Professor Frank Pasquale featured in The Record on ‘A Constitutional Right to Health Care’

Professor Frank Pasquale wrote a featured Op-ed in The Record, New Jersey’s most awarded newspaper, regarding a constitutional right to health care. Professor Pasquale, who is Associate Director of the Center for Health & Pharmaceutical Law & Policy and Editor in Chief of HRW, writes:

SHOULD the Supreme Court weigh in on America’s great health care debate? Yes. It should declare a constitutional right to health care.

This right is already enjoyed by prisoners. Law-abiding citizens deserve it, too.

The United Nations’ Universal Declaration of Human Rights states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including… medical care.”

Many advanced countries have adopted - and lived up to - similar commitments.

Of course, that’s not on the Supreme Court’s agenda. Instead, it will decide whether to cripple last year’s health reform, known as the Affordable Care Act, by declaring the individual mandate unconstitutional.

I understand objections to the mandate. Cash-strapped Americans don’t deserve one more drain on their resources. I’m also not a fan of making people buy health insurance from private insurers. They waste a lot of money, and are one reason why U.S. doctors’ administrative costs are a whopping 400 percent higher than those in Canada.

If I designed the ACA, I’d have given everyone a public option, modeled on Medicare.

But I didn’t write the bill, Congress did. In precedents going all the way back to the 1819 case of McCulloch v. Maryland (and affirmed as recently as 2010), the Supreme Court has deferred to Congress’s constitutional powers to solve national problems.

Politics

The court risks looking political if it abandons that approach now. It has already jettisoned once-venerable holdings on campaign finance, equal protection and antitrust.

Read the full Op-ed here.

What’s Worse than a Kidney Stone? or, “The Part II I had Hoped I Wouldn’t be Writing”

What’s worse than a kidney stone? For those of you who have had one, or read my post the other day describing how it felt–

…broke out in a cold sweat and quickly began writhing around and wailing in pain like a wild animal caught in a bear trap. The pain came in excruciating waves radiating as though I had just been punched below the belt– repeatedly.

that might be difficult to answer. But I’m going to go with two kidney stones– back to back, or more precisely, two kidney stones, and a tiny cyst and a 1.5 cm lesion on and in my kidney, respectively– which is my current diagnosis. An ultrasound  was unable to rule out cancer for the lesion.

And so I wait. A CT scan with contrast is next, probably sometime later this week– after a pre-cert from my insurer, Cigna– which has yet to fail me.

As you might imagine, the last week– what with the back to back kidney stones and all — was less than comfortable. But fortunately, the pain comes in waves and as the week wore on and I became more accustomed to the new and seemingly interminable rhythm, I was able to work in between the waves. And doing so brought me no small measure of joy– no longer reduced to a being defined solely by pain, I produced. I contributed. I was not merely subject to.

And so this blog.

The presence of the cyst caught me unawares. Initially diagnosed as one of two stones waiting in the wings back at the E.R., they were presented to me as nothing I’d have to worry about in the near future. Still in the kidney itself, they might have proved candidates for blasting. The follow-up trip to the urologist disabused me of this notion while apprising me that the one “stone” was a cyst which would have to be further examined so as to rule out density– which is a euphemism for cancer.

And in a moment it all changes. I got the sonogram later that day, and later that night I wrote to this blog’s Editor-in-Chief, somewhat incredulous as to how I signed things for that test– legal documents– in a haze of fear, pain and painkillers. Legally trained, I scribbled my name or initials on everything before me with what barely amounted to a perfunctory glance as I received one sentence explanations from the admittance clerk for one page fine print documents– no doubt painstakingly wrought by the pens of my legal brethren to ensure compliance– and payment. But I assure you, the compliance was a one-sided affair. Because, as our Editor-in-Chief Frank Pasquale has said so many times before, the acquisition of healthcare is fundamentally different than buying other commodities. It is not like buying a car; the economy of healthcare is unconventional– far more akin to “how much would you pay for a glass of water in the desert,” than how much of a rebate is available on that new Kia Soul. A hard bargainer, car dealers hate me. In the legal world, I’ve built a reputation as someone with a cold hard eye for a contract. In the hospital, I signed with an almost wild abandon–wondering who would take care of my children as I did.

And today I got the results. One kidney stone gone, one still making its way, and

“Tiny parapelvic cyst right kidney. This does not appear to correspond to the 1.5 cm visualized right renal lesion on CT scan. Therefore, possibility of a solid lesion not visible ultrasonographically cannot be ruled [out].”

His footsteps loud as he walked down the hall, the melodramatic stringed theme from “The Godfather” played in the room as the doctor entered and explained. Even if it is cancerous, I’m told it’s small. Maybe even too small to do anything but wait to see what it does– and test the rest of me to see if it migrated from someplace else.

But whatever this process may be, I think there might be some value in my writing about it– for both of us. No longer mired in the abstractions of healthcare, I am, it seems, walking straight into the belly of the beast. Consider this a postcard of sorts– with the hope that it can work itself into being a guide.

Recommended Reading: Recent Legal Scholarship on Decision-Making about Health and Healthcare

In Health Choices: Regulatory Design and Processing Modes of Health Decisions, Orly Lobel and On Amir briefly summarize a fascinating series of experiments they have conducted with the support of the Robert Wood Johnson Foundation that test individuals’ ability to make decisions about their health in the face of cognitive depletion or overload.  A longer version will be available in September, but the summary is well worth reading.  Lobel and Amir begin by reviewing a line of research demonstrating, perhaps unsurprisingly, that “psychological depletion caused by a prior task” — in one study it was eating radishes while resisting cookies–leads to a reduced ability to exercise “executive control” and “persist in demanding cognitive activities.”  As the authors note, applying this research to the context of health related decision-making is important because patients and providers alike are frequently asked to process information about relative risk and make reasoned, reasonable decisions under conditions of cognitive depletion or overload.

