Viewpoint

Racial Disparities, Prescription Medications, and Promoting Equity

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                    [post_content] => The United States has the highest drug prices in the world and it's not even close. For millions in the country, the cost of prescription drugs is an ever-growing barrier to proper disease treatment. This is most often the case for minority groups, who have long experienced disproportionally adverse health access and outcomes. But high drug prices alone do not explain the inequity we see. Though cost is a major factor, Colon, et al. found that disparities are not simply a function of socioeconomic status—the story is more complicated.

Minorities Face Many Barriers to Prescription Medicines

Costs White Americans are, on average, much wealthier than Black and Hispanic Americans. The median net worth of White households in 2016 was 9.7 times higher than African-American households and 8.3 times higher than Hispanic households. Wealth disparities result in negative health consequences. Among insured adults with diabetes, Tseng, et al, found race and ethnicity to be a significant predictor of medication underuse—patients underusing their medication in order to prolong supply—due to cost. (Medication underuse is a somewhat common cost saving strategy, per the CDC.) The authors attribute this to lower incomes and higher out-of-pocket drug costs. Although study participants all had health insurance, disparities persisted. Lack of Insurance Affording medications is even harder for those without coverage. Though the Affordable Care Act (ACA) reduced the number of uninsured Americans, over 28 million remain without insurance. More than half (55%) of uninsured Americans under the age of 65 are people of color. For those with no insurance, paying retail prices for medications is often financially impossible. Implicit Racial Bias in Prescribing Practice Race can have an implicit effect on the prescribing practices of providers. For example, one study showed that White children treated at pediatric emergency departments inappropriately received antibiotics for respiratory infections more often than Black or Hispanic children, indicating that prescribing patterns can vary depending on the race of the patient. Terrell, et al., found that in their sample, ethnic and racial minorities were prescribed analgesics at a lower rate compared to White patients when discharged from the emergency department.

Practical Policy Pursuits

Here are four policy options for addressing racial disparities in access to prescription medication: Continue to Expand Medicaid One in five people of color have access to prescription drugs through Medicaid. Virginia recently expanded Medicaid (becoming the thirty-third state to do so). Medicaid expansion is on the November 2018 ballot in Utah and Idaho (Atkeson and Jones write more about the Idaho intiative here) while supporters in Nebraska are collecting signatures to get it on the ballot. A Maine state court has ruled that Governor LePage must submit the paperwork to expand. Promote the ACA and an Essential Benefits Package The ACA has played a key role in increasing health insurance among low-income people of color. Prescription drugs are one of ten essential health benefits the ACA requires insurers to cover. Interventions to increase coverage are needed, particularly in regard to medications. Research shows that promoting coverage gains through increased advertising is effective. Reduce Implicit Bias in Prescribing   Parity in prescribing practices is possible. New research shows that reducing stigmatizing language in electronic health records can reduce implicit bias in physicians-in-training, influencing their attitudes about both patients and prescribing behavior. Value-based  Formularies to Reduce Costs Pharmacy cost reduction is critical. One method for cutting costs is to use value-based formularies (VBFs), which guide prescription decisions based on cost-effectiveness. Simply, if there’s a drug with similar efficacy that costs less, that drug can be placed on an insurer’s formulary in favor of a competitor. For example, Express Scripts, the nation’s largest pharmacy benefit manager, cut Amgen’s Repatha (evolocumab) in favor of Sanofi and Regeneron’s Praluent (alirocumab), which is used for preventing cardiovascular disease, because of the latter’s willingness to lower the price to match valuation done by the Institute for Clinical and Economic Review (ICER). The multidimensional nature of health disparities and pharmaceutical law, policy, and practice requires multiple, synergistic approaches like those mentioned here, as a means to promote equitable access to necessary and effective medications for minorities. Feature image: Thomas Hawk, Prescriptions (detail), used under CC BY-NC 2.0 [post_title] => Racial Disparities, Prescription Medications, and Promoting Equity [post_excerpt] => For millions in the US, drug prices are an ever-growing barrier. Here are four policy options for addressing racial disparities in access to prescription medication. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => racial-disparities-prescription-medications-equity [to_ping] => [pinged] => [post_modified] => 2018-08-21 07:45:46 [post_modified_gmt] => 2018-08-21 11:45:46 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5386 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

For millions in the US, drug prices are an ever-growing barrier. Here are four policy options for addressing racial disparities in access to prescription medication.

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Viewpoint

On Vacation

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                    [post_content] => We're on vacation! Public Health Post is taking our #summertime publishing break. Thank you from the whole crew for reading PHP and The Public's Health, and for joining us in conversation on social media.

We'll be back online on Monday, August 20. See you then!

