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The ADA, 27 Years On

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                    [post_content] => As a kindergartner, William “Nick” Crow transitioned from what he calls “spec ed” to “mainstream” classes. Some of his schoolmates must have wondered why he needed to use a walker.

Just some months earlier, several activists left their own walkers and other disability devices at the bottom of the Capitol Building. During what came to be known as the “Capitol Crawl,” they advanced the steps using their arms and chanted “ADA now!”

This was 1990, the year the Americans with Disabilities Act was passed. Parents had for decades sought an integrated curriculum and accommodations for their children’s impairments. The ADA furthered Section 504 of the 1973 Rehabilitation Act, which banned discrimination on the basis of disability by recipients of federal funds. People with health conditions that interfere with at least one activity of daily living were recognized as a minority group.

Nick laughs when asked whether he considered himself disabled. “You try not to think about it. But it comes to the forefront more often that not.”

He numbers among the 2.4 out of 1000 who by age six are diagnosed with cerebral palsy. He has encountered many misconceptions about his non-progressive neurological condition. While he has used a motorized wheelchair since high school and has difficulties with fine motor skills, he points out that actor RJ Mitte actually played up his milder cerebral palsy symptoms as Walter White Jr. on Breaking Bad.

Nick “think[s] disability can stem from living in a big city, honestly. In the suburbs, people were always in a culture of tolerance and going with the flow.”
“Boston’s an older city. Unfortunately the builders didn’t have 300 years of foresight,” he says.  
Some major provisions of the Americans with Disabilities Act set requirements for public and commercial entities. Several major crosswalks in downtown Boston are fairly generous with walk time and are more likely to have auditory cues indicating that it’s safe to cross. Curb cuts are the actual name of the small ramps set into sidewalks at regular intervals. Doors have literally been opening – with the assistance of button-activated motors – for the disabled. [caption id="attachment_1228" align="alignright" width="300"]Nick Crow boarding a RIDE van Nick Crow boarding a RIDE van. Photo: Kendra Sims[/caption] The ADA has made countless tiny reconfigurations to our landscape. However, when Nick moved to Boston he was most surprised how much of a challenge old architecture can pose. “Boston’s an older city. Unfortunately the builders didn’t have 300 years of foresight,” he says. He finds old architecture, grandfathered into non-ADA compliance, “frustrating but understandable. And I just can’t get in.” The Americans with Disabilities Act nears its 27th birthday. Even so, Nick has found again and again that accessibility is not the default for many establishments. He suspects that ignorance and cost-cutting play equal roles. Changing that takes a complaint, with agencies including Housing and Urban Development, or sometimes the city itself. After moving into his new apartment downtown, for instance, Nick realized that his double unit was not required to be handicap-accessible. “It’s taken cooperation from the building and adjusting in my own way,” he says, “I find new and interesting ways to advocate for myself.” Nick works for the MBTA, determining eligibility for its paratransit service THE RIDE. An average day on the job might include him interviewing a few arthritic grandmothers, a music professor with retinitis pigmentosa, and a woman accompanying her non-verbal autistic son. Nick educates his clientele and coworkers. But it’s gone both ways. “Before this job, I will admit ignorance and arrogance,” he says of learning how physical, visual, cognitive, and psychiatric conditions prevent individuals from taking a public bus or train. “The RIDE has broadened the horizon of disability for me.” Nick schedules RIDE trips for himself when unplowed ice or snow could pose a barrier for his powerchair. A single RIDE trip is priced between $3.15 and $5.25 for him, though the true $60 cost -that covers the trained drivers’ salary, vehicle upkeep, and gas- is subsidized by taxpayer dollars. The RIDE is one of the single biggest expenditures for the nation’s oldest existing transit system. Nick regularly uses his disability pass for the MBTA, which saves money for himself and the system alike. His commute is made possible by the elevators at the stations, along with the bridge plate that allows his chair to cross from platform and the kneeling feature of all buses: all reasonable accommodations, along with the existence of the RIDE, that the MBTA must make to ensure accessibility for disabled riders. “I prefer taking the T for independence. I’m more a part of society.” Nick says. “Boston has opened my eyes, and I’ve had to go outside my comfort zone.” Feature Image: Nick Crow boarding a RIDE van. Photo: Kendra Sims. Graph: Disability in America Infographic  [post_title] => The ADA, 27 Years On [post_excerpt] => William “Nick” Crow discusses THE RIDE, the challenges and gaps in accessibility presented by old architecture, and how the ADA has made countless tiny reconfigurations to our landscape. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => ada-27-years [to_ping] => [pinged] => [post_modified] => 2017-08-22 18:00:01 [post_modified_gmt] => 2017-08-22 22:00:01 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=1318 [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 )

William “Nick” Crow discusses THE RIDE, the challenges and gaps in accessibility presented by old architecture, and how the ADA has made countless tiny reconfigurations to our landscape.

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Climate and Health: Adapting at the Local Level

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                    [post_content] => Extreme weather events are becoming more common as climate trends shift across the globe. In Wisconsin, we’re seeing warmer and wetter weather. Extreme weather events and changing climate trends create health risks that we as public health professionals must be prepared to address. For example, extreme heat events cause heat-related deaths among vulnerable populations; extreme precipitation events can cause gastrointestinal illness from ground water contamination; longer summers increase the pollen season effecting the health of those with asthma and allergies; and warmer seasons can increase the geographic distribution of ticks and mosquitos as well as increase the transmission for vector-borne diseases including Lyme disease and West Nile Virus. Because extreme weather events happen at the local level and affect communities differently, the public health impacts of these extreme weather events and changing climate trends are best addressed at the local level.

What is being done about it? 