To test their hypothesis that “absent sufficient resources for executive functions individuals will take more risk in their [health-related] decisions,” Lobel and Amir conducted a lab experiment with approximately 700 participants and a web-based one with over 3000 participants, including 300 medical doctors.   The findings from their studies support the conclusion that depletion affects people’s ability to process risk, albeit not in entirely intuitive or predictable ways.  For example, when parents are cognitively depleted, they become more risk averse regarding vaccinating their children, but when policymakers are cognitively depleted, they become less risk averse regarding population-wide vaccination.  When consumers are in a state of attention and focus, a long list of potential side effects will deter them from using a new drug.  When cognitively overloaded, though, they paid “less attention to warning lists the longer they were.”  The implications of Lobel and Amir’s work are many, varied, and vast; I am looking forward to reading the full paper when it comes out in September.

I also highly recommend Christopher Tarver Robertson’s Biased Advice, which was published in the Emory Law Journal earlier this year.  Robertson conducted a series of experiments that built on the groundbreaking 2005 study by Daylian M. Cain, George Loewenstein & Don A. Moore evaluating the effect of a conflict of interest, and of disclosure of the conflict, on the quality of advice given by advisors regarding the number of coins in a jar and on the accuracy of advisees’ estimation of the number of coins in the jar.  Cain and his colleagues’ most surprising finding was that when a conflict existed, disclosing it caused the accuracy of advisees’ estimates to decline, in part because advisors gave more biased advice when their conflicts were disclosed than when they were not disclosed.

Among other questions, Robertson examined whether a more concrete disclosure about an advisor’s bias–that is, that “prior research has shown that advisors paid in this way tend to give advice that is $7.68 higher on average than the advice of advisors who are paid based on accuracy”–would aid advisees.  It did not, because advisees did not do what “one would hope and expect” and simply subtract $7.68 from the advisor’s estimate.  Rather, it appears that they “used the bias disclosure not as a mechanism of calibrating their reliance more precisely, but rather as a strengthened warning suggesting that the advice is altogether worthless.”

On the other hand, disclosing to advisees that an advisor was paid based on the accuracy of the advisee’s estimate–i.e. that the advisor’s financial interest aligned with that of the advisee–led advisees to rely more heavily on the expert’s advice and, as a result, to more accurately estimate the number of coins in the jar.  Disclosure of a conflict of interest is also likely to be valuable where advisees can seek out another advisor; a second, unconflicted, opinion dramatically increased the accuracy of advisees’ estimates.

Robertson’s research is important and interesting.  As he observes, one of the reasons that it is so difficult to rein in health care costs is that “[t]he health care industry is characterized by radically distributed decision making, with each patient deciding upon her own course of treatment within the range of treatments offered by providers and covered by public and private insurers.”  Improving individual decisions may be key to bending the cost curve.  Robertson’s research suggests that a disclosure mandate could help under certain circumstances, where, for example, there is “epistemic charlatanism” and a physician’s disclosure of a financial conflict of interest would lead a patient to reject the physician’s not-so-expert recommendations.  Robertson emphasizes, however, that disclosure does not improve layperson decision-making nearly as much as unbiased advice does.

Exploitations of Immortality

Rebecca Skloot’s remarkable book The Immortal Life of Henrietta Lacks has quite a following among health lawyers. As an excerpt from the book explains,

Henrietta Lacks was a poor Southern tobacco farmer who worked the same land as her slave ancestors, yet her cells — taken without her knowledge — became one of the most important tools in medicine. The first “immortal” human cells grown in culture, her cells — known as “HeLa cells” — are still alive today, though she has been dead for more than 60 years.

If you could pile all HeLa cells ever grown onto a scale, they’d weigh more than 50 million metric tons — as much as a hundred Empire State Buildings. HeLa cells were vital for developing the polio vaccine; uncovered secrets of cancer, viruses, and the effects of the atom bomb; helped lead to important advances like in vitro fertilization, cloning, and gene mapping; and have been bought and sold by the billions. Yet Henrietta Lacks remains virtually unknown, buried in an unmarked grave.

Skloot tells the story of the Lacks family, which never shared in the prosperity based on the HeLa cells. This is old news for any property student familiar with Moore v. Regents, but it’s particularly poignant in this context.

Now Skloot has worked to share the book’s proceeds with the Lacks family. As a recent news article explains,

Since the book’s debut a year ago, it has earned rave reviews, prizes, a movie deal with HBO and a steady spot on best-seller lists. And Ms. Skloot is making good on her pledge to share the financial windfall with the Lackses. Soon after the book came out, she created the Henrietta Lacks Foundation to help Mrs. Lacks’s descendants, some of whom suffered from the whirlwind of publicity, misinformation and scam artists surrounding HeLa cells, not to mention a lack of insurance to pay for any of the medical advances Mrs. Lacks’s cells made possible. . . .

The foundation — which is still in the process of applying for nonprofit status — is paying for a high-tech hearing aid for Mrs. Lacks’s youngest son, Zakariyya; truck repairs for her middle son, Sonny; new teeth for her granddaughter Kimberly; braces for her great-granddaughter Aiyana Rodgers; and, yes, tuition, books and fees for five of her grandchildren and great-grandchildren.

Whatever one thinks of the proper compensation for research subjects, it is disheartening to consider the economic difficulties of the Lacks family. (How can a society that spends, on average, $1425 per year on care and maintenance of its pets, not provide dental care for all?)