Feature image: Kevin Jones, Gatsby swimming, used under CC BY 2.0
                    [post_title] => On Vacation
                    [post_excerpt] => Public Health Post is taking our summertime break. Thank you from the whole crew for reading PHP and The Public's Health. We're back online Monday, August 20. See you then!
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Public Health Post is taking our summertime break. Thank you from the whole crew for reading PHP and The Public’s Health. We’re back online Monday, August 20. See you then!

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Viewpoint

Race, Discrimination, and Health: 50 Years after MLK

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                    [post_content] => Now in the North it’s [discrimination’s] different… But it has its subtle and hidden forms and it exists in three areas: in the area of employment discrimination, in the area of housing discrimination, and in the area of de facto segregation in the public schools.” —Martin Luther King, Jr., 1963

On April 4, 2018, the United States commemorated fifty years since the assassination of Dr. Martin Luther King, Jr. From speeches to memorial services, the nation relived the transformative legacy of the reverend from Montgomery, Alabama. Nevertheless, fifty years later, many of Dr. King’s concerns remain unchanged. Racism, discrimination, and prejudice continue to fill the national discourse, especially regarding health care. The social justice that Dr. King fought for remains critical to American health today. These ongoing challenges include employment, housing, and education.

Employment Discrimination

The New York Times recently highlighted findings showing that Black men are less likely to create wealth than White men, regardless of family background and the neighborhood where they were raised. Researchers found that Black Americans make up nearly 35% of children raised in the bottom 1% of income distribution and less than 1% of children at the very top. Previous evidence has described the role that income plays in the prevention and management of disease, from the ability to afford healthy food to novel medications. Yet, while the overall US unemployment rate has dropped below 5%, Blacks continue to experience the highest levels of unemployment. Along with increased opportunities for healthy behavior, employment is crucial to gaining insurance, which remains central to health care access. As the number of states requiring employment to receive public insurance grows, the impact of job discrimination on health is as important as ever.

Housing Discrimination

The discriminatory practices of redlining and predatory loans that resulted in the segregated neighborhoods that Dr. King marched through, continue to influence society today. Such segregation persists despite President Lyndon Johnson signing the Fair Housing Act into law one week after Dr. King’s death, which outlawed racial discrimination in the rental, sale, and financing of housing. This Act should have transformed the geographic distribution of Americans nationwide, yet Blacks, including the most affluent, continue to live in poorer neighborhoods than Whites. Similar to employment, zip code may influence health as much as genetic code. Access to green space, safe environmental conditions, and healthy supermarkets all play a significant role in the prevention of poor health. Additionally, many researchers have shown the impact of housing instability and homelessness on higher rates of infectious and cardiovascular diseases.

Education Discrimination

Education is key to obtaining employment and maintaining housing. Since the Brown vs. the Board of Education ruling, education discrimination continues to shape our society. Today, Black and Brown students still study in overcrowded and under-resourced public schools, often separate from their White counterparts. A growing body of research shows that educational attainment has a lasting effect on life expectancy and health behaviors. In addition, access to education results in increased health literacy which has been closely linked to engagement in care, patient satisfaction, and improved health outcomes. Yet, compared to other high-income nations, the United States continues to spend a disproportionate amount on health care delivery compared to social services, including education.

The Next Half-Century

Fifty years after Dr. King’s death, the health system has increased its attention to the social determinants of health. Hospitals like Boston Medical Center recently launched an affordable housing initiative. Health insurance plans are working with providers to enhance collection of social determinants data while health care startups like City Block are designing Neighborhood Hubs to address non-medical factors. Despite these efforts, discrimination in employment, housing, and education, and its effect on health disparities requires further innovation and advocacy from researchers, physicians, and community leaders alike. This is the only way that the next generation can look back with a sense of pride, realizing that Dr. King’s dream of justice has finally been fulfilled. Feature image: B.C. Lorio, "Martin Luther King, Jr. Statue," Newark, New Jersey, used under CC BY-NC-ND 2.0 [post_title] => Race, Discrimination, and Health: 50 Years after MLK [post_excerpt] => Fifty years after Dr. Martin Luther King's death, racism, discrimination, and prejudice continue to fill the national discourse, especially regarding healthcare. The social justice that Dr. King fought for remains critical to American health today. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => race-discrimination-and-health-50-years-after-mlk [to_ping] => [pinged] => [post_modified] => 2018-06-13 13:39:55 [post_modified_gmt] => 2018-06-13 17:39:55 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5049 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Fifty years after Dr. Martin Luther King’s death, racism, discrimination, and prejudice continue to fill the national discourse, especially regarding healthcare. The social justice that Dr. King fought for remains critical to American health today.

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Viewpoint

No MENA Category is a Mistake

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                    [post_content] => An estimated 3.7 million Arab Americans live in the United States. Most are US citizens. Our understanding of this group’s health needs is limited. The limited research is partly due to the absence of an ethnic identifier for Arab Americans in official statistics. The research that does exist points to high levels of chronic disease (including hypertension), obesity, and depression in this population.

