Health Policy

This week the Supreme Court is devoting an impressive six hours of argument, over three days, to the Affordable Care Act. Four different federal Courts of Appeal had reached decisions about various provisions of the Act; the Court asked to hear arguments about four specific issues:

1. Does the Anti-Injunction Act keep the Court from deciding the constitutionality of the individual mandate until the various penalties imposed by various parts the Act are actually imposed (probably in 2014)?
2. Is the “individual mandate” within the powers the Constitution confers on the Congress?
3. Does the Act’s required expansions of State Medicaid programs violate the Constitution? and
4. If some provisions of the Act are unconstitutional, are those provisions “severable,” allowing the rest of the Act to go into effect, or “inseverable,” forcing the whole legislation to fall?

I will be commenting briefly on the arguments each day. I should note, though, that oral argument is a very uncertain guide to the how the Court, or even its members, will vote. Some justices never say anything at oral argument (Justice Thomas last asked a question more than six years ago), some like to play devil’s advocate, and (more fundamentally) Justices views can evolve as the arguments proceed and as the draft opinions are written, and re-written, and re-written. So, take all predictions of the Court’s ultimate conclusions that are based on oral argument with a teaspoon of salt. (Take all predictions based on other ground with at least as much salt.)

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I’m a big fan of a piece of pending California legislation, AB 2109, that is designed to increase vaccination rates among children enrolling in school and daycare. Right now, instead of showing vaccination records upon enrollment, parents who have chosen not to vaccinate are permitted to sign an exemption form stating they have made their choice because of their personal beliefs. A post on About.com’s Pediatrics blog explains how the new law, if passed, will change that:

Instead of simply signing a personal belief vaccine exemption form on their own, parents will be required to have a written statement signed by a health practitioner that says the parent was given information about the benefits and risks of immunizations and the risks of certain vaccine-preventable diseases.

… “With the increase in outbreaks of common vaccine preventable diseases in California and nationally, now more than ever, parents need to get the right information about vaccines before exempting their children from immunization,” said Jeff Goad, Pharm D., President of the California Immunization Coalition. “This legislation simply mandates that parents receive accurate information about the risks and benefits of vaccines and the diseases they prevent before making decisions about not vaccinating their children.”

I feel strongly about this legislation in part because I write about the kids that this law is designed to protect: infants who are too young to receive vaccinations and children whose medical conditions make vaccination unsafe. Kids whose lives have been saved by organ transplantation, for instance, can’t be vaccinated because of the immune-suppressing drugs they must take to keep their transplants healthy. These children rely on the “herd immunity” conferred by high vaccination rates to protect them from potentially deadly infectious diseases such as measles and whooping cough. The new law would ensure that parents will learn about their role in building “herd immunity” – the importance of vaccinating to protect not just their own kids but also others – before they choose to forgo vaccines.

That leads to the second reason I feel strongly about this legislation: I’m a mom. Interviewing families whose children are dangerously ill has given me a real appreciation for how fortunate I am to have a healthy child. I think it’s part of my civic duty to make sure my toddler won’t spread germs that endanger the lives of the most fragile members of our community.

If you live in California, here’s a source for information about how to support the pending law.

Previously: “Herd immunity” causes dramatic drop in infant chicken pox, Washington state starts school year with tougher requirements for vaccine exemptions, How to save $83 billion? Vaccinate and Unvaccinated children may pose a public health risk
Photo by Jill A. Brown

How healthy is your state’s health insurance coverage?

The Atlantic depicts current levels of uninsured people by state, less than a week before the U.S. Supreme Court will hear oral arguments over the constitutionality of the individual mandate of the Affordable Care Act.

The under-, sort-of- and well-insured states are identified by different shades of green. Take a look at the Gallup poll map here.

Previously: Helping the uninsured sign up for health insurance, Report shows millions of jobless Americans forgoing needed health care, prescription drugs, U.S. Appeals Court rules against health-care law, Being healthy out of financial reach for some families

Since publishing the seminal text Who Shall Live? Health, Economics, and Social Choice in 1974, Stanford’s Victor Fuchs, PhD, often has been cited on the economics of health care policy. Now, in a perspective piece published today in The New England Journal of Medicine, Fuchs provides a historical view of health care trends in the United States.

