Here’s an Idea: Asking Doctors about Health Care Reform

The New York Times just published a very interesting article that ties the efforts of the medical community to bring about change in the American health care system with Congress’s attempts to reform health care through legislation.  The article, which details the research of a team of health care providers in the Intermountain Healthcare system in Utah and Idaho, offers insight into what doctors are doing on their own to effect change while waiting for our nation’s leaders to implement the means to better health care for Americans.

As can be seen by American Medical Association’s recent endorsement of the Democratic House bill, and the long time call of the National Physician’s Alliance for reform, there is a consensus among  health care providers for health care reform.

Of course, essential in that reform is delivery system reform. Part of delivery reform is likely to emphasize not only preventive care, a cornerstone of Obama’s plan, but also a careful monitoring and consideration of the outcomes of health care practices.  Although there is debate about the best way to monitor and measure such practices, and some bridle at the prospect of being “confined” to protocols derived from large studies,  the evidence-based medicine model is emerging  as a favored tool with which to analyze how health care providers themselves can produce more cost-effective, life-preserving results. Evidence-based medicine puts protocols in place (which may be overridden at a doctor’s discretion) and relies heavily on the statistical analyses of a health care system’s performance (i.e., patient outcomes from particular practices).  Such is the model executed by the Intermountain Healthcare system highlighted in the Times article.

The protocols ultimately implemented sometimes differ from the usual course of treatment offered by some doctors. The physicians at Intermountain Healthcare admit that it is often hard for doctors to hear that they are doing something wrong– or perhaps “not optimally” would be a better choice of words.  The Executive Director of Intermountain Healthcare Institute for Healthcare Delivery and Research, Brent James, relates that some doctors do not believe the results of the statistical research because doctors are reluctant to change their ways, but that oftentimes when presented with clear statistical evidence doctors change their practices.  He gives the example of obstetricians who were performing elective inductions prior to 39 weeks for pregnant women for the sake of convenience, as the inductions save hours of labor for the mothers and therefore hours of hospital time.  However, an analysis showed that babies born prior to the 39th week of gestation were far more likely to wind up in intensive care. After doctors saw the data, and protocols were put in place, James found that the rate of elective inductions fell dramatically. A similar protocol developed for the treatment of one form of pneumonia was said to have cut the rate of death for that condition by 40% over several years.

Some doctors contend, however, that the medical metrics of evidence-based models are not the best way to bring change in health care practice, both because doctors will feel pressured to follow set protocols without considering other possible treatments and because humans are not statistical data that can be remedied through calculations and formulas. The danger, of course, is in negating the healing art– in throwing the proverbial baby– independent critical thought– out with the bathwater.  Doctors of this school of thought often espouse  revamped medical education as a better way to reform health care practices; after all, the basis of how health care providers develop their practices is the way in which they were/are taught.

And one wonders if there isn’t room for both approaches. If the education of medical students can be changed to incorporate better and cost effective practices based on studied outcomes (perhaps in part culled from the Health IT initiatives), and changed to incorporate greater emphasis on preventive care (coupled of course with a pay system which rewards patient wellness), while still respecting doctor autonomy so as not to prepare a generation of medical robots. It doesn’t sound “un-doable.”

Interestingly enough, medical schools have seen an increase in students applying to their programs.  In response, four new American medical schools have opened.  With the older generation of health care practitioners on its way to retirement, the need for more doctors is imminent.  But, we need doctors that are able to help carry the new ideals and practices of a reformed health care system; reaching into the med school curriculum would seem to make a lot of sense.

The House Democrats’ Health Care Plan Unveiled, Questions on Women’s Access to Health Care Remain

Last Thursday, October 29^th, House Democrats announced their bill for health care reform, the Affordable Health Care for America Act.  The House bill includes provisions such as a public option and employer mandates.  For women, the House bill has been a controversial issue; though the bill contains provisions that will expand women’s access to certain areas of health care, other areas have been neglected.

On the plus side is the bill’s prohibition of domestic violence being categorized as a pre-existing condition for health insurance purposes.  Ms. Pelosi was able to follow through on her promise to women that such a discriminative practice would be ended through the House bill.  Meanwhile, U.S. News attributes the inclusion of women’s health needs in the bill to the widespread women-led activism for health care reform.  Still, as significant aspects of women’s access to health are yet left unaddressed, some advocates wonder if we should have asked for more.