The US Office of Management and Budget (OMB) released racial and ethnic standards for federal statistics and reporting in 1977 and updated them in 1997. The OMB has not made changes to these race and ethnicity classifications since 1997 despite significant demographic changes over the last 20 years. Some groups have not received their own ethnic and racial identifiers despite having large representation in the United States. This includes those who consider themselves to be Arab Americans or who have ethnic, linguistic, or hereditary origins in 22 Arabic-speaking countries in the Middle East and North Africa.
Despite this guidance, best available evidence suggests that some Arab Americans select "Other" because they do not feel White properly describes them.  
The OMB issued a notice on March 1, 2017 soliciting comments from the general public about improving the accuracy of race and ethnicity information by including a Middle East and North African (MENA) reporting category. The category was tested in the 2015 National Content Test for the Census after significant lobbying by the Arab-American community. In January of 2018, the Census Bureau announced that they would not include the MENA category in the 2020 Census. Individuals with origins from the Middle East are therefore encouraged to indicate White/Caucasian on the Census and other health surveys. Despite this guidance, best available evidence suggests that some Arab Americans select "Other" because they do not feel White properly describes them. In epidemiologic terms, either choice is a misclassification that may ultimately impede our understanding of disease risk in this population. The potential for misclassification is highlighted with a thought experiment: imagine we are studying a hypothetical diverse population similar in racial/ethnic composition to metropolitan Detroit composed of 10% Arab Americans, 45% White Americans, and 45% who identify as Other.  Then imagine that respondents have only two racial classifications to choose from: White and Other. Imagine we know that 25% of Whites and 50% of those identifying as Other are at risk for depression while Arab Americans have an increased risk at 75%. If all those who are Arab American identify as White, we overestimate the relative risk of depression for Whites in the population by 36%. This misclassification will limit our ability to target interventions to the population most in need of appropriate mental health services.
The incorporation of a MENA category on the Census, and medical and public health surveys would improve our understanding of Arab American health and the health of the communities in which they live.  
The incorporation of a MENA category on the Census, and medical and public health surveys would improve our understanding of Arab American health and the health of the communities in which they live. When minorities with unique health needs and social experiences in the United States are counted within the majority group, researchers may be unable to properly calculate disease risk for either group and, therefore, unable to develop effective community-level interventions. Arab Americans represent a vulnerable minority population which is difficult to help without proper racial and ethnic classifications in electronic medical records, surveys, and the US Census. The lack of a MENA identifier on the Census inhibits a true understanding of the health of all Americans, not just Arab Americans. Feature image: AH86/iStock [post_title] => No MENA Category is a Mistake [post_excerpt] => The Census Bureau will not include a Middle East and North African (MENA) category in the 2020 US Census. The incorporation of a MENA category on the Census and medical and public health surveys would improve our understanding of Arab American health. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => no-mena-category-is-a-u-s-census-bureau-mistake [to_ping] => [pinged] => [post_modified] => 2018-06-07 07:13:45 [post_modified_gmt] => 2018-06-07 11:13:45 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5091 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

The Census Bureau will not include a Middle East and North African (MENA) category in the 2020 US Census. The incorporation of a MENA category on the Census and medical and public health surveys would improve our understanding of Arab American health.

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Viewpoint

Women in Leadership and Public Health

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                    [post_content] => Record numbers of women are running for office, especially Democrats, many inspired by the Trump election. However, large numbers of losses are expected. Not only are more women running this campaign year, but so are more men, and thus the share of women candidates has only moderately increased. Many of the women on the left are running in districts more likely to elect a male Republican candidate. But losing isn’t the end. The experience, name-recognition, and respect gained from the process both within one’s party and in the public eye, are valuable. NPR reporter, Danielle Kurtzleben, says this wave of women is not seen as “the next election’s worth of candidates” but rather “the next generation’s worth.”

How Women Are Underrepresented

Although the number of women in government has been rising since the 1960s, we are still struggling for equal representation. Women make up half of the population and yet barely hold 20% of the seats in the U.S. Congress. Pennsylvania does not have a single woman in its Congressional delegation. It’s not just the House and Senate that lack fair representation. Throughout all levels of government, the percentage of women is far below that of men. For all statewide executive offices (governors) and local offices (mayors) women make up less than one quarter of the seats. The percentage of women in state legislature positions is larger, highest in Arizona and Vermont at 40%. Positions of power are still unquestionably dominated by men.