I think part of the answer lies in our constant striving for “innovation,” and the comparative devaluation of dissemination of innovation. My colleague Gaia Bernstein has written about these trends in several contexts. I have also worried about the lack of a US industrial policy for distributing the gains of innovation. I first came to these conclusions in the context of a paper I wrote on “immortal stem lines,” almost a decade ago. As the abstract argued:

[I]nnovations that now look benign might lead to an era of untrammeled biotechnological manipulation of our lives. For example, the same technology used to eliminate disease-causing genes or to clone embryos may eventually be deployed to produce genetically engineered children. That could, in turn, entrench class differences, since only the wealthy could afford the most desirable genetic enhancements. . . . Public debate on regenerative medicine must acknowledge this inequality. Societies and individuals can invest in it in good conscience only if they are seriously committed to extending extant medicine to all.

Without more attention to those at the bottom of the economic heap, the biotech project might recall these haunting lines from John Bunyan’s “The Pilgrim’s Progress:” “Now he had not run far from his own door, but his wife and children perceiving it, began crying after him to return, but the man put his fingers in his ears, and ran on, crying, Life! Life! eternal life.” Gary Shteyngart’s recent novel imagines a world where a company that sells modern-day “immortalization services” only takes on clients who promise to prioritize payments for the company’s “dechronificaiton” over any claims by relatives for help. They don’t even consider the possibility that those seeking endless self-preservation might be tempted to give to charity instead. Michel Houllebecq’s much worse novel, The Possibility of an Island, carries the trope further, imagining a future where the wealthy simply clone themselves into the future rather than worrying about reproducing.

In my article on immortality, I reach conclusions similar to those of Andre Gorz in The Immaterial. Whenever we come across a project that

will enable ‘us’ to free ‘ourselves’ from the contingency of our factuality. . . . to recreate and transcend ‘ourselves’ or even abolish the human condition[,] [t]his re-creation might be said the be the supreme stage of self-production. But it is a grammatical mirage. . .. [There is a] difference between the natural body and the body reprogrammed by science. . . .

In my own words, from my 2002 article:

Artificial-intelligence [based immortality] projects are unconvincing because their products lack bodies, and therefore cannot experience the sense-perceptions that are fundamental to human consciousness. Given the inevitable decay and profound importance of the brain, perpetual rounds of organ replacement seem only to offer their beneficiaries a series of lives, and not really a chance to maintain a coherent one. Neither the inorganic nor the organic forms of immortality offered by these two families of technologies offers indefinite life that is recognizably human or continuous with that of the person who employs them.

Nevertheless, I expect the “immortality project” will continue to attract followers. John Gray’s book “The Immortalization Commission” follows the Soviet elite who wished for a this-worldly resurrection. He sees similar aspirations today:

The hopes that led to Lenin’s corpse being sealed in a Cubist mausoleum have not been surrendered. Cheating aging by a low-calorie diet, uploading one’s mind into a super-computer, migrating into outer space [are all present day aspirations] . . . Longing for everlasting life, humans show that they remain the death-defined animal.

Today it is not a communist elite that is likely to continue the immortality project, but rather those billionaires who believe their lifespans should be as much longer than the average Joe’s as their fortunes eclipse his bank account. There is a slight chance the innovations they fund can “trickle down” to all, but in a world of limited resources, new variations on cryonics may not be the best place for funds to be allocated.

A Trip to the Cardiologist, A Lipitor Future, and “Why Doesn’t My Health Insurer Want Me to Know if I’m Likely To Have a Heart Attack?”

I visited with a cardiologist last week. My inadvertent but no less harmful dalliance with two different kinds of drain cleaner having set off an entire chain of long past due check-ups. A little more than two years shy of fifty, I listened intently as I was told that although I had had a good run, a diet composed of grease, chocolate, quick carbs, coffee and unfiltereds was simply not going to cut it as I ventured into the last half of life (last third is more likely, but also more painful to consider– and I suppose for the doctor, harder to say).

I now look forward to a battery of tests. The first, done today, is designed to detect artery calcification: “Coronary calcium is specific for atherosclerotic plaque and can be detected with high sensitivity and accurately quantified by computed tomography (CT) to help predict future cardiac events related to coronary artery disease.” I had to pay for the test out of pocket as it seems my insurance company deems such screening unworthy of coverage– despite the tests highly vaunted predictive power. Quite a few people in this country die each year from heart disease–hard to understand how it wouldn’t be worth the $318 to know who was vulnerable–and if unchecked, destined for the very expensive Intensive Care Unit.

Tomorrow brings an echocardiogram and my first ever stress test. I readily assented to the tests as it is good, I suppose, to know where one stands. But in addition to testing and making dietary changes, the doctor also wants me to start taking Lipitor. A statin prescribed to lower cholesterol. I did not react well.  The prescription it seems is, in more than one sense, a life sentence.

And I am generally suspicious of the pharma zeitgeist. And terribly so as it concerns myself.

The prescription is not, in this instance, a treatment for an acute condition, it treats the endemic. If one has risk factors, it is prophylactic and is prescribed to reduce the risk of heart attack, stroke and other heart diseases. It is doubtful whether once I start taking this drug I will ever stop. There is no foreseeable time (while alive) that I will wish to stop reducing the risk of heart attack or stroke. And that I suppose is the essence of the onset of age– piling up prescriptions. A daily regimen that will follow one to the grave–only the dosages or the brand names changing as each day welcomes a regimen of pills. In short, this prescription feels like the onset of dependence. The forward guard, if you will. A harbinger of a pharmaceutical future.