One issue of contention is that an amendment to the the bill allows for 12 years of exlcusivity for biologic drugs– some of which have been found particularly efficacious in the treatment of breast cancer. In addition to the 12 year exculsivity period, manufacturers will also be able still to engage in the process known as “evergreening,” the practice of changing a drug slightly–such as altering the time release mechanism– and thereby garnering additional periods of exclusivity. These periods of exclusivity prohibit cheaper generic versions of the drug– known as “follow-on biologics” or “biosimilars” from entering the marketplace. (To read more about the biologic exclusivity debate read here and here.) The end result would seem to point– if money matters (and when does it not?),  to a decrease in the availability of breast cancer biosimilars and thus a decrease in available efficacious treatment.  One of the bill’s sponsors, Anna Eschew of California, defends the proposal on the grounds that it does not interfere with women’s access to breast cancer treatment, and that it only curbs the ability of bio-pharmaceutical generic competitors to freely utilize the costly, extensive research and development of the original bio-pharmaceutical innovators.  Eschew believes that lesser periods of exclusivity will have a chilling effect on biologic research and development– as lesser exclusivity would make it more difficult for the original developers of the drugs to recoup the large expenses associated with such development.

Reproductive health care issues have also come to the forefront of the debate, but with a clear consensus yet to have emerged on what the bill does or does not cover within the various exchanges, options and subsidies within the bill.

While political groups are preparing to battle out these issues, one thing remains constant, women are a force that both democrats and republicans want on their side.  The House Democrats were paying attention when drafting their health plan, but the holes still left in women’s health care access might mean that women need to make themselves heard again–and this time, maybe a little louder.

Another Call for Women’s Action on Health Care Reform

Just a little over a month ago, Michelle Obama called upon women to take action to make sure their representatives would vote for health care reform.  This past week, Michelle made another request for women to respond to the national health reform debate during a breast cancer event at the White House.  As the debate seemingly winds towards a conclusion of reform, still, women are unsure that health care reform will actually accomplish that which really needs to be done to help women access better, more comprehensive health care.  While mom’s of America are saying the current health care reform proposals do not include their needs, the National Women’s Law Center exclaims “I am not a preexisting condition.”

The National Women’s Law Center released a second report this month on the affect of gender bias and discrimination in health insurance on women’s lives.  Their report includes an analysis of the discrepancies in health care access between men and women as well as an updated state-by-state comparative chart of states that still allow gender-rating and pre-existing condition discrimination in their health care plans.  Another interesting aspect of the report is the information on states that have, as of late,  reformed their health care systems to be more inclusive of women’s access to health care. One might wonder if the reformation was spurred or enabled in part as a result of the initial report’s publicity.

If you’re wondering about how your state fares in relation to women’s health care issues, be sure to check the most recent NWLC Report as well as Kaiser’s www.statehealthfacts.org.  Also, the Commonwealth Fund has just released a new report comparing the various Congressional health reform bills of 2009.  The report shows that the proposals which seem to pay most (though not enough) attention to women’s health care needs are that of the Senate Health, Labor, and Pensions Committee and the House of Representatives Tri-Committee, which both hope to establish an Office of Women’s Health.  All of these online resources are a great way to get more information and find out where holes in the health reform bills still need to be filled.

To be able to voice direct concerns, the organization Women of Color United for Health Care Reform is hosting a call-in day on Tuesday, October 27^th that will directly connect women to their respective Senators and Representatives.  The calls will be a chance for women to tell their Congress members what they want from health care reform and why allowance of pre-existing conditions denials and gender-rating are not acceptable.  Such calls worked well earlier this month in an event organized by Organizing for America, which enabled callers to tell Congress that they wanted health care reform– with many saying they that really wanted a public option.

Action needs to be taken– and the Obama Administration is asking for exactly that from women.  Though women are most often the health care decision makers in the family unit, men are also needed to voice their concerns:  why their mothers, daughters, wives, and sisters deserve a health care plan that serves their needs.  Call in on Tuesday, the 27^th and let Congress know what’s on your mind.