Why Women Are Underrepresented

According to Pew Research, 75% of Americans believe that men and women are equally capable of leading. That’s across the board for Republicans, Democrats, and Independents. Women also win elections at the same rate as men and, once in office, demonstrate equal quality in performance. So why are there fewer women in office? Until this recent surge, women weren’t running. Gendered social roles and lack of encouragement have prevented women from feeling the confidence to run. Women reported feeling significantly less qualified and doubting their abilities. It took Senator Kirsten Gillibrand two decades as a law firm associate, and ten years of volunteering before she felt confident enough to run for office. Yet she knew as young as age 8 that she would one day run for office.  

The Good that Women Do for Public Health

Women being elected isn’t just good for visual representation. Women govern differently than men do when in office. A study by Michele Swers from Georgetown University found that women cosponsor the most healthcare legislation, with Democratic women cosponsoring the most overall and Republican women cosponsoring twice as many bills as their male Republican colleagues. Women also tend to focus on education, civil rights, and social welfare. Women were significantly more likely to sponsor bills in these area than men between 1973 and 2014. Women tend to have more legislation enacted as well, with women in Congress averaging 2.31 bills enacted versus 1.57 for men. Women in Congress also fare better when it comes to federal money. On average, women in Congress brought 9% more money back to their districts for federal programs than men did. These programs focus on agriculture, education, research, and more. Today, social networks focused on women and leadership, such as EMILY’s List (acronym for “Early Money Is Like Yeast”) and Maggie’s List help train and support women to become educated, authoritative, and to run strong campaigns.

So What's Next?

What can we do to get more women into office? According to the Center for American Women and Politics, a suggestion to run is the strongest predictor of whether a candidate will enter a political race. Women need to be encouraged to run, and not just once. They need to be encouraged repeatedly.  Rep. Monica Youngblood thought it was “a joke” when she was first called to run for Congress, and needed to be asked several times and encouraged by family before she felt confident enough to do so. Women are also more motivated when encouraged with phrasing that suggests opportunities to fix problems and improve communities. Women who are already campaigning need donations. Women face a gender gap in campaign financing, and many cite fundraising as a barrier to running for office. While women donate based on who they support regardless of gender, men tend to donate to male candidates, thereby tipping the scale in their favor. Women leaders such as as Susan Collins, Tammy Duckworth, and Tammy Baldwin have focused their efforts on improving health, human rights, and equity. We can all play a role in getting more women into office, and we’ll all be better off if we do. Feature image: Cheng-ting Chang, Women Power!, used under CC BY-NC-ND 2.0.  Graphics from Pew Research Center Social & Demographic Trends, Women and Leadership, Women in Congress, 1965-2015 and Men and Women Equally Capable Political Leaders, January 13, 2015. [post_title] => Women in Leadership and Public Health [post_excerpt] => Women make up half of the population and yet barely hold 20% of the seats in the U.S. Congress. Here's why women candidates are important for public health. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => women-in-leadership-and-public-health [to_ping] => [pinged] => [post_modified] => 2018-05-22 22:38:28 [post_modified_gmt] => 2018-05-23 02:38:28 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=4371 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Women make up half of the population and yet barely hold 20% of the seats in the U.S. Congress. Here’s why women candidates are important for public health.

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Viewpoint

Why Not Single Payer Now?

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                    [post_content] => Democrats and moderates spent the last decade building support for, developing, and then defending the incrementalist Affordable Care Act. It has (narrowly) survived eight years of vicious, distorted attack.

Now, a resurgent progressivism would abandon it. Sixteen Democratic U.S. Senators (a record number) have co-sponsored Bernie Sanders’ Medicare-for-All bill, and Washington, D.C.’s influential Center for American Progress, recently rolled out Medicare Extra for All.

The policy arguments for a single-payer system have long been clear—universality, simplicity, administrative and (potentially) other savings. Even Taiwan, that bulwark of capitalist resistance to “communist” China, settled on Canadian-style Medicare as the best model for universal coverage.

And there’s an emotional factor as well behind the Democrats’ swing left: incrementalism seems to have done nothing to mollify the right. After withstanding repeated efforts at “repeal and replace,” resurgent liberals might take pleasure in dropping their unrequited efforts at compromise in favor of more fundamental change. Sweet revenge, indeed, on all those Republicans who mouthed sympathy for the uninsured before 2010, only to viciously attack the very moderate, market-oriented ACA!

However, a Democratic push for single-payer is exactly the wrong move now. It would be wrong for three reasons.

First, the ACA is working: The uninsured rate for legal residents has been cut in half. Expanding Medicaid and private coverage is associated with greater access to prevention, primary care and prescription drugs, higher rates of diagnosing and treating chronic conditions, and improved control of hypertension. Its reach is also growing. If Virginia expands Medicaid, as seems likely, two-thirds of the states (and the District of Columbia) will have done so under the ACA. More will likely follow if Democratic wins insulate it from repeal.