The Wisconsin Department of Health Services (WI DHS) understands and appreciates the importance of addressing emerging climate-related health impacts. In order to best do this, the WI DHS received funding from the Centers for Disease Control and Prevention (CDC) to manage and implement a grant called Building Resilience Against Climate Effects (BRACE) to address the health impacts of climate effects in Wisconsin. This grant opportunity allowed the WI DHS to build knowledge and capacity at the state and local level around the changing public health impacts of climate and extreme weather events in Wisconsin. The Climate and Health Program at the WI DHS has worked through a five-step framework of 1) assessing vulnerabilities and forecasting climate-related health impacts, 2) projecting disease burden, 3) assessing climate-related public health interventions, 4) creating a statewide climate and health adaptation plan, and 5) evaluating programmatic process and outcomes. While implementing the BRACE five-step framework, the Wisconsin Climate and Health Program realized that the greatest impact could be achieved by addressing the effects of extreme weather events and changing climate at the local level. By sharing our knowledge of the health impacts, local and tribal health departments could engage in adaptation planning in their own communities.
A wide variety of stakeholders were invited to participate in each mini-grant community engagement process, including members of local businesses, city planning departments, police and fire departments, and environmental nonprofits.  

How is it being done? 

The WI DHS funded two cohorts of competitive mini-grants to help local and tribal health departments increase their knowledge of and ability to adapt to the public health impacts of extreme weather events and climate effects. Over the course of two and a half years, seven mini-grants were awarded to a total of 11 local health agencies that worked independently or as a consortium to conduct climate and health adaptation work. Once selected, these agencies worked with a broad set of stakeholders through a community engagement process to prioritize climate-related public health issues in their community, devise adaptation strategies to address these health concerns, and create action plans to implement the selected adaptation strategies. Mini-grantees were encouraged to choose strategies that could be incorporated into already existing plans (such as Community Health Improvement Plans and Community Health Needs Assessments) that could be maintained in perpetuity. A wide variety of stakeholders were invited to participate in each mini-grant community engagement process, including members of local businesses, city planning departments, police and fire departments, and environmental nonprofits. This increased each community’s ability to address the variety of public health concerns affecting their citizens and created new partnerships at the local level.

Examples of Strategies Implemented

Kewaunee County To combat the increase in the number of Lyme cases, the health department developed and implemented comprehensive public health messaging to raise awareness of vector-borne disease. Sauk County To decrease negative mental health outcomes related to flooding, social media was used to share information on the mental health impacts of flooding and direct citizens to mental health services. St. Croix County To educate residents traveling to areas with Zika and reduce the risk of disease importation, prevention kits were distributed to over 600 residents at a booth at the county fair. Richland County To reduce the negative health impacts of flooding, the BRACE Flood Toolkit was shared on Richland County Health Department’s website during a recent flooding event. The toolkit provided valuable information for residents on ways to ensure that their drinking water was safe and also prevent flood-related injuries and illnesses.
While each mini-grant process was unique, there was substantial overlap among the public health issues of greatest concern: nearly all grantees selected mental health issues and water quality as the greatest climate-related public health impacts.  

What Have We Learned?

While each mini-grant process was unique, there was substantial overlap among the public health issues of greatest concern: nearly all grantees selected mental health issues and water quality as the greatest climate-related public health impacts. These common climate and health-related concerns confirm the need for a diverse group of stakeholders, many of whom work outside of the traditional realm of public health, to be involved in local climate and health adaptation planning work. The WI DHS understands that climate-related public health impacts don’t usually fall within the typical scope of work for local public health agencies, and the WI Climate and Health Program does not anticipate the ability to continue providing mini-grants for local public health climate adaptation planning into the future. In order to ensure sustainability of this work moving forward, the WI DHS created a Climate and Health Community Engagement Toolkit available on the WI DHS website. This toolkit guides interested local public health professionals through the process conducted by the mini-grantees. The WI DHS Climate and Health Program hopes that through the cutting edge local health agency climate adaptation pilot work, more local health agencies and tribal health agencies will utilize the resources made available to conduct their own locally-driven climate and health adaptation planning. Feature image: U.S. Department of Agriculture, Gay Mills DSC_0105. The downtown of Gays Mills was flooded when the local river jumped its banks, used under CC BY-ND 2.0/cropped from original.  [post_title] => Climate and Health: Adapting at the Local Level [post_excerpt] => Facing warmer and wetter state weather, the Wisconsin Department of Health Services developed a model to address public health impacts of extreme weather and changing climate at the local level. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => climate-health-adapting-local-level [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:05:05 [post_modified_gmt] => 2017-08-27 03:05:05 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=1294 [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 )

Facing warmer and wetter state weather, the Wisconsin Department of Health Services developed a model to address public health impacts of extreme weather and changing climate at the local level.

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Living with Purpose

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                    [post_content] => Beating cancer once is a miracle of modern medicine. Surviving it a second time is a rare privilege afforded very few. I should know. I’ve done both recently while working with children with (often late stage) cancer in a resource-limited setting.

Cancer is full of surprises: from the initial shock and general horror of the diagnosis; the weird way the symptoms manifest (hair loss everywhere but still had to wax my legs); the profound love that those close to you surround you with; to the delightful surprise of old friends from a distant misty past reappearing to offer support (mostly in the form of tea and chocolate).

Coming face to face with a personal cancer diagnosis as a pediatric oncologist (especially in Tanzania where it is mostly raw and late and often horrific) should not be so shocking. I guess it’s hard to prepare yourself for such a blindsiding reality check. The shock is visceral. And yet it has been a strange (scary) but remarkably educational journey.