Opportunities at the Intersection of Health Law and Public Interest (If You Seize Them)

I was given the honor of moderating a panel on Non-Profit Organizations and Health Law at the ASLME Conference at Seton Hall Law last Friday.  After listening to the panelists speak about the benefits and detriments of working in non-profit health law, I was left pondering the potential job opportunities in the field.  The speakers, Keri Logosso of Wynona’s House and Bryn Whittle of the Community Health Law Project, both discussed their journeys toward their respective careers as health lawyers.  One of the women characterized herself as a “non-practicing” attorney, whose original career goal was to become a doctor; the other said she was had never expected to be a trial advocate, but through the eventual twists and turns of her career history found herself representing low-income, disabled New Jersey residents.  Through the narratives of their personal success stories, Ms. Logosso and Ms. Whittle imparted helpful advice for the future health lawyers in the audience.

When did you know you wanted to be a health lawyer? Both of the panelists spoke of the moments in their lives when they realized that combining their passion for serving and healing others with their interest in legal issues was what they wanted from their careers.  Though this was not an epiphany they had early on, both women found that their career choices had come full circle in that each of their prior work experiences led to the eventual goal of practicing health law.  That sort of incremental realization certainly gives hope to those of us who are still unsure as to career paths.

How do I get hired in the field of non-profit health law? Both speakers addressed the characteristics of ideal candidates for jobs in the field of non-profit health law.  While those characteristics included such traditional requirements as past experience in the field, willingness to learn, and strength in knowledge of health law issues– some non-traditional factors also came up:

1.       An aspiring health lawyer needs to have the tenacity that will take him past the initial crush of being turned down from fellowship opportunities or legal work at an advocacy organization. Other opportunities will arise which will ultimately allow one to work towards the goal– but you have to remain open to them.

2.      The recent health law graduate should be willing to take not only that work that ideally interests him but any work that could potentially be of use later on in his career.  Jobs you originally think might not interest you greatly could be career changers as was the case for both of these panelists.

3.      The trained health lawyer must build connections at every step of his career.  Ms. Whittle stressed the importance of getting your name out and building contacts for when you might need references or recommendations.

4.      Finally, the health law student must be tenacious.  The best way to get a job is by making that extra call or writing that additional letter.  Also, the health law graduate should not be afraid to reach out to government leaders.  Ms. Logosso stated that students should call their local elected officials to inquire about available work.  Such techniques helped her once secure the position of Governor Corzine’s Health Policy Advisor.

5.      The health law graduate should not shy away from trying out private law opportunities.  Ms. Logosso said that in such private sector work there are often opportunities to perform high-level pro-bono work and to gain the necessary experiences to develop your strengths as a lawyer.

What’s the competition like? With all that has been happening in the field of health law, it is certainly an opportune time to be looking for a job in the field.  The health law world is experiencing change on a unparalleled level. Such changes will require regulatory, compliance, and litigation advocates in unprecedented numbers as the dust settles on pending reform legislation. Lawyers, at all levels, will help define the fine print. As we posted a few months ago, according to American Lawyer magazine, Health Law jobs are already on the rise.

Having said that, it was also said that competition in the public sector can be stiff– and one needs to prepare oneself fully in order to successfully compete.  The inspiring stories of Ms. Logosso and Ms. Whittle demonstrated, however,  that it is certainly not impossible to get a job as a public interest health lawyer, and that one may work towards the dream job over a period of time– gaining at each turn the skills and experience requisite for that job of all jobs.  It all brought to mind for me that famous quote from Warren Buffet: “I don’t look to jump over 7-foot bars: I look around for 1-foot bars that I can step over.”

Domestic Violence Victims Denied Coverage by Insurance Companies; Meanwhile, Verizon Takes a Stand of its Own

The thought of it might have kept Michelle Obama awake at night, but it’s a real issue that happens more often than is recognized.  Insurance companies can deny coverage to men and women who have been victims of domestic violence. They often do.  Through detailing the story of a 52-year-old attorney who was denied health insurance due to a past incidence of domestic violence, a recent article by Kaiser Health News helps to illustrate the prevalence of such practices among insurance providers.