Seeing my, shall we say, chagrin, the cardiologist told me that, like over 50% of the cardiologists he knows, he takes a statin. “We’ve seen the data.” Another recently told me  “Yeah, I take it. They should put it in the water.”

And so I will take this drug. But I am not happy. I am loath to think of myself in these terms. Only 12 or so years ago I played starting defensive tackle on a semi-pro football team. Soon I will be discussing my cholesterol numbers and God only knows what other numerical health indicators at cocktail parties.

The essence of good health is simply not having to think about it. It is not an issue. I have to think about it now. And I have a sneaking suspicion, that like when I first became a parent, the terms of my existence have just changed.

UPDATE

Photo credit to incurable_hippie.

Access to HIV/AIDS Medicines

The Campaign for Access to Essential Medicines explains why UNITAID’s efforts to develop a patent pool of HIV/AIDS treatments are so important:

Meanwhile, the US health care finance system appears to be getting into a bit of a standoff with HIV/AIDS drug makers:

Without reliable access to the medications, which cost patients in the AIDS Drug Assistance Program an average of $12,000 a year, people with H.I.V. are more likely to develop full-blown AIDS, transmit the virus and require expensive hospitalizations. Eleven states have closed enrollment in the federal program, most recently Florida, which has the nation’s third-largest population of people with H.I.V.

The need for programs like the Health Impact Fund is more urgent than ever.

Veterans, Health Care and the VA

Consider this a follow-up to my Memorial Day post on Veterans & Health Care. There’s an interesting article over at GoozNews regarding health care for veterans at the VA. Goozner writes:

Journalist Phil Longman at the New American Foundation recently updated his book “Best Care Anywhere,” which documents the 1990s rejuvenation of the Veterans Administration’s health care system. Between editions, the wars in Iraq and Afghanistan placed strains on the VA not seen since Vietnam. Here’s his thoughts on the current state of the system, and the lessons its transformation holds for other delivery systems in the U.S.

How does contact with the VA healthcare system compare in terms of
medical outcomes for its patients? How about in other measures of
quality?

In study after study published in peer‐reviewed journals, the VA beats other health care providers on virtually every measure of quality. These include patient safety, adherence to the protocols of evidence medicine, integration of care, cost‐effectiveness, and patient satisfaction. The VA is also on the leading edge of medical research, due to its close affiliation with the nation’s leading medical schools, where many VA doctors have faculty positions. The VA has its problems, but compared to those found elsewhere in the U.S. health care system, it offers “Best Care Anywhere.”

Read more

Veterans & Health Care

As we come upon Memorial Day, it is fitting that we take a moment to consider health care and veterans. We are, after all, a Nation at war. And we have been at war now for closing in on a decade; the casualties mount. As of May 28, 2010 the Department of Defense official number for American deaths is 5,480. My own research experience with official DoD representations in Seton Hall Law’s world renowned GTMO Reports leaves me somewhat skeptical as to the numbers (I cannot tell, for instance, whether post-service and/or inactive reserve veteran suicides are included in this number, but suspect they are not: “There is no epidemic in suicide in VA,” Dr. Ira Katz, the VA’s head of Mental Health told CBS News in November. “But in this e-mail to his top media adviser, written two months ago, Katz appears to be saying something very different, stating: ‘Our suicide prevention coordinators are identifying about 1,000 suicide attempts per month among veterans we see in our medical facilities’” ). Having said that, as in the GTMO reports, we’ll take the government at its word. Not counting civilian contractors, in addition to 5,480 deaths, 37,865 are said to have been wounded. The ratio of wounds to death is approximately 7 to 1.

Such a high ratio of wounded to deaths is a feature of advancing medical technology. More of the injured are kept alive. A quick look at the ratios of deaths to wounded in other American wars witnesses a trend capped off with a precipitous jump.

War	Deaths	Wounded	Approx. Ratio
Civil War (Union only)	281,881	364,511	1 to .8
Spanish-American	2,446	1,662	1 to .7
WWI	116,516	204,002	1 to 1.8
WWII	405,399	671,846	1 to 1.7
Korea	36,913	103,284	1 to 2.8
Viet Nam	58,177	153,301	1 to 2.6
Iraq & Afghanistan	5,480	37,865	1 to 6.9

In modern warfare, through advances in medical technology, more lives are saved, more of the critically injured are kept alive; but it is also true that many of those lives saved have been affected by wartime trauma in often serious and debilitating ways. Many have lost limbs and sight and hearing, experienced traumatic brain injuries, and suffer from grave psychological harm. They do and will require care. We, as a Nation, committed to that care the moment we sent those men and women into harm’s way.

In his Memorial Day address, Secretary of Veterans Affairs, Edward K. Shineski, offered the following quote:

“Poor is the Nation that has no heroes, but beggared is the Nation that has and forgets them.”

This Memorial Day, as we honor those who gave their all in service of their country, let’s not forget our end of the bargain. The care for the families of the fallen and of disabled veterans is perhaps the most sacred contract of all. Men and women who risk their lives for their country have every right to expect that that country will help take care of them –and their families–to the utmost of its ability in the event that they are in some way hurt, disabled or deceased. We simply cannot ask of them to serve and risk if we are not there to help mend.

On May 5, 2005 President Barack Obama signed into law the Caregivers and Veterans Omnibus Health Services Act.

At signing the President said the following:

With this legislation, we’re expanding mental health counseling and services for our veterans from Afghanistan and Iraq, including our National Guardsmen and Reservists. We’re authorizing the VA to utilize hospitals and clinics outside the VA system to serve more wounded warriors like Ted with traumatic brain injury.