Second, the ACA can be improved. This can be done simply by reversing Republican efforts of the past 15 months to undercut it, plus relatively modest increases in the tax subsidies to encourage direct enrollment. Massachusetts Senator Elizabeth Warren has introduced The Consumer Health Insurance Protection Act to do just that.

With its growing popularity, the ACA offers a sturdy platform on which to build. It is now more popular than at any time since its passage, and most voters think Democrats and Republicans should work together to improve it. (See figure.) Independents, who will decide the next elections, can be turned by Republican strategists against single-payer “socializing medicine.” But 59% support fixing the ACA, as do 70% of Democrats. Promoting single payer would allow Republicans to switch from defending their record on Obamacare to attacking “spend-and-tax” Democrats.

Chart showing favorable and unfavorable views of the ACA

Third, re-taking Congress in 2018 and the White House in 2020 is more important to Americans’ health than any healthcare financing reforms. To cite just one among many issues, the health benefits of arresting this administration’s attack on the environment far outweigh the benefits of insuring another 5-7 percent of Americans (the legally resident, uninsured). There are many such issues – food insecurity, education, public housing and income inequality – where halting this administration’s policy trajectory would confer health benefits beyond the most optimistic expectations for single-payer.

So, NOT giving Republicans a big fat ideological target in November is crucial to our public health. Single-payer is so easily labelled a government takeover of medicine demanding massive tax increases. It has failed ballot initiatives in liberal California and Colorado by margins of 3-to-1. Even Senator Sanders’ home state of Vermont, having enacted single-payer in 2011, reversed course after calculating the tax requirements.

Trump’s Republicans have made a colossal mess—gutting reasonable restraints on pollution, cutting health programs, raising annual deficits into the trillions, and sabotaging the norms of decency and informed debate that are essential to representative government. Liberals should not allow them to evade the electoral consequences by scaring voters about a government “takeover” of healthcare. If Democrats do, we may yet snatch defeat from the jaws of victory.

Graph from Kaiser Health Tracking Poll – February 2018: Health Care and the 2018 Midterms, Attitudes Towards Proposed Changes to Medicaid, Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. Published: Mar 01, 2018.
Feature image: Victor Moussa/Shutterstock
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Democrats and moderates spent the last decade building support for, developing, and then defending the Affordable Care Act. A resurgent progressive interest in single payer health care would abandon it.

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Viewpoint

Saving Lives Begins with Death Certificates

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                    [post_date] => 2018-04-16 07:00:47
                    [post_date_gmt] => 2018-04-16 11:00:47
                    [post_content] => Death certificates are more than a bureaucratic record that collects dust. They are a trove of data that inform public health research, policymaking, and resource allocation. For instance, the current tracking of and planning to address the opioid crisis in Massachusetts relies heavily on information from death records. Based on how widely they are used, it seems logical to assume death certificates are accurate.

I learned otherwise in an epidemiology class. One of my classmates, a physician, challenged the legitimacy of death certificate data and offered a compelling explanation of the inaccuracies. I decided to dig further. For public health, demographic data is a core resource for understanding patterns of morbidity and mortality. If an information source is not trustworthy, in what ways do the inaccuracies affect health policy and programming? Can death certificates be trusted to inform research and the implementation of programs that aim to save lives? I set out to investigate this public health mystery by making a documentary film.

I chose documentary because I wanted to explore the veracity of death certificates in a narrative context. With open source equipment, I made a 10-minute film. Three respected experts graciously offered their knowledge to shape the narrative: Dr. Tom Land, a public health data scientist; Dr. Al DeMaria, an infectious disease epidemiologist; and Dr. Michael Grodin, a health law ethicist. Each helped me build the storyline by speaking from their decades of experience.
Today public health professionals are unveiling innovations in the way death certificates inform prevention efforts.  
The story begins in the Massachusetts State House. In 1849, the American Statistical Association successfully petitioned the Massachusetts State Legislature to legally grant the use of death records for tracking preventable and premature deaths. Following this legislative turning point, other states adopted similar laws that would also lead to a movement to establish public health departments. Tracking mortality is now a ubiquitous practice across the country. Today public health professionals are unveiling innovations in the way death certificates inform prevention efforts. Public health professionals often link death certificates with other government records to solve public health mysteries. Dr. Land described how the Massachusetts Department of Public Health employs this approach to track the current opioid epidemic: “We link together information from the Medical Examiner, the State Police, and death certificates to create a model that predicts the likelihood a death is opioid related.” Information collected across various government agencies can intertwine to tell the complete mortality story of an individual. Physicians are a vital character in the death certificate narrative and their training or lack of training influences accuracy. Other than coroners, they are the primary authors of death certificates. A lack of physician training on recording mortality data emerged during my interviews and research as a key factor that can lead to inaccuracy. Dr. DeMaria and Dr. Grodin, who are also clinicians, explained that junior medical staff with inadequate training are traditionally tasked with death certificate data entry in hospitals. Training medical students to correct data entry and emphasizing the public health value of death certificates will be an important step toward improving accuracy. Parallel themes build the death certificate story. The design of a strong data collection system and robust training for those recording data are critical to ensuring that mortality data is accurate. Moving forward, accuracy of data is not the only important consideration. Institutions, public and private alike, influence the structuring of data systems. I now work as a legislative aide at the Massachusetts State House. From observing the intersection of advocacy, policymaking, and community engagement firsthand, it has become clear to me that institutions are a key influencer in the use of data to improve health outcomes. History shows us that saving lives begins with keeping track of and scrutinizing how we die. Feature image: Alexander Lyubavin, IMG_2991 гроб, used under CC BY 2.0 [post_title] => Saving Lives Begins with Death Certificates [post_excerpt] => Death certificates are a trove of data that inform public health research, policymaking, and resource allocation. History shows us that saving lives begins with keeping track of and scrutinizing how we die. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => saving-lives-begins-with-death-certificates [to_ping] => [pinged] => [post_modified] => 2018-04-18 06:51:43 [post_modified_gmt] => 2018-04-18 10:51:43 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=4163 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Death certificates are a trove of data that inform public health research, policymaking, and resource allocation. History shows us that saving lives begins with keeping track of and scrutinizing how we die.