Last Tuesday, House Speaker Nancy Pelosi addressed the treatment of domestic violence as a pre-existing condition before Congress.  She said that Democrats were no longer going to accept this practice and promised that such would be banned in forthcoming health care reform legislation. Another Democrat engaged in the fight is Senator Patty Murray of Washington, who is a member of the Health, Education, Labor and Pensions (HELP) Committee.  In 2006, Murray attempted the same type of reform by introducing an amendment to ban domestic violence as a pre-existing condition; the amendment did not pass. One of the “no” votes came from Senator Michael Enzi of Wyoming.  He’s still on the HELP Committee and sits there now as its  highest ranking Republican.

Some states have already taken the matter into their own hands, but 8 states and the District of Columbia still do not disallow insurance companies to reject coverage to men and women who have been victimized by domestic violence.  Read more

Public Option Alternatives

The public option has had a difficult time making its way through Senate Finance Committee mark-up sessions.  In the past week, two separate proposals for including a public option in health care reform were nixed.  Rejection of the plans, one proposed by Senator Charles Schumer of New York and the other by Senator John Rockefeller of West Virginia, is said to be indicative of a further adoption of the middle-of-the-road approach.  Still, some are optimistic that because Obama has the de facto final say on health reform legislation, he will work hard to include a public option; others debate whether the President is willing to compromise the public option for overall reform.

Instead of approving of Schumer’s or Rockefeller’s proposals, the Senate Finance Committee voted to include a proposal by Senator Maria Cantwell of Washington.  Cantwell’s amendment is said to be a compromise between Democrats and Republicans on the public option.  The plan, which would be federally-funded, would be available to those individuals who earn too much to qualify for Medicaid but are below 200% of the federal poverty level.  At present, an implementation cost analysis for the plan is still unavailable, but Cantwell says that the plan, which also give states the power to negotiate down the price of insurance, would be able to cover 75% of the uninsured population.  The plan would mirror the current health care system of Washington State.

Though many important Committee members like Sen. Baucus have approved of such an amendment, others like Senator Olympia Snowe of Maine have voted against it.  Keep in mind, Snowe has been labeled “the key to health reform.”  For Snowe, a public option would only be provided in states in which 95% of the population is deemed to not have access to “affordable” insurance through an Insurance Exchange.  Senator Tom Carper of Delaware has proposed a similar plan; however, his version leaves it up to the states to decide what it deems best for its constituents.  Under Carper’s version, states would get to choose between opening up state-funded health care plans for government employees to all residents, or creating a health insurance provider or a co-op to compete with private insurance companies.

The proposals of Carper, Cantwell & Snowe have their respective positives and negatives and are subject to, and seemingly born of, the political process. They smack of compromise.

What will it take to get any one of these proposed bills passed during the full Senate vote? The ongoing divide between liberals and conservatives on the issue of providing a public competitor to private insurance companies has created a fissure which has echoed through the common landscape now for months. But we are getting close– as the NY Times  put it– “tantalizingly close,” to sweeping Health Reform.  Floor debate will ensue shortly. Predictions abound. But in the words of Lamar Alexander, the number 3 Republican in the Senate, “There is nothing predictable about the Senate floor.”

Compromise. President Lyndon B. Johnson, key to passage of both Medicare and the Civil Rights Act famously declared: “I’m a compromiser and a maneuverer. I try to get ’something.’ That’s the way our system works.” As evidenced by the two aformentioned Johnson successes, however, Johnson also knew when to expend enough political capital to make that ’something’ meaningful. I would suggest we stand at the precipice of one of those times.

The Truth About Young Invincibles

Recently released data has indicated that young people don’t care about health care reform.  Or at least not in large numbers. The poll, released by Gallup, says that only 34% between the ages of 18 and 34 want their Congress members to vote for reform legislation.

But this conclusion, drawn by so many, may be somewhat at odds with what the underlying situation might realistically be: that young people actually do care about health care reform itself– but are reluctant to bear the costs for not only themselves–but aging boomers as well–especially as young people have borne disproportionately the effects of the economic crisis.  For those of us who are in between still being dependents on our parents’ insurance and having health coverage of our own through employment, health care coverage is important –and we’re not so stubborn so as to not admit it– but the cost of insurance at the onset of a working life can be a significant barrier.