Of course there are down sides. I’ve lost my sense of immortality for one. Random aches and pains, once barely acknowledged, now lead instead to occasional sleepless terrors at 4 a.m. which vanish as the sun comes up. Then there’s the transient loss of self – for several years during and immediately after treatment I felt less human and more like an amorphous blob. My skin didn’t feel right, my clothes didn’t fit. My heart ached. It didn’t last but it wasn’t a fun phase. There’s also the sudden onset (recovery from and then relapse-induced reappearance) of menopause to contend with. Without consultation, cancer stole the choice (I had unconsciously already made), making it feel like an injustice rather than the decision it was.
‘Save the Girls.’ I get what it’s trying to say but to be honest, it is misdirected in my opinion. ‘Save the girl’ is far more important and valuable.  
Not to mention the loss of the breast. Which brings me to a particular irritation of mine with a well-known campaign – ‘Save the Girls.’ I get what it’s trying to say, but to be honest, it is misdirected in my opinion. ‘Save the girl’ is far more important and valuable. Do I care that I am now lopsided? A little, for sure, but a recent sighting of my naked self, post-shower, highlighted just how little. I studied and silently bemoaned my least favorite body part and the fact that despite my now-healthy vegan teetotaling exercising lifestyle I was officially unlikely to ever lose my wobbly waist. It was only after a few seconds pondering this that I suddenly, with a laugh of surprised relief, realized that I completely overlooked the missing boob! I believe the medical world is far too focused on ‘saving the girls’ which means they often don’t consider or explain other viable options. I loved my medical team. My oncologist, a close personal friend, directed my treatment while calmly including me in all decisions. I felt heard and respected even at my most panicked. My surgeon could not have been better or kinder and I’d choose him again (obviously hoping that won't be necessary). But at the first diagnosis (and before I relapsed) when I mentioned mastectomy, he explained that survival rates were comparable with either mutilating surgery alone or combining minimal surgery and radiation … ‘saving the girls’ hurray! And that is true. But I’m hoping the bar is set slightly higher than survival. Five weeks of radiation is not without consequences – short and long term  – nor, it turned out, was the tiny 5% risk of leaving breast tissue to relapse that inconsequential. Mastectomy is not mutilating. It is an important treatment option with fewer side effects and risks than some other more popular options. We need to stop using words like that when presenting options to patients. As a doctor I was so used to discussing statistics that it was only as a patient that I understood, or learned the hard way, how meaningless they are. Eighty percent of women with localized triple negative breast cancer are cured with modern treatment. Sounds great until you have a real chance of being in the 20%. Someone has to be, right? I joked with friends to stop telling me about all their aunts, cousins, and sister-in-laws who had survived breast cancer as all those success stories were stacking the odds against me. That clearly came back to bite me! Despite all the trauma a cancer diagnosis delivers, if you survive it you can gain so much of value. I learned simple truths that should have been obvious to me as a doctor: that ‘bad news is better than no news,’ for example. How many times did I leave the hospital in Dar es Salaam late in the evening without informing a family of a last minute email result, telling myself I’d give them one more night without the reality of cancer in their lives? When in fact, the torture of uncertainty is far less bearable than any diagnosis I could explain. Certainty brings a relief. Another lesson was to find out that I’m not, in fact, indispensable – the service in Tanzania ran beautifully without me. The local team stepped up and owned the entire program. It was a magical thing to witness and something that made me very proud. I also learned about symptoms in a way that is only possible by living them: constant nausea is worse than vomiting, and constipation is sometimes really something beyond pain. If it wasn’t so toxic I’d be recommending every aspiring oncologist take at least one course of chemotherapy.
Mastectomy is not mutilating. It is an important treatment option with fewer side effects and risks than some other more popular options.  
I learned about nutrition and exercise, about mindfulness and healthy living (mostly through my amazing brother) – none of which is explained in hospital. All give you a sense of focus when you are otherwise out of control. Why also did I not know the direct risk linking alcohol and breast cancer? These lessons have influenced my own life and also have newly shaped my clinical practice (though alcohol consumption is less of an issue in kids with cancer). But more than all these practical lessons, the most important knowledge cancer unlocked was simply understanding how incredibly lucky I am. Born lucky in fact, into a position in the world where I automatically benefit from all the risks taken by so many brave pioneers of oncology – decades of doctors, nurses, and most of all, patients. Of course I was lucky before I was sick: incredible family, and life choices limited only by my own imagination. But I guess it took confronting mortality at 39 to focus the mind. It made me realize that on the grand scale of life and the universe there is essentially no difference between living 40 or 80 years – what matters is whether you live well or squander those years. Living with purpose should always have mattered but now it is essential. For me it has meant altering my life plan in two ways. I’ve moved from helping a single hospital build a pediatric oncology service to a slightly larger vision of  helping the National Service reach and care for every child with cancer in Tanzania. Every child should have the chances I have been given... and I never turn down a fun invitation or miss an important social occasion. It’s not the easiest balance but I definitely feel like these days I’m making the most of my time here. Jack London said it best – "I would rather be ashes than dust!" Feature image courtesy of Dr. Trish Scanlan.  [post_title] => Living with Purpose [post_excerpt] => Dr. Trish Scanlan shares her story of surviving breast cancer not once, but twice, while working with children with late-stage cancer in Tanzania. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => living-with-purpose [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:09:22 [post_modified_gmt] => 2017-08-27 03:09:22 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=1157 [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 )

Dr. Trish Scanlan shares her story of surviving breast cancer not once, but twice, while working with children with late-stage cancer in Tanzania.

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Critical Public Health Fund Would Be Lost With ACA Repeal

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                    [post_content] => When public health works, no one sees it – a truth that I’m quite proud of, but also one that creates significant challenges when public health needs support (which is all the time). Evidence of a successful public health program is when people are not getting sick, but unfortunately, decision-makers often notice only when people are getting sick.

This is our challenge as we try to save the Centers for Disease Control and Prevention (CDC)-managed Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) program, a source of crosscutting support for public health laboratories funded under the Affordable Care Act (ACA) through the Prevention and Public Health Fund (PPHF). The PPHF is the first and only mandatory public health funding program in the United States.

ELC is the bedrock of America’s public health detection system. It strengthens epidemiology capacity, laboratory capacity and health information systems (aka, health IT) in 65 local, state and territorial epidemiology and laboratory programs. APHL members – local, state and territorial laboratories – rely on ELC to maintain capacity to effectively and rapidly protect the public’s health. But as President Trump and members of Congress work to repeal the ACA with a focus on the healthcare component, ELC is at risk of repeal without replacement too.

