The United States is knee-deep in what some experts call the opioid epidemic’s “fourth wave,” which is not only placing drug users at greater risk but is also complicating efforts to address the nation’s drug problem.
These waves, according to a report out today from Millennium Health, began with the crisis in prescription opioid use, followed by a significant jump in heroin use, then an increase in the use of synthetic opioids like fentanyl.
The latest wave involves using multiple substances at the same time, combining fentanyl mainly with either methamphetamine or cocaine, the report found. “And I’ve yet to see a peak,” said one of the co-authors, Eric Dawson, vice president of clinical affairs at Millennium Health, a specialty laboratory that provides drug testing services to monitor use of prescription medications and illicit drugs.
The report, which takes a deep dive into the nation’s drug trends and breaks usage patterns down by region, is based on 4.1 million urine samples collected from January 2013 to December 2023 from people receiving some kind of drug addiction care.
Its findings offer staggering statistics and insights. Its major finding: how common polysubstance use has become. According to the report, an overwhelming majority of fentanyl-positive urine samples — nearly 93% — contained additional substances. “And that is huge,” said Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health.
In FY2023, mandatory spending accounts for an estimated 63% of total federal spending. Social Security alone accounts for about 21% of federal spending. Medicare and the federal share of Medicaid together account for another 25% of federal spending. Therefore, spending on Social Security, Medicare, and Medicaid now makes up almost half of total federal spending.
These figures do not reflect the implicit cost of tax expenditures, which are revenue losses attributable to provisions of the federal tax laws that allow a special exclusion, exemption, or deduction from gross income or provide a special credit, a preferential tax rate, or a deferral of tax liability.8 As with mandatory spending, tax policy is not controlled by annual appropriations acts, but by other types of legislation.
The sixth edition of The Little Book of Data presents original and curated visuals, charts and graphics to offer a fresh perspective on topics shaping our world, including climate change, artificial intelligence, inflation, economics and geopolitics.
Looking a bit more closely you see why Grail’s test is actually useless, or dangerous, or both. Let’s start with the sensitivity of the test. For a cancer screening test to work, it must find disease before it has caused symptoms — when it is in an early or premalignant stage. Say what you want about lung cancer screening, mammography, PSA, and colonoscopy (I’m talking to you Drs. M and P) but at least they look for, and succeed at finding, early stage/premalignant disease. Here is the sensitivity of the Galleri test by stage: stage 1, 16.8%; stage 2, 40.4%; stage 3, 77%; stage 4, 90.1%.
The test is nearly worthless at finding stage 1 disease, the stage we would like to find with screening. The type of disease that is usually cured with surgery alone.
How about specificity? Let’s consider a fictional, 64-year-old male patient who presents to his internist worried about pancreatic cancer. I pick pancreatic not only because it is a scary cancer: we can’t screen for it, our treatments stink, and it seems to kill half the people in NYT obituary section. I also chose it because it is the anecdotal disease in the WSJ article.
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Working through the math (prevalence 0.03%, sensitivity 61.9%, specificity 99.5%), this means our patient’s likelihood of having pancreatic cancer after a positive test is only 3.58%. For our patient, we have caused anxiety and the need for an MRI. You almost hope to find pancreatic cancer at this point to be able to say, “Well, it was all worth it.” If the MRI or ERCP is negative, the patient will live with fear and constant monitoring. (You will have to wait until next week to consider with me the impact of this test if we were to deploy it widely).
If the evaluation is positive, and you have managed to diagnose asymptomatic, pancreatic cancer, the likelihood of survival is probably, at best, 50%.
Let’s end this week with two thoughts. First the data for the Galleri test is not good, yet. The test characteristics are certainly not those we would like to see for a screening test. Even more importantly, good test characteristics are just the start. To know that a test is worthwhile, you would like to know that it does more good than harm. This has not even been tested. The WSJ article scoffs at the idea that we would want this data.5
The current setup is nothing like the situation following WWII. Don’t expect another baby boom.
Instead, expect a massive wave of boomer retirements (already started) that will pressure Medicare and Social Security.
Depending on the kindness of foreigners to increase demand for US treasuries is not exactly a great plan.
Artificial Intelligence (AI) will undoubtedly increase productivity. But that is not going to offset the willingness of Congress to spend more and more money on wars, defense, foreign aid, child tax credits, free education, and other free money handouts, while trying to be the world’s policeman.