We’re increasing support to veterans in rural areas, with the transportation and housing they need to reach VA hospitals and clinics. We’re expanding and improving health care for our women’s veterans, to meet their unique needs, including maternity care for newborn children. And we’ll launch a pilot program to provide child care for veterans receiving intensive medical care.
We’re eliminating co-pays for veterans who are catastrophically disabled. And we’re expanding support to homeless veterans, because in the United States of America, no one who has served this nation in uniform should ever be living on the streets.

Finally, this legislation marks a major step forward in America’s commitment to families and caregivers who tend to our wounded warriors every day. They’re spouses like Sarah. They’re parents, once again caring for their sons and daughters. Sometimes they’re children helping to take care of their mom or dad.

These caregivers put their own lives on hold, their own careers and dreams aside, to care for a loved one. They do it every day, often around the clock. As Sarah can tell you, it’s hard physically and it’s hard emotionally. It’s certainly hard financially. And these tireless caregivers shouldn’t have to do it alone. As of today, they’ll be getting more of the help that they need.

If you’re like Sarah — and caring for a severely injured veteran from Afghanistan or Iraq — you’ll receive a stipend and other assistance, including lodging when you travel for your loved one’s treatment. If you need training to provide specialized services, you’ll get it. If you need counseling, you’ll receive it. If you don’t have health insurance, it will be provided. And if you need a break, it will be arranged — up to 30 days of respite care each year.

So today is a victory for all the veterans’ organizations who fought for this legislation. It’s a tribute to those who led the fight in Congress, including Senator and World War II vet Danny Akaka, and Senator Richard Burr; and in the House, Representatives Mike Michaud and Bob Filner. And I thank all the members of Congress who are joining us here today.

This law looks like a good step in the right direction. I’ve been highly critical in the past regarding the politics first agenda of a bickering and often, it seems, obstructionist Congress. Such was not the case here. As politics has absolutely no place in this discussion, I commend all involved for a job well done.

But if this legislation fails to make available needed services to veterans and their families, and you have experienced such personally, please consider Health Reform Watch open to you as a forum to make systemic shortcomings known to a wider audience.  I can be reached at michael.ricciardelli@shu.edu and I will work with you to publish your thoughts and experience as an article.

May God bless our troops and the families of those who have served.

An Update on the So-Called Young Invincibles: What Health Care Reform Does for Them

Last year I wrote about why the misconceptions about my generation, dubbed “young invincibles” by many, have perpetuated a belief that young people do not care about health insurance.  Thankfully, the health care reform legislators realized that we too, with our superpowers and all, prefer to be healthy and insured.

The most immediate benefit that dependent young people will see under the Patient Protection and Affordable Care Act is the ability to stay on their parents’ insurance until the age of 26; this will take effect in six months. For recent college graduates, and many who have chosen not to pursue a college education, this brings a sigh of relief. The bill also loosens the requirements for who qualifies as a dependent. Even for those who will be approaching 26 soon after the bill passes, the new age limit will afford some time to get coverage through a job with benefits. Marriage status may not necessarily restrict whether or not a child can stay on their parents insurance, as noted by young uninsured expert Sara Collins. Employed children may also qualify for the dependency status as long as they do not have the option of health insurance through their employer. The new bill also applies to all health plans, whether fully insured or self-funded, which was not the case under most state health care extensions to young people.

For those young people that will be 26 before this September, there are other options. The organization that helped esure representation of young people throughout the health care debate, aptly named Young Invincibles, provides a timeline of the other health reform bill measures that will offer help to the young uninsured. It also shows  when these provisions will take effect.

One of the main benefits to consider is that by 2014, more young people will qualify for Medicaid. This will help insure about 9 million young people. Young Invincibles co-founder Ari Matusiak finds that young people will be some of the greatest beneficiaries of the health care reform bill because the young population is currently the poorest of the age demographic groups and because the bill aims to make health care more affordable for those least able to afford it.

One of the other benefits young people will be afforded comes in the form of  tax credits to purchase insurance from the individual market. These are available to those individuals who earn less than $43,320. While the individual market is not the friendliest place to be, new reform measures will ensure that health care prices will not be based on pre-existing conditions and limits the ratio of premiums based upon age (down to 3:1).  The pre-existing condition restriction certainly helps those young people who have chronic conditions (about 15% of us.) Though the age rating restriction benefits older people more than young people, Ari Matusiak rightfully points out that young people are not going to be young forever and can appreciate the idea that we will have security of being able to get insurance without being discriminated against in the future.

Scare tactics are rearing their ugly head again, as many say that the new benefits offered to young people are just increased burdens. Yes, young people will be required to purchase insurance under the new reform bill or they will be subject to a penalty.  The fine will be $95 in 2014 and will gradually increase each year (until 2016, when it tops out at $695 or 2.5% of an individual’s annual income). Given this minimal penalty at the outset, many assume that young people will opt out of purchasing insurance and just pay the fine instead. These are the same people that think young people don’t care about feeling secure with health insurance.  Well, to put this succinctly, we do care. Some may, out of economic desperation, eschew coverage, but so many of us have relatives and friends who have had catastrophic health issues that have left them in debt (or further in debt), that the choice is not likely to be made lightly. We have had our own health issues.  We need prescription medicines and regular checkups. We are not invincible– and we know it.

A majority of us are supportive of the health reform bill.  As young people, we must educate ourselves about the health reform bill so that we know where we stand. We are an integral piece of the reform legislation working as planned.  And while we won’t be duped to do something that harms us more than helps us, we also won’t be beguiled into believing that the new health care legislation is not for us — it is for us– and we should reap its benefits as part of our political patrimony, knowing that in doing so we also help to provide for our posterity.