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Viewpoint

Will you still need me?

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                    [post_date] => 2018-04-09 07:00:01
                    [post_date_gmt] => 2018-04-09 11:00:01
                    [post_content] => What comes to mind when you think of a children’s hospital? Imagine your child being rushed to such a place because of a serious illness. What kind of reception will staff give them? What will their room look like? How will they be treated? Now think about a nursing home. What comes to mind? If your parent had to move into one tomorrow, how would they react? And you?

If you have trouble conjuring pictures for this thought experiment, open two Google image search tabs, type in the phrases "children’s hospital” and “nursing home,” and scroll down. The contrast may surprise you. Personalization versus institutionalization. Colorful versus drab. Imaginative abundance versus boring repetition.

A recent survey asked 1,300 adults age-50-and-over whether they agreed with this statement: I would rather die than live in a nursing home. Sixty-two percent said they would rather die. Yet adults over 75 are more likely to die in nursing homes than at home.

I conduct research on improving nursing home quality and struggle with this disconnect between people’s desires and their likely reality. Most of us don’t want to think about nursing homes. And no wonder. We’re inundated with scary information about them. Nursing homes vary widely in quality. And the media predominantly portrays them negatively, which likely influences consumer choices. But interventions and advocacy can positively influence this negative tide.

After all, kids in children’s hospitals and adults in nursing homes are the same individuals, separated only by time. Remember that child you had in mind earlier? If they live to sixty, they have a greater than 50% likelihood of spending at least one night in a nursing home. And that percentage rises dramatically as they age. As we age. Because nursing homes aren’t for other people. They’re for our parents, our friends, our children. They’re for us. When we think about them and work on improving them, we’re reforming our own future.

What can you do to become part of the growing movement to improve the image and reality of nursing home care?
  1. Educate yourself about and become involved with organizations working on these issues, such as the Pioneer Network, the Green House Project, and the National Nursing Home Quality Improvement Campaign.
  2. Be proactive in thinking about the future possibilities for yourself and those you care about. Check out options and know what to look for and what to ask when deciding on care.
  3. Start a conversation. Age is irrelevant. Someday, you hope, you and your loved ones will get old. So someday, I wager, all of you will stay in a nursing home. So get over your fear and start embracing nursing homes as your future playground. They will be then what you make them now.
Together, as families, as age cohorts, as a society, we can help care become equally appealing and equally humane across the age spectrum. As the young Beatles asked decades ago, “Will you still need me, will you still feed me, when I’m sixty-four?” Let’s work together on making the answer, “Yes, just as much, my love.” Feature image: Heiko Küverling, iStock [post_title] => Will you still need me? [post_excerpt] => Nursing homes aren't for other people, they're for all of us. Here are three steps everyone can take to improve the image and reality of nursing home care. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => will-you-still-need-me [to_ping] => [pinged] => [post_modified] => 2018-04-08 22:37:44 [post_modified_gmt] => 2018-04-09 02:37:44 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=4092 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Nursing homes aren’t for other people, they’re for all of us. Here are three steps everyone can take to improve the image and reality of nursing home care.