Here’s a quick primer on how ELC works (it’s rather complicated even for those of us immersed in it). ELC has two components. The first is a crosscutting base program which supports basic epi, lab and health IT functions. This is the section that’s included in the PPHF and ACA, and is at risk of being eliminated. It includes support for staff liaisons between laboratory and epidemiology programs, courier systems for transporting potentially hazardous samples and materials, lab equipment and maintenance contracts, scientists who can work across various areas of a laboratory, electronic lab reporting and other crosscutting activities. The second component of the ELC, which does not reside in the ACA, funds response to specific infectious diseases such as Zika, influenza, antimicrobial resistance and foodborne diseases. While this, too, is a critical public health program, its place outside of the ACA means it is safe for now so APHL is focusing efforts on saving the first component.
The public needed this testing far sooner than Congress approved to fund it. Until supplemental funding arrived, public health laboratories could rely on ELC funding to begin their surge testing and response.  
What does ELC really mean for public health? How has ELC proven itself invaluable? When it first became clear that Zika posed a significant threat to our country, APHL collaborated with federal partners to expedite implementation of public health laboratory testing. Laboratories needed proper equipment, scientists with the expertise to operate the equipment, systems for receiving samples, systems for communicating results and more. These are activities that would be covered by designated Zika funding once approved by Congress and distributed by CDC, but, as you may remember, that took about nine months which is a very long time. Public health labs couldn’t wait for the money – they needed to begin surge testing as the number of samples steadily increased. Each of those samples was from an individual desperate to know if they had Zika. In many cases, the individuals were pregnant women and their partners who were concerned for their baby’s health. The public needed this testing far sooner than Congress approved to fund it. Until supplemental funding arrived, public health laboratories could rely on ELC funding to begin their surge testing and response. Without that funding, the labs – already short on funding for routine testing operations, much less an unexpected outbreak – would not have been able to test the thousands of samples arriving at their doors.
To be very honest, without ELC, I’m not sure what will happen when the weather warms and Zika returns to the US.  
I know with certainty that laboratory staff have the expertise and passion to respond, but they are only human. To be very honest, [ictt-tweet-inline]without ELC, I’m not sure what will happen when the weather warms and Zika returns to the US.[/ictt-tweet-inline] How will public health laboratories respond effectively to a new threat while still managing routine testing for infectious and foodborne diseases? ELC has allowed public health laboratory staff to jump into action and provided them with necessary support. Without it? I just don’t know. It’s unfortunate that politics can get in the way of committed epidemiologists and laboratory scientists doing their jobs to protect the public’s health, but it seems to happen often. The frustrating irony of this debate over ACA and concerns over rising health insurance costs is that disease prevention cuts healthcare costs across the board. If people don’t get sick, they don’t miss work, they don’t see their doctors and they don’t go to the hospital. Disease prevention saves money. Yet this deeply political and divisive debate over the ACA has not included mention of the ELC. If you are interested in supporting the #SaveELC effort, [ictt-tweet-inline]contact your elected officials to remind them that ELC is part of the ACA and to emphasize its value.[/ictt-tweet-inline] Encourage them to support keeping ELC intact or, should the ACA be repealed, support an equally impactful replacement. Losing this program will be detrimental to infectious disease detection and response, which could jeopardize the public’s health. Here is additional information on ELC that might be helpful to share. Contact your US Senators, Representative, and President Trump. Feature image: CDC Global, A blood-engorged female Aedes albopictus mosquito feeding on a human host. More information on the Zika virus. Used under CC BY 2.0/cropped from original.  [post_title] => Critical Public Health Fund Would Be Lost With ACA Repeal [post_excerpt] => What does the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) really mean for public health? [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => critical-public-health-fund-lost-aca-repeal [to_ping] => [pinged] => [post_modified] => 2017-08-22 18:03:09 [post_modified_gmt] => 2017-08-22 22:03:09 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=1162 [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 )

What does the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) really mean for public health?

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Lessons from the Tea Party

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                    [post_content] => Supporters of the Affordable Care Act (ACA) are in a tough position. Now that Donald Trump has become President, the threat of a Senate filibuster will be the only thing keeping Republicans from being able to do whatever they want—or at least whatever they can agree to amongst themselves—from repealing Obamacare to privatizing Medicare and block granting Medicaid. Republicans can actually make significant health policy changes without having to worry about the filibuster, such as by using regulation to alter climate change policy at the Environmental Protection Agency or the Congressional reconciliation process to repeal the major coverage provisions, like the individual mandate, exchanges, and Medicaid expansion. I suspect Congress will punt on some of the toughest ACA questions, passing major decisions on to the states. Once again, states would then become a primary battleground in the fight over health reform.

[ictt-tweet-inline]Supporters of the ACA should look to an uncomfortable place for ideas on how to respond: the Tea Party[/ictt-tweet-inline]. In fact, the recent Women’s March in Washington D.C. and in cities around world is a great parallel for how the Tea Party was launched. The first rallies took place in February 2009, shortly after a new president took office and large numbers of people were worried about the economy and about being marginalized by the new administration. Many people are asking what they do now that they are home from the march. Look to the Tea Party.