Why is there a problem of young uninsured people anyway?  19 years of age seems to be the limit for when young people in our country can still get medical coverage under their parents’ policies.  Although many states have altered this equation, many have not. For many private insurance companies as well as Medicaid, young people are cut off from coverage at the age of 19 or when they graduate from high school.  Many insurance companies cover those dependents that go on to college, and many college insurance plans provide some level of coverage. But those who choose to join the workforce  directly following high school graduation are largely left without.  In addition, once a “young and invincible” graduates from college, most are severed from insurance coverage altogether (that is, if they weren’t already).

Again, what might lend itself to misconstrual among all the data on health care legislation support is the difference between young people wanting health reform and being able to afford it– even if we get it.  According to the Commonwealth Fund, the majority of the uninsured young adult population (ages 19-29) are from low-income households.  Also, more than 2.5 million recent college graduates are unemployed.  Important to remember is the fact that recent graduates simultaneously face the difficulty of paying off college loan debt.  Thankfully, President Obama has not forgotten that fact.

Some policymakers think that because young people are so “invincible” we make an ideal group to add into the health care insurance pool: we are healthy, cheap to cover, and take up a small percentage of overall costs on health care.  For them, it makes perfect sense to add a relatively healthy group to the larger pool of Americans requiring insurance so as to drive premiums down overall and/or increase the profitability of insurers.  Ideas like this overlook (or disregard) the resultant fact that young people will then bear the responsibility of subsidizing health care costs of older generations– counterintuitive and somewhat contraindicated  when we look at wage status and unemployment numbers for recent high school and college graduates entering the workforce, don’t you think?

Importantly, besides the issue of unemployment, the types of work young people are usually able to secure affect their chances of getting health coverage too.  Those who are able to obtain jobs usually start off working part-time or lower-wage jobs, ones which typically do not offer benefits such as medical insurance.  Read the story about this young woman who was highlighted in the LA Times; she was unlucky enough to need an operation to remove a cyst while she was still in the introductory period as a new-hire (no insurance until you prove yourself, of course).  The only way she was able to cover the out-of-pocket expense of $12,000 was through her parents’ refinancing of their home.

Implicit in all this is age rating. For many reasons beyond its potential negative effects on both young and old, age rating should be divorced from actual health care reform.  Age rating would allow insurance companies to actively discriminate against its beneficiaries based on age alone.  For young people, such proposed age-rated, young-invincible plans are not even comprehensive; they would only cover medical care in times of emergencies or extreme illness, giving the plans the name of “catastrophic insurance.”  That sounds enticing.  Hard to believe young people wouldn’t be banging down the doors of their elected officials, adamantly demanding “catastrophic insurance,” right?

Better plans would incorporate the real needs of young people: preventive care, prescription benefits, and affordability.  These issues are not just unique to older generations.  If we want to keep the so-called invincibles healthy, we have to give them better options than just care in times of dire need.  Keeping young people on their parents’ insurance until a certain age limit is a good idea, as long as it plays out in practice too.  Anything is better than forcing young people to get coverage they can’t afford.  If you want our support for health care reform, try tailoring some of the reform bills to what we actually need.

Because She Said So: Michelle Obama Wants Women to Stand Up for Health Care Reform

Last Friday, First Lady Michelle Obama addressed the nation’s women, asking them to mobilize in support for health care reform.  Similar to the sentiments expressed in my post last week, Obama presented health care as a woman’s issue– further stating that health care is most important to what she called the “sandwich generation,” those who have the responsibilities to care for the elderly in their family as well as the children.  Obama calls the current health care system “unacceptable,” and one that needs reform to “ensure women have opportunities that they deserve.”  Included in such opportunities for women, as the First Lady said, is the freedom and ability to care for their families.

Further complicating the situation, many women find themselves earning more than is allowed to be eligible for public insurance yet not enough to purchase private insurance.  Women are also less likely than men to secure employer-based insurance, which can be attributed to the fact that women are more likely to work part-time and have lower incomes.  Employment equality issues ring a bell?  Check out this New York Times web tool, which gives a comparative analysis on how different individuals are affected by health care reform.  It is interesting in that it shows that for women, especially those who are unmarried, the current system leaves them largely to fend for themselves in the individual market; it also shows the potential benefits of a public plan option.  As I detailed last week, the individual market in health insurance, not subject to a host of anti-discriminatory legislation and regulation, poses significant problems to women when it comes to supplying affordable and reliable insurance.

