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From “Medicare for All” to “Health for All”

In the shadow of a global pandemic, national unemployment crisis, and ongoing presidential impeachment hearings, the debates surrounding Medicare for All that dominated news cycles through the summer and fall of 2019 may seem like a quaint and distant memory. However, as a newly minted Democratic-controlled legislative and executive branch elected on the promise of Medicare for All look to define policy priorities for the next four years, we in healthcare would be well served to consider how we might shape discussions of healthcare reform in the years to come, particularly given the unique spotlight the pandemic and race-related protests have placed on health disparities. There is no denying that public attitudes about healthcare reform have shifted dramatically over the past quarter-century, with 2017 marking the first year a majority of Americans supported government-instituted national health insurance coverage and 74% of Americans now reporting that they would like to see the government do more to provide care for all citizens.1 Yet, for all the political success of the Medicare for All campaign, universal healthcare coverage—even if achieved—in reality, represents not a panacea but one piece of the comprehensive healthcare reform needed to achieve improved health for all in the United States.

Identifying the other components and priorities of meaningful healthcare reform is no easy feat, but it is a necessary one. Doing so ultimately requires that we, as a society, achieve consensus on our healthcare values and begin to engage in discussions of costs and tradeoffs involved in the daily application of health policy. If achieving health equity ranks among these priorities as so many recent editorials and calls to action in the cardiovascular community demand, a reimagining of how we define healthcare quality is required. The American healthcare system has become notorious for its nearly singular focus on individual-level outcomes in measuring healthcare quality, but in doing so population-level performance, and in turn disparities in care, have been largely ignored at the system level. This is to the detriment of minority and underserved communities who experience ill-health in greater numbers, as well as the larger population, all of whom share in the downstream effects of rising healthcare costs driven by acute and tertiary care services. While providing universal coverage may lower or eliminate one barrier to care for underserved groups, unless paired with interventions to reach underserved populations, expand primary and preventive care resources, lower drug costs and expand access to preventive therapies, gains in health equity are unlikely to be achieved.

There are few better examples of this than in the case of cardiovascular disease, which affects more than 80 million people in the United States and is one of the largest single drivers of health expenditures, costing about $444 billion in direct healthcare costs and accounting for $1 of every $6 in health spending.2 Healthcare costs in cardiovascular care have continued to rise and are estimated to reach $818 billion in direct costs and $275 billion in lost productivity by 2030.3 This is, of course, largely preventable. Reductions in the prevalence of smoking and hyperlipidemia, improved recognition and control of high blood pressure, and expanded access to aspirin and statin therapy over the past four decades have driven substantial and consistent declines in cardiovascular mortality. However, disparities by gender, race, and geography remain unchanged in the same time period, demonstrating that while prevention is key in reducing the burden of cardiovascular diseases, unequal access to services and interventions and failure to engage systems of discrimination and racism will continue to hinder our progress toward improved cardiovascular health for all.

So how can we, as cardiologists, begin to reimagine an approach to prevention that meets the magnitude of the current demands for a better and more equitable healthcare system, while also not further ballooning spending? Doing so will require innovative thinking about how to deliver high-value care, a lesson we may well gain from studying the examples of resource-limited settings. Too often, we have seen the American healthcare system as incompatible with models of healthcare from low- and middle-income countries, but these countries and systems offer valuable lessons in how to reach vulnerable populations and provide high-quality care at low cost. This is not to say that any one country has fully achieved the vision of healthcare to which we strive, but rather to suggest that we may improve our own performance by broadening our approach to resource-limited care and embracing ideas with demonstrated efficacy. Over the course of this series which will roll out over the next 3 months, I’d like to explore some of these approaches and their respective strengths and weaknesses, starting with models of task-shifting, use of mobile health technologies, and polypills among others, specifically imagining how such interventions may apply to cardiovascular health in the U.S. and may act to reduce disparity and improve cardiovascular outcomes. These interventions are by no means comprehensive nor capture all of the intricacies of healthcare reform policy but may help us to identify tools at our disposal as we consider how healthcare may function to promote equity while improving health outcomes. By doing so, I hope we can begin to see how a vision for “Medicare for All” might eventually evolve to a vision for “Health for All”.