The Tea Party was amazingly effective at influencing policy outcomes in states around the country, in many cases beating an unprecedented coalition of the historically most powerful interest groups in health such as insurers, hospitals, doctors, small businesses, and consumer advocates. I have interviewed more than 200 policymakers about these fights, including many Tea Party activists. I have learned at least seven lessons from this research that supporters of the ACA should consider as they try to save the act
  1. Get involved
Tea Party activists (as opposed to politicians who co-opted the movement) were almost always regular citizens with virtually no experience in government. They were not even political junkies who paid disproportionately close attention to policymaking. They were grandmas and grandpas who were deeply concerned with the direction they saw their country heading. They were not polished, but if anything this enhanced the sincerity of their message. They did not wait for invitations to get involved or formally join an organization. They self-mobilized. [ictt-tweet-inline]If you really disagree with Paul Ryan or worry about what Donald Trump will do, then you need to get involved[/ictt-tweet-inline].
  1. Make it personal
Where should you begin? By personally connecting with your elected officials. Politicians care deeply about reelection and so generally make themselves accessible to constituents. Tea Partiers did not just write letters and disagree on social media, they called and made staff members listen to them. They showed up at district coffee hours and vented to their representatives. They dropped by their legislators’ office. They went to town hall meetings and spoke up. This article does a great job summarizing tips from a former Congressional staffer (@editoremilye) on the best ways to get your representative’s attention. I did not always agree with Tea Party activists I interviewed, but I was almost always impressed by their commitment. I regularly came away feeling that our political discourse and policy outcomes would be very different if more Americans across the political spectrum showed the same level of interest and dedication. One of the most important ways to fight for the rights of vulnerable populations is to make sure politicians see the people behind the arguments. Immigrants, LGBT youth, and recently insured Americans need to put their stories out there and personally introduce themselves to their leaders. The daily reality of work and family obligations mean it will be harder to get involved than it is for retirees, but these voices need to be heard. Go to marches. Attend town hall meetings held by your Member of Congress. Call or email your state leaders. Speak up on social media. Engage with local government. Run for office. Last week I collected enough signatures to get on the ballot for a position in my town. I realize that participating in the governing of a small town in the liberal state of Massachusetts won’t change national policy, but it is my way of stepping up and getting involved and will add up if enough people do the same.
Many people are asking what they do now that they are home from the Women's March in Washington DC. Look to the Tea Party.  
  1. Learn the process
The Tea Party first gained prominence through its large rallies around tax day in 2009, but activists had the most influence by inserting themselves in the minutiae of the policy-making process. For example, one leader in Michigan wrote on her blog that “Attendance at a Committee Meeting is more effective than large rallies” (emphasis in the original). In my forthcoming book Exchange Politics: Opposing Obamacare in Battleground States, I chart the spike in the number of Tea Partiers that attended committee hearings about an exchange in the subsequent months and the effect this had on the outcome. Many of them testified against an exchange, but even the mere presence of groups as small as 10 people has the ability to dramatically change the dynamic. Legislators are chronically worried that a spike in attention is just the tip of the iceberg signaling that many more will mobilize if they vote the wrong way. Regular people wanting to affect policy outcomes should make a point of understanding how Congress and their state legislatures work. Figure out how to follow the process and show up at key moments.
  1. Need for leadership
There is no such a thing as THE Tea Party. It is actually a decentralized collection of local movements. This is an advantage in many ways but creates a power vacuum. National and state-level organizations played an important role as the de facto leaders in many states. Sometimes these were conservative think tanks and sometimes they were dark money groups funded by the Koch brothers, Charles and David, wealthy contributors to conservative and libertarian causes and campaigns. They did not have power in a hierarchical sense, but they were instrumental in educating regular citizens on the policymaking process and explaining policy debates in simple terms. They alerted people through social media and blogs about key hearings or legislative votes. If a grassroots movement defending the ACA and blocking Trump is to succeed, these types of organizations will need to step up.
  1. Simple Framing
The Tea Party movement is driven by fairly simple ideology. I was often jealous of an interviewee’s ability to boil any complex argument to two words: freedom and liberty. Did the policy in question enhance or jeopardize freedom? They were not interested in talking about the risks of adverse selection; an insurance mandate is bad because it restricts liberty. Just about anything that increases the role of government should be resisted because it infringes on freedoms. We have to appreciate that better evidence is not enough to win policy arguments; we have to tap into and frame these ideas in terms of core American values. There is no reason that supporters of the ACA and those who disagree with Donald Trump can’t take back ownership of words like freedom and liberty. Policies that would limit immigrant rights or restrict access to health care should be framed in these terms. People are not free if life, liberty, and the pursuit of happiness are not options.
We have to appreciate that better evidence is not enough to win policy arguments; we have to tap into and frame these ideas in terms of core American values.  
 
  1. Redistricting reform
[ictt-tweet-inline]Priority number one should be changing how Congressional districts are drawn.[/ictt-tweet-inline] As I wrote right before the election, the shape of our maps dramatically affect everything about our politics. Balancing our districts won’t guarantee that Democrats will win a majority or even more seats—but that is not the point. The goal is to move our arguments to the center where the incentive is to compromise and solve problems rather than stay on the extremes where the incentive is to fight and resist compromise.
  1. Warning
There are a number of risks to encouraging grassroots activism of this sort on the left. For one, I am a firm believer that [ictt-tweet-inline]population health goals transcend partisan politics[/ictt-tweet-inline]. Public health needs a stronger stomach for politics and should focus more on building more bridges than getting in the mud. The Tea Party stoked an unhealthy “us vs. them” mentality that culminated with the ugly 2016 election cycle. What I am imagining would hopefully have the opposite effect. We should reject political discourse that is personal and mean. I am intrigued by Van Jones’ call for a #LoveArmy to reach out with “respect to the Trump voters who don’t subscribe to everything he has ever said.” As Jones puts it, “The problem is not the abundance of people with bad intentions; it’s the superabundance of people with good intentions who don’t know what to do yet.” If you are one of these people, I suggest you get involved, personally [ictt-tweet-inline]meet your elected officials, learn the policy process, and advocate for redistricting reform[/ictt-tweet-inline]. Lessons from the Tea Party was originally published on Public Health Post under Research on December 13, 2016. The current article is also published on the February 9 issue of BU Today Feature image: Cody Williams, Make Peace, used under CC BY 2.0 [post_title] => Lessons from the Tea Party [post_excerpt] => Supporters of the Affordable Care Act (ACA) are in a tough position. The recent Women’s March in Washington D.C. and in cities around world is a great parallel for how the Tea Party was launched. Many people are asking what they do now that they are home from the march. Look to the Tea Party. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => lessons-tea-party [to_ping] => [pinged] => [post_modified] => 2018-01-18 15:26:00 [post_modified_gmt] => 2018-01-18 20:26:00 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=1069 [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 )

Supporters of the Affordable Care Act (ACA) are in a tough position. The recent Women’s March in Washington D.C. and in cities around world is a great parallel for how the Tea Party was launched. Many people are asking what they do now that they are home from the march. Look to the Tea Party.