One of the biggest issues Michelle Obama seemed to have with the current system was gender rating; it continues to force women to pay much higher premiums than men in private insurance plans.  The actuarial argument, that women’s health care needs require regular preventive care (which in reality, women and men alike should be getting) is significantly undermined by the research which shows the ultimate cost benefits of preventive care–for both women and men. It seems both ironic and counter-productive that this justification is used to punish with higher premiums those who embark upon the proactive health maintenance which so many agree is both the key to ultimate health care cost control and one of the primary goals of health care reform. Hopefully, Obama’s optimism that such gender rating will be removed through the current reform process will prove true.

With so many challenges aligned against women, it is apparent that, as stated by the Congressional Joint Economic Committee, “The status-quo health insurance system is serving women poorly.” Perhaps this is why the Obama administration, in its drive to convince Americans that the issue of health care can no longer be pushed aside, is turning to women.  A smart choice, whichever way you look at it, since women as a whole are one of the groups most strongly supporting health care reform.

So what can women do to get active in the health care reform movement, as Michelle Obama asks of us?  For now, make sure you stay on top of what the language of health reform bills says about health care for women and families.  The National Women’s Law Center is a great organization to get connected to for updates and summaries of the effects of new legislation on women’s access to health.   Through the National Women’s Law Center, you can also contact your Members of Congress to let them know that you support health care reform that addresses women’s needs.  Spread the word to your mothers, daughters, sisters, and friends; tell them Michelle Obama needs our help.

Maternity Care and Health Care Reform

In the last few weeks, health reform has been receiving more public attention than it had before, much of which can be attributed to President Obama’s efforts to unify Congress in passing a bill.  For consumers, the politics of reform have helped to blur the defining components of each reform bill, leaving them unsure of what their health care insurance will or will not cover (let alone how they will pay for it) if reform is passed.  This is a real frightening thought considering that consumers will be the ones directly affected by whatever Congress decides.  In most American family units, the women make the majority of health care decisions for the rest of the family; women also have a lot at stake when it comes to their own health care access.  For these reasons, it is essential for women to understand and know what their legislators are planning for their health.

One of the areas of women’s health care that certainly needs to be reformed is maternity care.  Currently, women in the individual market can be denied health coverage if they seek coverage after becoming pregnant.  And that’s not the only  pregnancy related preexisting condition out there - if you’ve had a C-section before, you could be charged far greater premiums or even denied health coverage altogether.  It may seem that women who are uninsured are the only ones that would have to deal with such scenarios; however, women with insurance from the individual market or employer-based insurance face similar challenges in accessing care.  Read this story about a woman who had coverage through a private insurer and still had to pay $22,000 for having a baby.

Among the different types of private insurance that women have (or can have), there are major discrepancies with regard to maternal health coverage.  You are most likely best-off if you have employer-based insurance; best being a relative term.  Protection from discrimination in employer-based coverage exists through the Pregnancy Discrimination Act of 1978, which made any pregnancy-based discrimination unlawful.  However, the individual market is another story altogether.  The Pregnancy Discrimination Act and a number of other consumer safeguard regulations do not apply to the individual market.  States allow for insurance companies in the individual market to calculate premiums based on categories like gender, age, and pregnancy status.

The issue of access to maternity care for uninsured women, however,  is surely the case of the worst-off.  The obvious translation here is poor prenatal care, which is a vital aspect of not only the mother’s health but the child’s as well.  Considering the fact that our country has one of the highest infant mortality rates among developed nations, the need for reform to address maternity care for the uninsured is a serious one.  While Medicaid is able to assist in covering some of these uninsured women, a large overhaul of the maternity health care services of public programs like Medicaid should be requisite within national health care reform.

Congressional health reform proposals have not yet fully revealed what they will do to ameliorate the maternity health challenges that women face in our country.  However, we do know that certain systems have historically served women’s maternity health care needs better than others.  At this point in the national health care reform stage, women should be particularly concerned with the type of reform that Congress will pass.

Any health reform or insurance plan legislation which fails to provide access to care to ensure healthy pregnancies should be seen as strongly suspect-as this fundamental disregard for the basic needs of women (and children), dire in itself, would surely be a harbinger for a further disregard of women’s rights going forward.

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