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Viewpoint

Clinical Pharmacy Innovations and Team-Based Healthcare

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                    [post_date] => 2018-03-26 06:45:26
                    [post_date_gmt] => 2018-03-26 10:45:26
                    [post_content] => Clinical pharmacists are specially trained to provide comprehensive medication management to patients and to collaborate with physicians and other providers. Clinical pharmacy specialists (CPS) make significant contributions to patient care and are recognized as performing as well as physicians in managing chronic disease. In this era of team-based medical care, the CPS role has expanded beyond conventional medication dispensing in the United States. Health professionals differ in their expectations of clinical pharmacy services, which can range from prescribing medications to administering vaccines as well as working in mental health, cancer and surgical care, etc. Clinical pharmacy is rapidly expanding and the knowledge of what clinical pharmacists can contribute to team-based care is under-recognized. This article highlights what CPSs can contribute to patient care and their potential to ameliorate some persistent problems in patient care.

What are clinical pharmacy specialists?

Clinical pharmacy has undergone innovations in the past 40 years. In addition to involving a rigorous doctorate-level PharmD degree, pharmacy residencies (post-doctoral training) train pharmacists in particular skills and specialty knowledge in a wide range of areas like, pain management, specific disease management (diabetes, anticoagulation, blood pressure), mental health care, and more. In many medical schools, CPSs and doctors train side-by-side. CPSs in the Department of Veterans Affairs (VA) and in many states (through collaborative practice agreements) have the legal authority to prescribe, order laboratory tests, and perform all functions for comprehensive medication therapy management.

Exploring the CPS Scope of Practice

Clinical pharmacy specialists operate most effectively in close collaboration with physicians/prescribers. A CPS can operate in both independent and collaborative roles with a physician/prescriber. For example, CPSs can work collaboratively under physician recommendations to manage a disease state with a patient. A CPS can also independently run a disease clinic where they monitor dosing adjustments and work one-on-one with patients as needed in perpetuity (e.g., anticoagulation clinic) or until a patient’s goal has been reached (e.g., diabetes clinic). Clinical pharmacy specialists have the schedule capacity to meet with patients more frequently and to work intensively on one particular health problem. Given a physician’s packed schedule, access to a CPS may get struggling patients into care sooner. It is important to note that CPSs do not diagnose. A CPS may run a disease clinic independently but patients are referred by doctors to that clinic and are copied on clinical notes. Physicians often consult with CPSs to explore medication options for patients with multiple chronic conditions or to solicit drug interaction information. Additionally, CPSs can answer patients’ questions about their medications.

Challenges

The types of care CPSs are authorized to provide vary greatly by state and healthcare system. In the Veterans Administration, the largest integrated healthcare system in the United States, national policy dictates CPS scope of practice and reimbursement.  At the state level, however, patchwork regulations unevenly dictate what a CPS can and cannot do. Reimbursement for clinical pharmacy services is also complicated in terms of both policy and practice. U.S. healthcare is limited by a shortage of primary care providers, an aging population, and the troubling and thorny problem of physician burnout. Team-based medical care is here to stay and CPSs are in an excellent position to make substantial contributions to improving access, quality, patient outcomes and controlling costs. Improving clinical pharmacy practice and policy at a national level will allow CPSs to contribute to team-based health care more consistently across systems and, ultimately, improve patient care. Feature image: Clever Cupcakes, Doctor Themed Cupcakes, used under CC BY 2.0 [post_title] => Clinical Pharmacy Innovations and Team-Based Healthcare [post_excerpt] => Clinical pharmacy specialists make significant contributions to patient care and are recognized as performing as well as physicians in managing chronic disease. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => clinical-pharmacy-specialists [to_ping] => [pinged] => [post_modified] => 2018-03-26 13:32:03 [post_modified_gmt] => 2018-03-26 17:32:03 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=4063 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Clinical pharmacy specialists make significant contributions to patient care and are recognized as performing as well as physicians in managing chronic disease.

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Viewpoint

The Undeserving

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                    [post_date] => 2018-03-15 06:45:53
                    [post_date_gmt] => 2018-03-15 10:45:53
                    [post_content] => The Center for Medicare & Medicaid Services (CMS) recently released guidelines for states interested in implementing Medicaid work requirements. The guidelines advocate for improving “work and community engagement” by making it a requirement for Medicaid eligibility. In other words, people would need to be deemed “engaged” in order to be eligible for Medicaid in interested states. The new Medicaid work requirement proposals further an ongoing dialogue about who is deemed deserving of help in the U.S.

Work requirements are not a new idea. Ronald Reagan famously coined the term “welfare queen” back in the 1970s referring to a single case of extreme welfare fraud in Chicago to urge welfare reform. Subsequent reform in 1996, during Bill Clinton’s presidency, replaced relatively broad eligibility for food stamp benefits with three months of benefits through the Supplemental Nutrition Eligibility Program (SNAP). SNAP tied eligibility for food aid to participation in work or work training in 36 month chunks of time. In other words, SNAP recipients who did not work or participate in a training program were cut off after three months.