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Re-examining Medical School

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                    [post_content] => In 1910 Abraham Flexner published his report "Medical Education in the United States and Canada," now more affectionately called the Flexner Report. This report challenged U.S. medical schools to re-evaluate their curricula, to become more academic in training; with an end result of removing the “weaker and superfluous” institutions.

While the Flexner Report was appropriate for its time, ensuring that physicians were being trained in rigorous environments, utilizing the scientific method, participating in original research and learning by doing; we have come to a point in healthcare where we must look beyond what “traditional academic medicine” has been providing for the past century. If the current physicians-in-training are to best serve the evolving needs of their patients and communities, it is of the utmost importance that medical education includes public health and prevention in the curriculum, thereby addressing social accountability of medical schools.

In 1995 the World Health Organization (WHO) defined the social accountability of medical schools as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and public.” Utilizing this model in medical education will in essence give medical schools a chief role in influencing healthcare systems both broadly and most directly affecting their communities in order to achieve and maintain quality, affordable, equitable healthcare.

In medical school, we are taught how to diagnose and treat any patient we may encounter. We learn about the human body from its most broad to most specific functions. There is not a nook or cranny left unstudied. And while we learn the science of the human body, we learn the pharmacology of the medicines we will prescribe in the future. Their names, their mechanisms of action, when to prescribe them and what side effects patients may experience when taking them. We learn about the ethics of medicine, how to interview patients, how to take a history, how to perform a physical examination. All of this happens in the first two years of training in the classroom, before we are even allowed to step into a clinical setting and practice what we have been studying.
Having training in public health would not only benefit those physicians-in-training heading into clinics to provide comprehensive care; but it would greatly benefit all of their future patients.  
While medical school curriculum varies among institutions, it is still common to find many schools that do not provide adequate training in public health issues and how they relate to the health of patients. However, [ictt-tweet-inline]many medical students do not fully comprehend that health extends beyond the examination room[/ictt-tweet-inline]. Some might equate having health insurance being access to care. Some might not consider the reason that a patient is not adhering to a treatment plan is because they have difficulties obtaining the prescribed medicine in the first place. Some might not even consider that climate change is disproportionately affecting the health of people of a lower socioeconomic status and fail to ask about things like breathing and drinking water. Having training in public health would not only benefit those physicians-in-training heading into clinics to provide comprehensive care; but it would greatly benefit all of their future patients. Today, we find that more medical students are choosing to pursue their Master of Public Health (MPH) degree either prior to matriculating into medical school or concurrently with their medical school education. At least 80 medical schools help their students obtain an MPH. Physicians-in-training recognize the importance and benefit of obtaining this training and many will go out of their way to get it. [ictt-tweet-inline]An MPH degree offers the perspective of health from an even broader view than we are exposed to in medical school. [/ictt-tweet-inline] It provides students with the perspective that a patient exists outside of the exam room, including that every patient has a multitude of interactions and conditions in their daily lives that directly affect their personal health. Medical students who have had exposure to public health education are likely to consider factors such as health policies, sexual orientation, race, access to medicine, access to childcare, education, socioeconomic status and a patient’s zip code (among many other factors) when assessing, diagnosing and treating a patient. When we look at healthcare in our country it is evident that many physicians are providing quality care. The Flexner Report did its job in helping to produce competent, qualified physicians. However, when we look at healthcare in our country it is also evident that [ictt-tweet-inline]many physicians are not adequately trained to improve health in our country.[/ictt-tweet-inline] As we see a rise in chronic health conditions, persistent health disparities and the perseverance of a system that values sick care over health care, it is crucial that medical institutions begin to educate physicians-in-training about public health issues that affect the overall health of their patients and the communities they serve. The Liaison Committee on Medical Education (LCME) publishes standards for medical school curriculum and has broadly incorporated public health in a few generic terms for the 2017-2018 academic year. The terms “social sciences, societal problems, cultural competence and health care disparities” all appear under Standard 7 of the document outlining Functions and Structure of medical schools. Institutions can interpret this how they wish and can provide as little or as much training in these areas as needed to fulfill the requirement. We, as physicians-in-training must hold our institutions accountable for providing us with the education surrounding comprehensive public health issues so that we can exit our medical training prepared not only to address health from within the exam room; but with the skill to think bigger and to take the patient’s life as a whole into account while diagnosing and treating. Feature image: A.Currell, A Visit To The Hospital Training Room Closet, used under CC BY-NC 2.0 license/cropped from original
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To best serve the evolving needs of patients and communities, medical education should include public health and prevention in the curriculum, thereby addressing social accountability of medical schools.

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Viewpoint

Let’s Not Panic About the Vaccine Commission Just Yet

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                    [post_content] => Many people are concerned about President-elect Trump creating a commission "on vaccine safety and scientific integrity." As someone who spends a lot of time studying child vaccine policy (such as this article in the Millbank Quarterly and this blog post published by NACCHO), I wanted to provide some reasons why I do not think we should panic just yet:

1. Much of child vaccine policy is set at the state level. Want to mandate that children receive the chickenpox vaccine? State governments are responsible for these laws. Want the right to opt out of vaccines due to religious reasons? State governments are responsible for this, too. Want to make sure that every parent of a seventh-grader is informed about the HPV vaccine? You guessed it, state governments again. While creating such a commission (or publicizing the fact that there might be such a commission) could cast doubt on the safety of vaccines, the federal government cannot change these types of laws outright.