Who’s the New Guy? – Obama Announces Choice for Next CMS Director

President Obama has announced his choice for the position of director of the Centers for Medicare & Medicaid Services (CMS), Dr. Donald Berwick, a pediatrician, professor, and advocate of improving patient care.  The CMS has been without a permanent administrator since 2006.  Berwick, whose appointment must be approved by the Senate before he may assume the position, certainly has the credentials for the important role the CMS director will surely play in the coming years.  Still, whether Republican Senators will be basing their confirmation decision on credentials or resentment of health care reform’s passage is yet to be seen.

Berwick is best known for founding the Institute for Health Care Improvement.  The Institute for Health Care Improvement is a non-profit think tank that is dedicated to helping hospitals improve their patient care delivery.  As attested to by the Institute’s co-founder Dr. Paul Batalden, Berwick takes incremental approaches to improving patient care that are cost-effective and do not lead to the rationing of care.  For example, Berwick finds that reducing the prevalence of hospital-acquired infections through something as small as keeping medical equipment sterile can help to bring down the rate of medical errors.

Berwick is also a proponent of utilizing medical information sharing, and is often called blunt in regard to how he finds the American health care system inefficient in delivering patient care.  Additionally, Berwick has advocated for patient rights on numerous levels, using a philosophy of patient-centered medicine.  He wants doctors to be rewarded based on the health care outcomes of their patients instead of how many procedures a doctor has performed. Having a leader interested in implementing infrstructural changes which incentivize outcomes as opposed to procedures as paydays without regard to outcome, is, many think, a step in the right direction. It is also worth noting that Berwick himself will be taking more than a 66% pay cut if he is appointed as the director of the CMS.

While Berwick may not have functioned as the head of a health care system in his career, he is not new to the world of national health policy.  In 1998, he was on President Clinton’s advisory commission that recommended ways to reduce medical mistakes and ensure consumer protection in the American health care system.  And also served at that same time as  Chair of the agency that is now known as the Agency for Healthcare Research and Quality. Berwick has also played a part in improving Britain’s National Health Service, for which he was given an honorary knighthood by Queen Elizabeth II.

Since Obama’s health care overhaul “contemplates key roles for both programs in extending insurance coverage to 32 million people at a cost of $938 billion over 10 years,” if selected to be the CMS’s director, Berwick will certainly need to bring his A-game in helping change the way our current health care system consumes Medicare and Medicaid resources.  Many also hope that good Medicare reforms will start a trend, motivating private insurance companies to also make cost-saving changes.  Before that challenge, Berwick will have to get past a Senate confirmation.  Republican Senators are likely going to make the process a rigorous one, where they will grill Berwick on how exactly he plans to effect the new health care reform legislation.

Given the importance of the CMS and the fact that it currently has no director, it would behoove the Senate to quicken the process of Berwick’s selection, considering his credentials and commitment to the rights and needs of American patients.  As the Washington Post said, “supporters and opponents of the new health-care legislation ought to be able to agree that leaving the agency without a confirmed head is not healthy.”  The job needs to be filled, and instead of using political tactics through rehashing the health care reform debate, the Senate should focus on the many qualities that Berwick has to offer.

Health Reform, Women Helped Make It Happen

As I watched C-SPAN last Sunday afternoon, I found it inspiring that the health care legislation was being voted on in the House during Women’s History Month.  And to see the fight to passage being led by two amazingly powerful women, Speaker of the House Nancy Pelosi, and her right-hand woman Representative Louise Slaughter of New York, the milestone of health care reform became even more monumental for me. The commitment to health care reform by women leaders such as Pelosi and Slaughter led to the reconciliation bill’s passage on Sunday.

Nancy Pelosi, who is now being called “Lyndon Johnson in a skirt,” was vital in rallying needed Democratic votes last Sunday.  Pelosi held individual meetings with many of the swing-voters, reminding them of the importance of the bill.  In addition, many cite her persuasive skills in keeping the Obama Administration from ceding more to Republican demands.  Meanwhile on the floor of Capitol Hill, Louise Slaughter, a Congresswoman whose district serves Rochester, Niagara Falls, and Buffalo, NY, added a personal element of to reform as she called on other representatives to share stories of their constituents’ everyday issues with the current health care system.

Though some were said to be uncomfortable with the executive order which essentially reiterated the Hyde Amendment, there are a number of wins that women can point to, regardless of their stance regarding the executive order.  Women will have cheaper premiums since insurance companies can no longer practice gender rating.  They will have coverage for needed preventive care like mammograms and Pap smears.  In 2014, insurance companies will be required to cover maternity care, newborn care, and certain mental health care.  Also by 2014, health insurance companies will no longer be able to discriminate based on pre-existing conditions such as C-sections and past domestic abuse.  Women who are small business owners also stand to gain from the reform.  By 2014, small firms will be allowed to pool together in exchanges to purchase health insurance.

Though neither side was fully satisfied with the final bill, the fact that uninsured Americans will be guaranteed access to quality, affordable health care warrants an applause for those leaders who worked to make health care for all a reality.

Betting on Health Care Reform

At least investors think health care reform will be happening some time soon.  The Wall Street Journal reported that managed care stocks fell after Obama asked Congress to take an up or down vote Wednesday afternoon.  It might be wishful thinking (or dreadful, depending on which way you look at it) for the investors who are moving their investments from managed care plans.  With Congress members still treating health care reform as a game of cat and mouse, whether a vote will happen and whether the vote will be for reform is yet to be determined.