In the piece, the author explains the almost continuous increase in expenditures in the last six decades and comments on the challenges undermining cost-control efforts. And he provides a staggering figure that situates the health care problem as a major, long-term economic one:

In 1950, health expenditures accounted for only 4.6% of the gross domestic product (GDP). In 2009, they accounted for more than 17%, a larger share than all manufacturing, or wholesale and retail trade, or finance and insurance, or the combination of agriculture, mining, and construction.

Fuchs doesn’t expect that number to come down anytime soon:

It is difficult to see how the health sector can continue to expand rapidly at the expense of the rest of the economy, but every past prediction of a sustained slowing of the growth of health expenditures has been proved wrong. Rapid growth may continue as a result of political gridlock regarding the form that curbs on expenditures should take. There is no public consensus about how much care should be provided for the poor and sick or how it should be done. Similarly, there’s no public consensus regarding efforts to increase the efficiency of care.

Previously: Views on costs and reform from the “dean of American health care economists”, Health economist Victor Fuchs looks at Who Shall Live, Why is cost-effective care so difficult to achieve? and Victor Fuchs talks health-care costs and reform in Q&A

I always love hearing what Stanford health economist Victor Fuchs, PhD, has to say about health care (I’ve been lucky enough to interview him numerous times over the years), so I happily dove into a New York Times piece on Fuchs that came across my desk just a few moments ago. In the Q&A, Fuchs tells writer Gina Kolata why we pay so much for health care, what we can do to improve our health-care system and how major changes likely won’t occur until something major outside of health care happens (which is something he also emphasized to me for an article I penned on reform several years back). And I especially appreciated his first quote, which is very Fuchs-like:

“If we solve our health care spending, practically all of our fiscal problems go away,” said Fuchs… And if we don’t? “Then almost anything else we do will not solve our fiscal problems.”

Previously: Health economist Victor Fuchs looks at Who Shall Live, Victor Fuchs talks health-care costs and reform in Q&A and Health economists give Obama their two cents on reform

A Kaiser Health News Q&A published yesterday takes a closer look at the much-discussed rule in the Affordable Care Act requiring insurance companies to provide contraceptives without a co-pay. The Q&A discusses who will be covered under the rule and whether the rule applies to male-based contraceptive methods or surgical procedures.

Regarding whether insurers are required to cover all products in a class, such as all intrauterine devices and all birth control pills, and whether insurers can require a co-pay for brand name drugs, writer Julie Appleby had this to say:

Many insurers have “tiered” pharmacy benefits under which patients pay differing amounts for brand-name, as opposed to generic, products. Some require patients who choose a brand-name drug, when an equivalent generic is available, to pay the price difference between the two. Insurers say HHS guidance allows them to use such “reasonable medical management” to help control costs. That would include allowing insurers to charge patients for brand name drugs, it says.

The HHS official confirmed that, but stressed the plan must “accommodate any individuals for whom it would be medically inappropriate by having a mechanism for waiving the otherwise applicable cost-sharing for the branded version.”

Advocacy groups and insurers are in discussions with HHS over those and other questions related to preventive care, says [Judith Lichtman, senior advisor to the National Partnership for Women and Families]. Her group hopes the agency will soon release additional guidelines that “are broad enough so that all methods prescribed by doctors necessary for women’s health will be covered.”

Previously: Government advisors call for free contraception for women, Another birth control revolution? New health law could provide free contraceptives to women and Women’s health groups launch campaign for no-cost prescription birth control
Photo by Raychel Mendez

The World Heath Organization today issued revised recommendations for women who are at high risk for HIV/AIDS and who are using injectable hormonal contraceptives. The new recommendations come on the heels of a study published last October in The Lancet Infectious Diseases, which found that women using these contraceptives, which are particularly popular in eastern and southern Africa, were at twice the risk of contracting HIV, although the absolute rate of infection was relatively low. HIV-positive women using the contraceptives also were found to be more likely to infect their partners.

The widely publicized study generated considerable concern, as millions of women are using these progesterone-only contraceptives in Africa, where HIV rates are among the highest in the world. The results prompted the WHO in January to convene a group of 75 experts from around the world to review the issue. The group found that the evidence wasn’t conclusive – as some studies didn’t find the same association and many of the studies were limited in their design.