2. It's tough to change state child vaccine policies. Even when the now-discredited article claiming the MMR vaccine-autism link came out, there wasn't a bunch of legislation passed to remove vaccine requirements or allow more parents to opt out of vaccines for their kids. Notably, in 2003, Texas (more about Texas later) and Arkansas changed their laws to allow for philosophical exemptions to vaccination. To qualify for a philosophical exemption, parents simply say that they do not believe in vaccination, or question the safety of vaccines, and their child is able to attend school unvaccinated. To be fair, if a couple states do end up changing their laws to allow more philosophical exemptions, it could spell trouble at the local level.
While talk of vaccine safety commissions is concerning to those of us who believe that vaccines are both safe and effective, there is no reason for us to panic just yet.  
3. The feds have turned to panels of experts before to examine vaccine safety. They found no causal link between the MMR vaccine and autism. (Granted, the investigation may be more politically motivated this time). The report referenced above is written for an academic audience and, as such, they bury the lead: "The committee concludes that the body of epidemiological evidence favors rejection of a causal relationship between the MMR vaccine and autism." A listing of additional independent vaccine reports by the Institute of Medicine is available here. Let's save federal dollars and effort and put them toward other pressing health concerns. Speaking of which... 4. We should be focusing our media and personal attention on other health-related policy issues (ahem, ahem, the ACA). I'll let you know when I'm worried about the state of state vaccine policy, which has been going the other way recently (see for example, laws in Michigan in 2014, and California and Vermont in 2015 that aim to increase vaccination among children). Speaking of which, a Republican lawmaker in Texas has introduced a bill that would require parental education prior to opting out of vaccination. This comes two years after another Republican lawmaker tried to get rid of the philosophical exemption entirely. Without going into too much detail about state politics, it is worth noting that both Republicans (e.g., Michigan and Texas) and Democrats (e.g., California and Vermont) work to promote childhood immunization. 5. While I'm not concerned about the Trump administration changing mandate and exemption laws (recall, these are state-level policies), the administration can exert control in some troubling ways. For example, I would be concerned about the fate of the federal-level Vaccines for Children program. This program provides free vaccines to children whose families can’t afford them. But, it's likely that a repeal and replace of the Affordable Care Act will take precedence over cuts to programs like this (I hope). While talk of vaccine safety commissions is concerning to those of us who believe that vaccines are both safe and effective, there is no reason for us to panic just yet. Featured image: Quinn Dombrowski, Day 354: First Shot, used under CC BY-SA 2.0 license/cropped from the original [post_title] => Let's Not Panic About the Vaccine Commission Just Yet [post_excerpt] => While talk of vaccine safety commissions is concerning to those who believe that vaccines are both safe and effective, here are some reasons not to panic. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => lets-not-panic-vaccine-commission-just-yet [to_ping] => [pinged] => [post_modified] => 2017-08-23 17:44:46 [post_modified_gmt] => 2017-08-23 21:44:46 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=998 [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 )

While talk of vaccine safety commissions is concerning to those who believe that vaccines are both safe and effective, here are some reasons not to panic.

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Viewpoint

Lessons from 1993

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                    [post_content] => President Trump. I am stunned to see these two words side by side on my computer screen. But here we are. Donald Trump's inauguration today opens a dramatic new chapter in the debate over health reform in the United States. I thought we were done fighting over the ACA's existence. In my office at home I have a sign that I kept from being outside the Supreme Court the day King v. Burwell was decided in June 2015. "The ACA is Here to Stay" it reads.

The pendulum on opinions about the law's future quickly shifted last November. After Hillary Clinton lost many people said it was a done deal that the ACA would be repealed. Without question it is still vulnerable, however, [ictt-tweet-inline]I am more optimistic about the ACA's fate than I have been at any time since the morning of November 9th[/ictt-tweet-inline]. Recent history makes it clear just how hard it is to pass major health reform legislation. Yes, the type of reform that Paul Ryan, Mitch McConnell, and Donald Trump are trying to enact is fundamentally different from what Bill Clinton and Barack Obama attempted and so the lessons do not apply exactly. But [ictt-tweet-inline]the current reform debate feels more like the failed effort in 1993/1994 than the successful one in 2009/2010[/ictt-tweet-inline].
I am more optimistic about the ACA's fate than I have been at any time since the morning of November 9th  

Health Reform is Inevitable?

When Democrats took control of all three branches of government in 1993 there was a widespread desire to pass comprehensive health reform. This was the moment. Health reform was inevitable. Yet while there was consensus on a desire to pass health reform, there was no consensus on what type of reform to pass. Democrats couldn't decide whether to push for a single payer system or something more moderate. They considered using reconciliation but Senator Byrd said no. Their lack of consensus created a vacuum that opponents used to own the messaging. As a result, the Clintons' reform went nowhere, dying without a vote on the floor of either chamber. Republicans right now agree they want reform. They believe it is OK to fight over the details because repeal is inevitable. But they are far from a consensus on what to replace the ACA with once it is repealed. They have tried to get around this by delaying the date that repeal would go into effect and focusing primarily on what they can remove through reconciliation. This process lowers the vote threshold in the Senate from 60 votes to 51. However, even this is a very tough bar to clear with almost no room for a single defection. A handful of Senators have recently made it clear that they believe it would be a mistake to repeal the law without replacing it, raising questions about whether reconciliation is even feasible. Some have argued that enough Democrats will vote with Republicans on a replacement bill in order to mitigate the damage done by repealing the law. However, that does not seem to be the case. Democrats seem to have learned from the successful efforts by Republicans in 1993 and 2009 by uniting against the party in charge. [caption id="attachment_986" align="alignright" width="338"] Image taken by author outside Supreme Court on June 25, 2015[/caption]