REFERENCE

  1. KFF. Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage. 2020; https://www.kff.org/slideshow/public-opinion-on-single-payer-national-health-plans-and-expanding-access-to-medicare-coverage/. Accessed February 11, 2021.
  2. Shaw LJ, Goyal A, Mehta C, et al. 10-Year Resource Utilization and Costs for Cardiovascular Care. J Am Coll Cardiol. 2018;71(10):1078-1089.
  3. Heart Disease and Stroke Cost America Nearly $1 Billion a Day in Medical Costs, Lost Productivity. 2015; https://www.cdcfoundation.org/pr/2015/heart-disease-and-stroke-cost-america-nearly-1-billion-day-medical-costs-lost-productivity#:~:text=Annually%2C%20about%20one%20in%20every,costs%20could%20exceed%20%24275%20billion. Accessed February, 2021.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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Lose the COVID, Keep the Virtual Platform

As we close the chapter on a successful—if different—AHA conference in this pandemic year, and usher in the much-anticipated vaccination phase of the global pandemic, it is worth taking a moment to consider what future science and scientific conferences may gain from the insights of 2020 in the years to come and beyond. As my colleague Mo Al-Khalaf writes in his recent blog, 2020 has been a year of rapid adaptation and innovative solutions, particularly in the development and sharing of medical knowledge and expertise. Consider, for example, that four short weeks ago as we convened virtually for Scientific Sessions, the prospect of the rollout of two highly efficacious vaccines against COVID19 within weeks would’ve seemed so optimistic as to be foolhardy. Indeed, as quickly as COVID changed the reality of daily life, the scientific community changed its practices—for developing and testing therapies, sharing lessons learned from hard-hit regions, and revising journal and conference experiences so as to expand access to information and knowledge. It has been an imperfect process that has at times revealed weaknesses in existing systems, demonstrating for example the value of thorough peer-review in curating research and the bureaucratic roadblocks to rapid maneuvering of healthcare systems to respond to and prepare for surges, and highlighting the individuals and communities routinely excluded from scientific gains.

Nonetheless, the benefits of an at least partly virtual conference experience should not be lost as we tentatively allow ourselves to imagine a post-pandemic world. For starters, virtual conferences in the cardiology world have resulted in higher turnout than seen in prior years, likely due to the reduced costs of participation, ease of access to content, and time flexibility for participation. In fact, the European Society of Cardiology saw attendance increase by nearly four-fold this summer from a previous recent record of about 33,000 professionals representing 150 countries in 2019 to more than 125,000 professionals from 211 countries in 2020.1 Much of this growth likely represents groups previously disadvantaged when it came to conference participation, including students and trainees whose time and financial restrictions are often more stringent than more advanced stage practitioners, as well as providers with family and caregiving responsibilities for whom travel to distant cities for several days may be an impractical proposition. An online platform offers a degree of anonymity and equalizing of audience members, moreover, encouraging participation in discussion by attendees. One need look only as far as the chat boxes of live events at this year’s Sessions for evidence of strangers—ranging from students to experts—coming together to discuss research methodology and implications. The inclusion of such groups is to the advantage of all in the end, as the value of scientific conferences undoubtedly rests on their ability to reflect the diversity of the field and draw upon the most experiences and broadest audience.

At the same time, virtual formats have resulted in a smaller carbon footprint within the scientific community. Since the pre-pandemic world of 2015, climate change researchers have urged scientific groups to seek innovative ways to convene and share information, recognizing that academic researchers represent a high-emitter group due to frequent air travel for conferences, meetings and fieldwork, and noting the benefits of example setting to strengthen public investment in behavioral change for climate protection.2 As conferences in other fields of science experimented with virtual components, the pandemic ultimately forced all of us to embrace a more dramatic adjustment to entirely virtual experiences. Though not perfect—as others have noted, virtual conferences have suffered from a loss of some networking opportunities—this year’s initial experience demonstrates that virtual conferencing is both possible and practical. This will be an invaluable lesson as the existential crisis of climate change increasingly occupies the shared consciousness of society.

Sooner or later, our lives will begin the transition back to something resembling the world before COVID19. This will be for the better, as we again benefit from the experience of human contact and connection but need not come with an erasure of the lessons learned during this challenging year. Future conferencing may indeed benefit from a component in-person participation, but the demonstrated demand for a virtual experience suggests that on-demand lectures and virtual live chats are here to stay, and we will all be the better for it.