The Post reported that some politicians pointed to the rising death toll from “lethal drug overdoses” as a significant factor in declining U.S. life expectancy. The Post did, however, acknowledge that drug deaths “are not solely responsible for the decline in life expectancy.” It is worth noting that opioid overdose deaths began truly soaring after 2010 when users turned to illicit heroin and fentanyl after the introduction of Food and Drug Administration–approved abuse-deterrent formulations.
So how much do drug overdose deaths contribute to the recent decline in U.S. life expectancy? A 2021 comprehensive review of factors affecting mortality trends in the U.S. between 1999 and 2018 found that average life expectancy would “have been 0.3 years greater were it not for increases in unintentional drug poisoning.” In a 2023 preprint article, two Johns Hopkins University researchers calculated that opioid overdose deaths between 2019 and 2021 reduced U.S. life expectancy by 0.65 years. If politicians and policy makers really want to make increasing life expectancy a priority, one huge step would be to actually end the war on drugs. A cease-fire in the drug war would likely reduce gun deaths too.
About half of U.S. adults say it is difficult to afford health care costs, and one in four say they or a family member in their household had problems paying for health care in the past 12 months. Younger adults, those with lower incomes, adults in fair or poor health, and the uninsured are particularly likely to report problems affording health care in the past year.
The cost of health care can lead some to put off needed care. One in four adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost. Notably six in ten uninsured adults (61%) say they went without needed care because of the cost.
The cost of prescription drugs prevents some people from filling prescriptions. About one in five adults (21%) say they have not filled a prescription because of the cost while a similar share say they have instead opted for over-the-counter alternatives. About one in ten adults say they have cut pills in half or skipped doses of medicine in the last year because of the cost.
Those who are covered by health insurance are not immune to the burden of health care costs. About four in ten insured adults worry about affording their monthly health insurance premium, and 48% worry about affording their deductible before health insurance kicks in. Indeed, large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and to out-of-pocket costs to see a doctor.
Health care debt is a burden for a large share of Americans. About four in ten adults (41%) report having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt.
Notable shares of adults still say they are worried about affording medical costs such as unexpected bills, deductibles, and long-term care services for themselves or a family member. Additionally, about half of adults would be unable to pay an unexpected medical bill of $500 in full without going into debt.
Author(s): Lunna Lopes, Marley Presiado, and Liz Hamel
Seven months into what was predicted to be the biggest upheaval in the 58-year history of the government health insurance program for people with low incomes and disabilities, states have reviewed the eligibility of more than 28 million people and terminated coverage for over 10 million of them. Millions more are expected to lose Medicaid in the coming months.
The unprecedented enrollment drop comes after federal protections ended this spring that had prohibited states from removing people from Medicaid during the three pandemic years. Since March 2020, enrollment in Medicaid and the related Children’s Health Insurance Program had surged by more than 22 million to reach 94 million people.
The process of reviewing all recipients’ eligibility has been anything but smooth for many Medicaid enrollees. Some are losing coverage without understanding why. Some are struggling to prove they’re still eligible. Recipients and patient advocates say Medicaid officials sent mandatory renewal forms to outdated addresses, miscalculated income levels, and offered clumsy translations of the documents. Attempting to process the cases of tens of millions of people at the same time also has exacerbated long-standing weaknesses in the bureaucratic system. Some suspect particular states have used the confusing system to discourage enrollment.
Author(s): Phil Galewitz and Katheryn Houghton and Brett Kelman and Samantha Liss
Thirty-five years ago, geriatrics officially became a specialty of medicine. At that time, there were 76 million baby boomers who would begin turning 65 in 2011, a compelling demographic imperative for this new specialty that specifically focused on older adults.
Geriatrics is a field especially attractive to some physicians because of its differences from other specialties, including elements beyond single medical conditions such as multimorbidity, polypharmacy, function, and cognition. Geriatrics also places a special emphasis on interdisciplinary team care for complex older patients, and the needs of family caregivers.
Despite the surging older population, there are fewer geriatricians now (just over 7,400) than in 2000 (10,270), he noted in a recent piece in JAMA. (In those two decades, the population 65 and older expanded by more than 60%.) Research suggests each geriatrician should care for no more than 700 patients; the current ratio of providers to older patients is 1 to 10,000.
What’s more, medical schools aren’t required to teach students about geriatrics, and fewer than half mandate any geriatrics-specific skills training or clinical experience. And the pipeline of doctors who complete a one-year fellowship required for specialization in geriatrics is narrow. Of 411 geriatric fellowship positions available in 2022-23, 30% went unfilled.