The panel concluded that there should continue to be no restrictions on use of these contraceptives but it added a clarification to these recommendations, strongly advising HIV-positive women or those at risk of HIV to use condoms and other forms of protection.

Paul Blumenthal, MD, a professor of obstetrics and gynecology at Stanford who served on the panel, said the group sought to re-emphasize the importance of dual protection to minimize the risk of HIV transmission. He told me today:

It is also important to note that decreases in use of hormonal contraceptives, perhaps as a result of concern about HIV risk, may result in increased rates of unintended pregnancy, which, especially in areas where HIV risk is high, also carries increased risks associated with unsafe abortion and high maternal mortality. Thus, the revised recommendations represent an important balancing of the complex relationships between contraception, HIV risks and pregnancy-related risks.

A study in today’s new issue of Archives of Pediatrics & Adolescent Medicine takes a close look at food for sale in more than 3,800 public and private elementary schools across the U.S. between 2006 and 2010. The findings are discouraging: During a period when school menus have generated lots of attention as contributors to childhood obesity, kids’ access to sugary foods at school remained high, while healthy options remained less available.

Not surprisingly, the authors suggest that schools should take a hard look at the foods kids can buy on campus and provide more healthy options while removing unhealthy choices.

But an accompanying editorial by Packard Children’s Hospital’s Thomas Robinson, MD, a nationally-recognized childhood obesity researcher asks: “How do we know that those changes would make a dent in childhood obesity rates?”

Unless we conduct studies that compare different health policies head-to-head in rigorously designed experiments, we can’t be sure what actually works, Robinson writes. He proposes implementing randomized controlled trials that make use of existing state and national health-surveillance programs (21 states already have laws that mandate measuring children’s body mass index in school, for instance) and that assign schools to different proposed health-policy changes so that the policies’ effects can be evaluated.

If this idea sounds daunting, Robinson has prepared an answer for potential critics:

Too difficult? Too expensive? Not when compared with the unrecoverable costs of getting policies wrong. [...] Federal, state and local governments and nongovernmental organizations are already spending many hundreds of millions of dollars per year to implement policy interventions that may or may not have any impact on childhood obesity. If evaluated at all, it is usually with nonexperimental designs. It would be a terrible lost opportunity if we learned several decades from now that most of these dollars produced no health benefits.

The entire editorial is definitely worth a read.

From redesigning food labels to eliminating urban “food deserts,” researchers and policy-makers have proposed a number of solutions aimed at encouraging Americans to eat healthier. But recent data from the Share Our Strength’s Cooking Matters program suggests that difficulties in understanding nutrition facts and lack of access to good food may not be solely to blame for America’s poor eating habits.

As the Atlantic’s Jane Black explains today, the report (.pdf) hints that the greater obstacles to healthy meals may be planning skills, time and the price of food:

• Although families are largely satisfied with the variety (61 percent) and quality (64 percent) of healthy grocery items available to them, only 30 percent are satisfied with price
• Time is a barrier for some, especially families where the food decision maker works full time. This demographic has a significantly lower average number of healthy or made-from-scratch dinners in a typical week
• Low-income families that regularly plan meals, write grocery lists and budget for food make healthy meals from scratch more often (5+ times a week) than those who don’t. Unfortunately, 55 percent of families don’t regularly plan meals before going to the store, and 34% don’t regularly use a written grocery list

In her piece, Black goes on to weigh in on the findings:

The data reflects what my husband, Brent Cunningham, and I saw while reporting for six months in Huntington, West Virginia. Among the families we followed, the very poorest was the one most likely to cook healthy meals at home. But it required intense planning and basic cooking skills. The families least likely to eat well were the ones who, frankly, didn’t have to. They had enough money to swing by Burger King for dinner on the way home instead of cooking family meals and eating leftovers… They shopped impulsively, instead of methodically, at the grocery store, which meant their carts were filled with frozen pizzas, chips, and snacks.

Previously: When it comes to nutritional value, debating “organic” vs. “conventionally grown” may be beyond the point, Living near fast food restaurants influences California teens’ eating habits, CDC calls for improving kids’ access to healthy food and Mapping out our country’s “food deserts”
Photo by jessica mullen

In a Canadian Medical Association Journal editorial published today, a Canadian physician argues that the gender of a baby shouldn’t be revealed to the parents-to-be until after the 30-week mark. (This information is usually made available ten or more weeks earlier.) I was shocked by the reason that he says such action is needed, and you may be, too. Booster Shots has the story.