References

  1. Figures from ESC Congress.
  2. Quere CL, Capstick S, Corner A, Cutting D, Johnson M, Walker-Springett K, Whitmarsh L and Wood R. Towards a culture of low-carbon research for the 21st century. 2015.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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Social Justice and the Polypill: A Strategy for the Future of Health Equity

The American Heart Association Scientific Sessions kicked off this morning in everything but the usual fashion—socially distant, virtual, absent the normal red regalia and buzzing convention center. And yet, it felt as though the necessary distance created space for a kind and level of discussion and introspection I’ve never before experienced during a large scientific conference. In particular, the Opening Session set the stage for the day with a thoughtful and deliberate discussion of racial and gender inequity featuring the inimitable Drs. Nanette Wenger and Eugene Braunwald along with moderators Drs. Clyde Yancy and Robert Harrington. The session covered historical aspects of the fight for equity in medicine told from the experienced perspectives of Drs. Wenger and Braunwald, while recognizing how far we’ve come—and have yet to go—in realizing the promise of an equitable society and equitable healthcare. That the session was quickly followed by one on how best to use behavioral interventions to advance equity, and then another forum on how training programs can adopt antiracist behaviors and policies, demonstrated the depth of the commitment to address equity and disparities during this year’s Scientific Sessions.

I was, however, most enamored by the first late-breaking clinical trial presentation of the day, summarizing the results of the International Polycap Study 3 (TIPS-3) clinical trial, simultaneously published today in the New England Journal of Medicine.1 In an introduction by Dr. Dorairaj Prabhakaran, it was immediately evident how TIPS-3, a clinical trial evaluating a polypill containing low-dose simvastatin, atenolol, hydrochlorothiazide, and ramipril, fit perfectly within the context of the broader discussions of equity and social justice that permeated the day. The polypill, after all, is less the new-tech that many of us have come to expect in late-breaking sessions, and more a study in improving access to care. Noting the enormous burden of cardiovascular disease (CVD) in low- and middle-income countries, and the marked inter-and intra-country disparities observed in cardiovascular outcomes, Dr. Prabhakaran set the stage for how the polypill was—when all is said and done—a strategy study with the goal of improving equity. He summarized this idea simply and eloquently, concluding that while “medicine is inherently reductionist… the solutions have to be holistic.”

The TIPS-3 study, subsequently presented by Drs. Salim Yusuf and Prem Pais, evaluated the effects of the polypill and primary prevention aspirin against placebo in a two-by-two factorial design within an intermediate-risk population without preexisting CVD. The trial recruited 5713 participants from more than nine countries including India, the Philippines, Colombia, Bangladesh, Canada, and Malaysia, among others. Participants were followed for more than 4.5 years for a primary outcome of major CVD (including cardiovascular death, non-fatal stroke, non-fatal myocardial infarction), heart failure, resuscitated cardiac arrest, or revascularization. Despite achieving lower-than-anticipated levels of blood pressure and LDL-cholesterol reduction (5.8 mmHg and 19 mg/dL, respectively in the polypill arm), the trial saw a 21% reduction in the primary outcome in the polypill arm when compared to placebo (HR 0.79; 95% confidence interval [CI], 0.63 to 1.00), and an even more impressive 31% reduction in the aspirin + polypill group (HR 0.69; CI, 0.50 to 0.97). Unsurprisingly, aspirin alone did not significantly reduce the incidence of cardiovascular events, though this finding does make the additive reduction in CV events in the polypill + aspirin arm more unusual. The benefit of treatment with polypill + aspirin was, moreover, seen early (within the first two years of the trial), and was evident despite relatively high rates of discontinuation of therapy in the follow-up, driven primarily by logistical challenges in obtaining therapies.

With these findings, TIPS-3 adds to the growing and consistent body of evidence from prior trials including HOPE-32 and PolyIran study3, demonstrating that polypills have the potential to impact both intermediate endpoints and cardiovascular outcomes in a primary prevention population. The potential of the strategy to impact cardiovascular disparities is apparent, but the true test of our commitment to health equity globally will be seen in whether we are able to translate such findings into meaningful programs and interventions in the coming years.

 

REFERENCE

  1. Yusuf S, Joseph P, Dans A, et al. Polypill with or without Aspirin in Persons without Cardiovascular Disease. New England Journal of Medicine 2020.
  2. Yusuf S, Bosch J, Dagenais G, et al. Cholesterol Lowering in Intermediate-Risk Persons without Cardiovascular Disease. N Engl J Med. 2016;374(21):2021-2031.
  3. Roshandel G, Khoshnia M, Poustchi H, et al. Effectiveness of polypill for primary and secondary prevention of cardiovascular diseases (PolyIran): a pragmatic, cluster-randomised trial. Lancet. 2019;394(10199):672-683.

 

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”