The implications are stark: Geriatricians will be unable to meet soaring demand for their services as the aged U.S. population swells for decades to come. There are just too few of them. “Sadly, our health system and its workforce are wholly unprepared to deal with an imminent surge of multimorbidity, functional impairment, dementia and frailty,” Gurwitz warned in his JAMA piece.
This is far from a new concern. Fifteen years ago, a report from the National Academies of Sciences, Engineering, and Medicine concluded: “Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.” According to the American Geriatrics Society, 30,000 geriatricians will be needed by 2030 to care for frail, medically complex seniors.
More than two dozen attorneys general are urging Food and Drug Administration officials to take urgent action to address disparities in how well pulse oximeters, the fingertip devices used to monitor a person’s oxygen levels, work on people with darker skin.
In a Nov. 1 letter, the AGs noted that it had been a year since the FDA convened a public meeting of experts, who called for clearer labeling and more rigorous testing of the devices, and that no action had been taken.
“We, the undersigned Attorneys General, write to encourage the FDA to act with urgency to address the inaccuracy of pulse oximetry when used on people with darker toned skin,” said the letter, written by California Attorney General Rob Bonta and signed by 24 other attorneys general.
Pulse oximeters’ overestimation of oxygen levels in patients with darker skin has, in a slew of recent research studies, been linked to poorer outcomes for many patients because of delayed diagnosis, delayed hospital admissions, and delayed access to treatment, including for severe Covid-19 infections. Higher amounts of pigments called melanin in darker skin interfere with the ability of light-based sensors in pulse oximeters to detect oxygen levels in blood.
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The delay has frustrated health care workers who use pulse oximeters and have studied them and followed the progress toward creating new devices that work better. “I just get mad that these things are not on the market,” Theodore J. Iwashyna, an ICU physician at Johns Hopkins, told STAT. “Just last week in my ICU, I had a patient whose pulse oximeter was reading 100% at the same time that his arterial blood gas showed that his oxygen levels were dangerously low. I need these things to work, and work in all my patients.”
PEK: Your research reveals a conundrum when comparing a variable annuity with systematic withdrawals from investment accounts (assuming similar investment returns): the annuity will generally outperform. How do we convey this very basic equivalency to our clients?
BG: In my experience, I’ve seen that when some people get to retirement, they may have upwards of a half a million dollars in their accounts. Financial planners owe their clients more than just plans to help them accumulate assets and some well-wishes. Most people do not understand how to generate income from their savings that will last the rest of their lives.
Savings are exposed to market risk that can erode account balances before or in retirement, as we saw in The Great Recession of 2009 and the economic contraction during the coronavirus pandemic. And fifty percent of the population can expect to live beyond the average life expectancy in retirement, exposing them to longevity risk.
The practical reality is that most individuals cannot insulate themselves from risk on their own. Annuitizing a portion of a portfolio’s assets can help mitigate these issues.
PEK: You demonstrate that delaying the start of an annuity by five years may cost 5% in future income, which delaying ten years may cost 15%. Please talk about the time factor and the cost of delay.
BG: The concept is based on something called “mortality credits.” When buying an annuity, you join an annuity pool. Every time someone dies early (before he spent all the money he contributed) the leftover money stays in the pool and is shared by all those still in the pool. The money becomes a mortality ‘credit’ for those who did not die. These mortality credits allow the former to get lifetime income. They start adding value from the day someone enters the pool. Those who purchase the annuity at a later time were not in that pool and do not get that credit. Purchasers only receive mortality credits for those people who died after the purchasers joined the pool. Lower mortality credit means lower lifetime income. Mortality credits have value by adding to income.
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PEK: Likewise, how real is the prospect of outliving one’s assets today?
BG: It’s very real. Data from EBRI indicates that about 40% of Americans face the risk of running out of money in retirement.
Now, not many people continuously spend and then one day look at their account and say, “Oh no! There is no money left!” But well before that day, they will start adjusting their spending downward so as to make sure they don’t outlive their money. And some have to make drastic and painful decisions, like choosing between paying for rent or healthcare; to pay for the electric bill or for medicine. Some retirees will even take half the dosage of their prescribed medicine to conserve it. It may even require that retirees move in with a child rather than live in poverty. In certain family dynamics, living with elderly parents is expected, but it may not be ideal for many.