We’ve written in the past about the country’s growing problem with oxycodone abuse; Kentucky, Florida and West Virginia are three states that have been particularly hard-hit. Now comes a concerning report on the dramatic increase in painkiller use in our third-most populous state. From a New York Attorney General report (.pdf):

In New York, the number of prescriptions for all narcotic painkillers has increased from 16.6 million in 2007 to nearly 22.5 million in 2010 – prescriptions for hydrocodone have increased 16.7 percent, while those for oxycodone have increased an astonishing 82 percent. In New York City, the rate of prescription pain medication misuse among those age 12 or older increased by 40 percent from 2002 to 2009, with nearly 900,000 oxycodone prescriptions and more than 825,000 hydrocodone prescriptions filled in 2009.

The report goes on to outline the problems attached to these numbers – overdoses, addiction-related violence, increased government spending – and advocates for the establishment of  a controlled substance reporting system. The ultimate goal would be to ensure these drugs are given to people “who truly need them.”

Previously: Governors to Congress: Help us fight prescription-drug abuse, Florida’s prescription-drug problem, The Florida Governor’s questionable actions on drugs and How to combat prescription-drug abuse
Via Daily Intel

Smith as Dean Philip Pizzo

Anna Deavere Smith’s one-woman theatrical performances are so brilliantly drawn, so carefully textured that watching her onstage is always a rich and rewarding experience. Her artistry has been saluted all over the country since the ‘90s, when she captured American theater critics and audiences with two noted theatrical events: Twilight Los Angeles, about the LA riots following the trial of Rodney King, and Fires in the Mirror, about the Crown Heights civil disturbances.

Now another solo performance by Smith, Let Me Down Easy, has become a national theatrical sensation. The play premiered at New York’s Second Stage in the fall of 2009 (“Woman of 1,000 Faces Considers the Body” was headline of the New York Times review) and a national tour followed. PBS recorded it at Washington’s Arena Stage, and Let Me Down Easy will debut on PBS’s Great Performances next Friday, Jan. 13 at 9 p.m.

From the PBS press release:

Conceived, written and performed by Smith in her signature one person performance style, the play examines the miracle of human resilience through the lens of our current national debate on health care. Smith interviewed more than 300 people during her research and traveled to three continents.

Smith, a former Stanford professor, performed Let Me Down Easy in workshop at Stanford in 2006 as she was fine-tuning the piece. She also talked with a range of the medical school’s faculty about medicine, patient care and biomedical research. Philip Pizzo, MD, dean of the school, is one of the characters Smith performs in the play. She found his warning that we are in danger of slipping into a health-care system that “resembles that of a developing nation… unless it’s changed dramatically,” an apt description for the current tumult in U.S. health care.

I did a podcast about Let Me Down Easy with Smith in 2009, and I’ve seen Let Me Down Easy countless times. Each time it stirs me. A different character becomes richer, words are deeper and more meaningful or actions more affecting. You watch as a careful portrait is being drawn on stage. You realize a meticulous artist is at work. Each character is pulling a thread weaving a larger vision. You feel the human clock ticking. As the lives of the characters unfold, you consider too your own – the sorrows and joys of the human experience. Treasure the moment and live with grace. Is that the lesson here? Then a final word. A Buddist monk appears and is bathed in light. He lifts a tea cup and gently pours the water into his open hand. Finished!

Previously: How a med school dean became part of Anna Deavere Smith’s hit play, Playwright takes healthcare to the stage and Let me down easy
Photo by Joseph Sinnott / WNET

There is a thought-provoking essay by Donald Barr, MD, PhD, associate professor of pediatrics, in the Boston Review today discussing how rapidly rising health-care costs combined with expanding unemployment rates have left millions of families in the United States exposed to potential economic crisis in the event of an illness or injury.

The piece includes a number of alarming statistics on the inequities in the cost of health care and health insurance in America but, as Barr explains, this data only tells part of the story. He writes:

Economic inequality brings with it inequality in health outcomes, independently of access to health care. A 25-year-old American with income more than four times the poverty level will live, on average, five years longer than a 25 year old with income less than twice the poverty line.⁵ Those with a college education are three times as likely to report excellent or very good health status as those who did not finish high school.⁶ Those with less than a high school degree are twice as likely to experience coronary heart disease as those of the same age who have graduated from college.⁷ Money and education secure not just more life but a healthier one as well.