The idea underlying SNAP and similar policies comes down to the belief that beneficiaries are taking advantage of these public programs—living off of government benefits without lifting a finger. Research from the University of California Berkeley Labor Center suggests otherwise. The center estimates 73% of enrollees in American public benefit programs are from working families. Working families are defined as having at least one family member who works 27 or more weeks per year and 10 or more hours a week. Most of these workers are in low-wage occupations such as fast food workers, child care providers, and home care workers.

Medicaid Work Requirements

Medicaid eligibility as outlined by the CMS would require “work and community engagement among non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability.” The working theory is that work and community engagement will improve overall health. They list other social determinants of health, such as education, as examples of factors that improve health. Higher levels of education clearly correlate with better health outcomes. But health problems can disrupt children from attending school, thus affecting academic performance. The same can be said of employment. Sure, “higher earnings are positively correlated with longer life span.” But causality can move in the other direction as health problems can hinder ability to work and lead to unemployment. At the heart of this policy is the speculation that many Medicaid beneficiaries can work but choose to stay unemployed. Data from the Kaiser Family Foundation indicates the opposite. Most Medicaid enrollees have good reasons why they are not working. As depicted in the figure, most are ill or disabled or taking care of home or family. Only 6% could not find work. What this means is that these extra hurdles imposed to gain eligibility could be a barrier to many who should be eligible and need the insurance. The CMS guidance does not adequately address how states would check for eligibility and support citizens attempting to meet eligibility. Pie chart showing primary reasons for not working among Medicaid enrollees Currently ten states have submitted work requirements. Kentucky’s Section 1115 waiver to implement Medicaid work requirements, approved on January 12, was the first of its kind. States like Wisconsin and Kentucky have proposed changes such as drug-testing and requirements for beneficiaries to pay more out-of-pocket. Kentucky also proposed a controversial health or financial literacy course to re-enroll in Medicaid should you fail to meet work requirements. Details are still hazy for the courses and their mandatory quizzes. But, as Austin Frakt points out, many Americans, not just Medicaid enrollees, would struggle with a health or financial literacy test.
These families will make too much money to be eligible for Medicaid and not enough to qualify for ACA marketplace assistance which starts at 100% FPL ($16,400 annually).  
Medicaid enrollees in states that have yet to expand Medicaid will face a unique challenge. Medicaid expansion raised the federal poverty level (FPL) for eligibility in participating states to 138%. Eligibility in non-expansion states is much more difficult with typically lower qualifying federal poverty level. For example, Mississippi is a non-expansion state that has submitted a work requirement waiver for its Medicaid population. A parent in a family of two (or a single parent with a child) must have an annual income under 27% FPL to qualify for Medicaid, which is about $4,385. The $7,540 salary for working at least 20 hours per week at minimum wage ($7.25 per hour) would disqualify families from assistance. These families will make too much money to be eligible for Medicaid and not enough to qualify for ACA marketplace assistance which starts at 100% FPL ($16,400 annually).

By the Bootstraps

The CMS guidance on Medicaid work requirements is another example that help is not given to those who need it the most. Medicaid work requirements are sold as welfare reform under the belief that the undeserving poor are doing nothing to improve their circumstances. Thus, help should only be offered with many strings attached. Elizabeth Bruenig, a journalist with the Washington Post, observes that help in the form of tax breaks and subsidies is readily given to the wealthy without a discussion of whether they are lazy or deserving. Yes, the American government spent $200 billion on Medicaid in 2012. But, the government also lost out on $120 billion by subsidizing employer-sponsored health insurance. The phrase “by the bootstraps” reflects this feeling that the poor must be lazy if they cannot pull themselves out of poverty. I am not downplaying the accomplishments of people who have started with nothing and made a comfortable living for themselves. However, not everyone is able to pull themselves up by the bootstraps due to a variety of circumstances. Often, systematic and structural obstacles stymie their efforts to achieve a comfortable life. Under work requirements, a beneficiary could have Medicaid revoked due to either failure to comply with community engagement or absence of paperwork. We are asking the impossible of the poor in the U.S.: become successful while being locked out of essential services. So, who is deserving of help? According to the Medicaid work requirements guidelines, only the poor who are able to consistently hop over tall hurdles. Feature image: Ben LelisThe Mop, used under CC BY-NC-ND 2.0 [post_title] => The Undeserving [post_excerpt] => Qing Wai Wong questions the assumptions behind Medicaid work requirements policy, that everyone could pull themselves up by the bootstraps. Medicaid enrollees in states that have yet to expand Medicaid will face a unique challenge. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-undeserving [to_ping] => [pinged] => [post_modified] => 2018-03-15 07:10:20 [post_modified_gmt] => 2018-03-15 11:10:20 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=3877 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Qing Wai Wong questions the assumptions behind Medicaid work requirements policy, that everyone could pull themselves up by the bootstraps. Medicaid enrollees in states that have yet to expand Medicaid will face a unique challenge.

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