Take for instance Nathan Deal, a Republican from Georgia, who is purposely postponing his resignation from the House until a vote on health care happens so that he can get his nay vote in.  Then, there is the promise from Senate Republican leader Mitch McConnell to repeal health care reform before it has even been passed.  And despite Wall St. estimations to the contrary,  with the complications of reconciliation, the prospect of getting a bill that actually creates a mass exodus out of managed care seems at least somewhat iffy.

Interestingly, as the Washington Post revealed on Wednesday, private insurance companies, such as the infamous WellPoint, will be the primary beneficiaries of a failed health care reform attempt.  As Ezra Klien stated:

The argument is simple: Wellpoint’s business model is uncommonly concentrated in the individual and small-group markets. Those are the exact markets that health-care reform will drastically change. Those are the markets where people get rejected for preexisting conditions, where insurers spend 30 cents of every premium dollar on administration and where rate hikes are volatile and constant. Health-care reform wants to change all of that, and if it does, Wellpoint’s business model will be changed, too.

It would seem, then, that health care reform would not be difficult to carry through in considering who stands to win and who stands to lose if reform is not passed.  One of the major barriers is the Republicans’ animosity towards using reconciliation to pass a final health care bill, an idea they consider foreign to the democratic process.  However, as NPR just reported this past week, reconciliation is not “unprecedented,” and in fact, it has been used many times in the course of our country’s history to pass similar bills.  COBRA, Children’s Health Insurance Program (CHIP), and changes to Medicare have all happened through reconciliation.  Moreover, between 1981 and 2008, 16 out of 21 reconciliation bills were Republican initiatives.

Without a final vote on health care soon, many worry that the momentum will be lost.  Many members of Congress, steadfast in their platform promises, are not helping the process move any quicker.  In the meantime, insurance companies continue to prosper; Americans continue to pay the price.

While Medicaid Enrollment Rates Increase, States Face Financial Pressure to Decrease State Medicaid Spending

Last week, the Kaiser Family Foundation released a report indicating a large jump in state Medicaid enrollment from June 2008 to June 2009.  The report said that the 7.5 percent increase was the greatest one-year jump in enrollment rates ever, with over 3 million people joining the public health program funded jointly by the federal government and individual state governments.  The reason for the increase  is thought to be that because more people became unemployed due to the economic crash, more individuals turned to Medicaid for health coverage.  However, because the economic downturn meant less revenue entering into state budgets, state Medicaid programs have not been able to keep up with the rise in new enrollees.

During a convening of state governors at the White House this week, state officials will likely raise the issue of Medicaid spending. The issue is pressing in light of the impending funding cut when stimulus money from the American Recovery and Reinvestment Act of 2009 will expire in December of this year.  The governors will likely ask that the stimulus funding be continued until states can somehow make up for their large current budget deficits.  In addition to asking for more money, the governors will also likely discuss the feasibility of health care reform efforts.  With both House and Senate versions of health care reform proposing increases to state Medicaid programs to ensure the coverage of more uninsured individuals, the state governors would, understandably, like to know where the money for such expansion would come from.

The National Association of State Medicaid Directors estimates that states’ budgets will fall  short  $140 billion in the next fiscal year.  This means even less money for the likely further increase in Medicaid enrollment to come this year, as Medicaid enrollment generally lags behind unemployment.  To account for the deficit, many states are planning to reduce their Medicaid programs. USA Today finds that three categories of such reductions exist:

• California, Arizona and Virginia propose reducing who’s eligible. In Arizona, 310,000 people would lose coverage. California also wants to increase premiums.
• Michigan, Tennessee, Massachusetts and others propose eliminating benefits. Masachusetts’ elimination of restorative dental services would save $56 million, says Medicaid director Terry Dougherty.
• Texas, Pennsylvania, Louisiana and others propose cutting payments to hospitals, doctors or nursing homes. Several states are considering new taxes on hospitals as a way to avoid cutting these payments.

States that accepted stimulus money to expand their Medicaid programs in 2009 are restricted from any such cuts that would affect low-income enrollment.  However, if the stimulus funding is not extended, some states are planning on heightening eligibility requirements.  For other states, while decreasing hospital and doctor reimbursement seems like the worst possible option– given that many doctors have already stopped accepting  Medicaid patients due to what they deem to be an insufficient rate of reimbursement– many states’ officials find that the only other viable option they have is raising taxes.  Many state leaders refuse to increase taxes in fear of the political backlash come November.

Realizing the need for health care reform to help manage the burden of paying for health care, state governors have stated a desire to be part of the health care reform conversation.  Many have already expressed their dislike for individual mandates, which they believe will drive more individuals to state Medicaid programs.  For the most part, however, the governors want reform and they want it now, finding that they simply can’t afford to wait another year.

It is also worth noting that an underlying issue from these new numbers is whether the Medicaid program is actually a good prototype for expanding health care coverage.  Drew Altman, President and CEO of Kaiser, put in perspective Kaiser’s report as well as the concerns of public spending that were sparked by the Centers for Medicare and Medicaid Services’ projections for 2009-2019– which forecast that public spending on health care will surpass private spending.  He noted that while spending in public health insurance programs would increase, the cost-benefit would be better, since per capita costs on health care were lower in government-run programs than in private insurance programs.  According to Altman, such numbers did not undermine health reform efforts, but instead denoted “the need to control health care costs in the public and the private sectors alike.”

Obama’s Plan for a Health Care Summit and the Unenthusiastic Response

Last week, President Obama announced plans to hold a bipartisan health care summit to push forward on health care reform and to give both sides an opportunity to discuss ideas for health reform legislation that will be able to garner enough votes for passage.  While President Obama and Democratic Congressional leaders want to use the health care proposals that have already passed in the House and in the Senate, Republicans say that they are unlikely to vote for a bill unless the current proposals are scrapped and the process is started afresh.  It seems like Americans, once again, may be left watching the theatrics of the health care reform debate without actually being the focal point of it.