Barr is one of several Stanford faculty members, students and community leaders who are facilitating discussions on a range of topics, including disparities in education and health care, population growth and environmental sustainability, at tomorrow’s Occupy the Future event.

Also among the group is Mark Cullen, MD, professor of general medical disciplines, who is leading a teach-in session on health equity and inequity. Cullen said his talk will examine how “the underlying social and economic disparities are the root cause of health disparities. [How] these are compounded by high disparate access and quality of care, [which] are now made even worse by the increased shifting of the costs of care to those who can afford it least – working Americans.”

Previously: Occupy the Future awareness event to take place at Stanford tomorrow and Study shows increase in health disparities among young Americans

A series of teach-in style sessions inspired by the Occupy protests are being held on the Stanford campus tomorrow in an effort to increase awareness about social inequality, the erosion of American democracy and the link between unrestrained growth and the current environmental crisis.

The half-day forum was developed by a coalition of Stanford faculty, students and staff who united under the name Occupy the Future. During the event, faculty, students and community leaders will facilitate discussions on a range of topics including disparities in education and health care, population growth and environmental sustainability. Organizers’ outlined three main reasons for creating the forum in a statement (.pdf). The first is:

… the deep and growing division between the have and have-nots. Across multiple areas of life–health, education, income, housing–we see the greatest inequalities the U.S. has known since at least the Great Depression. “We are the 99 percent” is not a mere rhetorical device. It’s consistent with data showing that over the past decade only the top one percent of wage earners have seen their incomes rise. The next two to five percent has experienced flat wages, and everyone else has experienced a drop in earnings. The general trend toward increasing inequality has been going on for 30 years, but has now reached unprecedented levels. The top one percent has claimed nearly all of the growth in personal income over the past 20 years, with most of that accruing to the top .1 percent. Consider this staggering fact: in 2009 the net worth of the 400 wealthiest households in the United States exceeds that of the bottom 50 percent of all American households; 400 families have more than 155 million Americans.

The event includes concurrent teach-in sessions from noon-1:15 pm; a public rally from 1:30-3 pm at White Plaza; and an open forum at 3:30 pm in the Oak Room, Tresidder Union. Three of the sessions have a health-care focus. These talks include: Mark Cullen, MD, professor of general medical disciplines on health equity and inequity; Donald Barr, MD, PhD, associate professor of pediatrics, on the impact of economic inequality on health care and health status; and Michele Barry, MD, Stanford’s director of global health initiatives.

Stanford nutrition researcher Jennifer Otten and some of the promotional items given away with children's meals.

Do ordinances that restrict the ability of restaurants to give away toys with unhealthy kids’ meals have an impact? A new Stanford study looks at what happened in Santa Clara County in the months after the nation’s first such policy was enacted.

The study, published today in the American Journal of Preventive Medicine, examines the actions taken by a small number restaurants immediately after Santa Clara’s ordinance took effect in August 2010.

Although none of the restaurants in the study added healthier offerings for children, two of the restaurants removed toy marketing posters and two offered toys separately at an additional cost. One restaurant singled out the children’s meals that met the ordinance criteria as “promoting good nutrition” on its menu boards.

“Before, parents had no idea which meals met the nutritional criteria. After the law was implemented, one restaurant made it clear which ones did,” said lead researcher Jennifer Otten. “In addition, there was a clear decrease in toy marketing and advertising at some of the affected restaurants.”

With an increasing number of communities looking at ways to curb the rising rates of childhood obesity, Otten and her team want to gather objective data on the effects of policies like the one in Santa Clara County. “This ordinance gave us the opportunity to study a real-world example of a private-sector response to a public health policy,” she said.

But the effort won’t end there. The researchers surveyed almost 900 families before and after the ordinance took effect to determine whether it affected their fast-food purchases. The team is also collecting data from families and fast-food restaurants in San Francisco, where a similar law took effect on Dec. 1. They plan to publish the findings related to the family surveys and the longer-term restaurant responses in future papers.

Previously: Toying with Happy Meals and Are Happy Meals illegal? A public health lawyer says, yes
Photo by Norbert von der Groeben