for ignoring political and legal constraints, or for adopting policies that will not deal effectively with the problem.
This may help you make your point as taken from a series of posts
CMS’s Skilled Nursing Facility VBP program
The authors (Rubin and Hefele, etc. [JAMA Network and Health Affairs]) found all three of these categories (High Medicaid, Majority Black, or Majority Hispanic) of Skilled Nursing Facilities (SNFs) were far more likely to be penalized (fines, etc,) and far less likely to receive bonuses from CMS..
Conversely, Low-Medicaid and Majority-white Skilled Nursing Facilities (SNFs) were far more likely to receive bonuses.
The main defect? The program penalizes SNFs having larger numbers of or above average sick and/or poor patients who experience lower success rates with their care and resulting in smaller and fewer bonuses. In turn, SNFs with above average numbers of healthier patients experience more frequent and larger bonuses due to healthy conclusions.
This is an example of the “reverse Robin Hood effect.” The failure to recognize a SNF’s population makeup will lead to an inaccurate risk adjustment favoring the healthier over the less-healthy SNFs. Recognizing this problem in rewarding SNFs, a Nursing Organization asked Kip Sullivan to write on the topic.
CMS knew the calculation for this plan was inaccurate and they still used it to determine bonuses for Value-based rewards to Skilled Nursing Facilities (SNFs) .
Every time some Democrat tries to justify this, the Republicans pick up another 10,000 voters.
Nicely done and perfect close.
I live in one of those healthcare under-served neighborhoods and must drive 13 miles or more to reach a high quality clinician of any kind. So, I travel to the middle to upper middle class white majority town of Mechanicsville, VA, because Sandston, where I live, is majority black and super majority median and lower income. There were some better doctors here that retired, but for quite a while now the better doctors set up practice in higher income neighborhoods several miles away. Patients that either walk or rely on public transportation do not have the same choices. Sixty years ago when my home was first built, then this was an up and coming exurban neighborhood. When suburban development took over here then it brought upper income white flight.