Some conservative Congress members have already responded to the President’s invitation publicly to make their steadfast positions known.  Representative Eric Cantor (R-Va.) said this past week that he was not willing to discuss a “health reform package that spends money we don’t have.”  He added that “House Republicans have offered the only plan that will lower health care costs.”  If that is true, it is likely attributable to the fact that the House Republican bill would cover only 3 million uninsured Americans, compared to the Democratic House bill which would  insure an additional 36 million Americans.

On Monday night, House Minority Leader John A. Boehner (R-Oh.) joined Cantor in submitting a letter to White House Chief of Staff, Rahm Emanuel, which said that the Republicans were not willing to come to the table unless certain prerequisite questions were answered.  You can see the whole letter here.  In the letter, Cantor and Boehner express their non-support for reform that the American people themselves are not supporting; the basis for such being the recent Republican Senate win in Massachusetts.

Exactly what are the citizens of American thinking about health care reform anyway?  CNN reported on Tuesday that nearly two-thirds of Americans want Congress to persist in passing health care reform legislation.  The poll, an ABC News/Washington Post survey, also indicates that Americans blame both Democrats and Republicans on their unwillingness to compromise.  HHS Secretary Kathleen Sebelius herself is quoted as saying, “When people look up close at the personal activities of Congress they are confused and disgusted with the whole process and too afraid that whatever is going on can’t possibly be good for them or their families.”

Many believe that the idea for the health care summit was to address the back-door processes that led to American distrust and to make it all more transparent.  Still, there appear to be more differences between the conservative version of reform and the liberal version than points of reconciliation.  Though the prolonged tug-of-war between both sides does not seem like one that might be resolved in a day of convening, the summit is, perhaps, at least a start.

And, while the political contenders decide what to do about the summit, the health reform stalemate has presently-occurring repercussions. Many hospitals, which were holding on to the hope of reform, are now at the point where downsizing their health systems is thought to be the only step left.  Hospitals all around the country have been seeing more and more uninsured patients, and with no one to cover the full cost of services, the hospitals providing unreimbursed care are said to be further sinking into debt– and must therefore cut staff as well as services.  On the individual level, Americans are also finding it difficult to  keep up with the costs of health care, and while many forgo insurance, those that cannot due to chronic illness or necessity of care are finding the cost further prohibitive.

It would make sense, then, that Americans do want reform.  Andrew Rubin, Vice President for Medical Center Clinical Affairs for NYU Langone Medical Center and radio show host for HealthCare Connect, says that one of the underlying reasons why Americans are reluctant to give support for legislation is their lack of understanding of what is happening, not because they do not want to see change.  Let’s hope that the proposed health care summit will be used to clarify issues for Americans who do need and want health care, instead of for just another political brouhaha.

Medical Experts Say Haitians Will Need Health Care Help for Years to Come

The BBC recently reported that medical organizations with members serving the Haitian communities affected by the earthquake on January 12^th warn that one of the larger issues for Haitians will likely be the need for increased medical supplies, such as prosthetic devices and rehabilitation services.

Concerned about infection, doctors in Haiti have had to amputate the limbs of a great many injured patients.  In addition to the need for such resources as medical devices and prosthetic equipment, doctors are also still in need of simple medications.  Antibiotics are needed to prevent the spread of infections and painkillers to help damaged patients simply make it through the day.

Because many of the country’s hospitals were also destroyed by the earthquake, doctors in Haiti are performing most care in makeshift open areas.  And in such environments, infection spreads fast.  Though the few hospitals that are running are reported to be in relatively well-organized condition, many of the patients in those hospitals are not leaving as they have nowhere else to go, except perhaps the streets– where infections await their open wounds. So they stay,  Doctors are left with fewer and fewer areas to treat, and the number of patients increases. To remedy the situation, there are plans at present to quickly build a convalescent center.

The present medical needs are only the beginning.  The concerns of some medical experts extend to the years after the media eye has turned away from Haiti, after the NGOs have left the country, and after foreign doctors have returned to their home-countries.  These experts worry about how the Haitians that are being treated today will be able to continue with one less leg or one less arm in the future.  Without proper rehabilitation services or necessary follow-up medical care, many Haitians will lack the physical capabilities to rebuild their lives.  Mark Hyman, a doctor and volunteer with Partners In Health, calls these future medical needs of the injured Haitian community the “third wave,” and he finds that such aid is not yet realized:

Soon, very soon, there is the need for rehabilitation, helping the thousands with lost or broken limbs get back on their feet or foot again. There are no physical therapists, no facilities, and no place for them to go for care. As the immediate surgical needs are slowly addressed, the psychological needs explode magnified by each minor aftershock.

Some medical device companies have already donated supplies to aid the doctors’ efforts as well as money to support the other necessary aid efforts in Haiti.  While such donations are helping address an urgent need, they are being outpaced by the number of amputations being performed.  Hope lies in the idea that health care systems will be put in place before the external help exits; that prosthetic devices will ultimately be made available to the patients that need them; and that Haitian medical workers are trained to be able to properly care for those who cannot care for themselves.

The needs of the Haitian people are great, and the impact of this disaster will be felt for years to come.  Please give to help those who are working hard towards rebuilding Haiti.  Click here to find a list of the different organizations through which you can donate. And if you happen to be a part of a prosthetic device company which wants to do something amazing, we’d love to write the story.

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