Letting Congress Lead

One way this moment feels very different from 1993 is that the policy agenda is not being driven by the White House. Trump is criticized for saying he will leave the policy details of health reform to Congress. To some extent this is out of necessity - I don't think he really understands the policy details. Even so, he is putting in place a health policy team of Tom Price and Seema Verma that do understand the ACA. I suspect we will see a lot more policy details from the Trump administration once Tom Price and Seema Verma are confirmed. But letting Congress lead the conversation is actually smart politics. One of the main lessons from 1993 was that Clinton should have more fully respected the role of Congress in shaping policy. Committee leadership in the House and Senate were not interested in rubber-stamping a White House bill. Some accused the Obama administration of over-learning this lesson and being too distant, but letting Congress drive the process was an important reason the ACA passed. [ictt-tweet-inline]Republicans in Congress do not seem to have learned a couple major lessons from 1993 and 2009[/ictt-tweet-inline]. Most importantly, the clock is ticking and compromise gets harder with time, not easier. The Trump administration will soon have to produce a budget. The midterm elections will come sooner than seems possible. Long delays in the legislative process give an opening to opponents to attack. [ictt-tweet-inline]It might already be too late for Republicans to come to a meaningful consensus[/ictt-tweet-inline]. House Democrats in 2009 made an unprecedented move by writing a single bill for all three major health reform committees. It's true that this bill was not introduced until July 2009 and so it might seem like Republicans still have many months to get to this point. But remember that leading Democrats had actually spent most of 2008 working through issues, before even knowing whether the next president would be Barack Obama or John McCain. Paul Ryan seemed to want to do the same thing last summer with "A Better Way," but there was reportedly enough infighting over this that the blueprints are not detailed enough to provide much of a road map. It is still far too early to know how this will play out. Republicans are under enormous pressure to do something. But they are finding that being in a position to deliver on threats is very different from being in the minority when you can promise just about anything knowing it won't happen. Donald Trump is the wild card in this process. Politics has never seen anyone quite like him and he has already shown he can change national (and international) dynamics with a Tweet. He has encouraged Congress to act quickly and to pass something that makes insurance available to everyone. I am not convinced either is possible. In fact, the two might be mutually exclusive. Featured Image: DVIDSHUB, Marines support 57th Presidential Inauguration, used under CC BY license, cropped from original. Audience members wave flags from the National Mall during the 57th Presidential Inauguration in Washington, Jan. 21, 2013. More than 700 thousand people made their way to the National Mall for the day's events. For centuries, Marines and other service members have supported the inaugural events. U.S. Marine Corps photo by Staff Sgt. Mark Fayloga. [post_title] => Lessons from 1993 [post_excerpt] => I am more optimistic about the ACA's fate than at any time since November 9th. The current fight feels more like 1993 when Clinton failed than 2009 when Obama succeeded. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => lessons-from-1993 [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:49:03 [post_modified_gmt] => 2017-08-27 03:49:03 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=982 [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 )

I am more optimistic about the ACA’s fate than at any time since November 9th. The current fight feels more like 1993 when Clinton failed than 2009 when Obama succeeded.

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Put People and Prevention Ahead of Politics

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                    [post_content] => We're pleased to publish the winning essay in PHP's first essay contest "Dear Paul Ryan..."   Congratulations and thank you to all the students who submitted essays! Here are links to our Tuesday and Wednesday finalists.

Dear Mr. Speaker,

You and the new administration could largely dismantle the ACA by eliminating the individual mandate and subsidies through budget reconciliation. However, that pesky saying comes to mind, “be careful what you wish for.” The uncertainty of delayed repeal without a clear plan for replacement could prematurely collapse the insurance exchanges and leave the Republican-controlled Congress in crisis. As you mention in “A Better Way,” “people must come first” and we need to work towards a system that provides “high-quality health care for all.” Health reform often focuses on the decision making of individuals – patients and their doctors – and rightfully so. We try to elicit efficient consumption of health care from patients by balancing “skin in the game” with the long-run costs of foregone care. However, we have known for decades that patients are not good at differentiating between medically effective and low-value care with more recent evidence that increased cost-sharing can actually reduce utilization of clinically important services. We develop new payment models to address the supplier side incentives to increase utilization and hope that these mechanisms combine to yield more efficient use of care. Though accountable care organizations have gained traction as a new form of managed care, promising signs of reductions in low-value care in Medicare have not translated over to a more diverse Medicaid population. We also peg Medicare reimbursements to 30-day readmission rates that may be a flawed measure of quality of care–but perhaps correctable. There isn’t a silver bullet that will ‘fix’ health care spending. Greater price transparency would be great for consumers – in theory – if savings were substantial (not so far) and records from an MRI or blood tests could be instantly transferred from the low-cost provider to your preferred physician (but their EHRs probably can’t talk to each other). So what should we do? I would argue that all of this is important work given that even a half or one percent change in total health care spending is still billions of dollars. That said, it is only window dressing. We need to focus on the underlying causes of poor health and to do this, we must focus on public health.
Health insurance, no matter how well designed, cannot improve population health and create massive reductions in health care spending.  
A healthy population is critical to unleashing our innovative capacity and creating robust economic growth. Health insurance, no matter how well designed, cannot improve population health and create massive reductions in health care spending. Racial disparities in health care are associated with over $200 billion per year in economic losses through lost productivity and premature death, not including another $35 billion per year in excess health care spending. And that ignores the psychological toll on millions of Americans and their families. These disparities have evolved from the social determinants of health, including education, income, housing, and neighborhoods, which play a huge role in determining health outcomes. The fact that two children born a few Metro stops apart can have an 8 year difference in life expectancy doesn’t resonate with the vision of equal opportunity and social mobility that America is supposed to represent. So again, what do we do? Public health is about much more than infectious disease–it is about identifying the root causes and improving health through any means necessary. For example, CDC developed a hard-hitting media campaign that encouraged 100,000 smokers to quit at a cost of less than $500 per quitter in just its first year [Disclosure: I am part of the evaluation team at RTI International for this campaign.] Twenty-four cities in Missouri banded together to rebuild their community by thinking holistically, the Columbia Gorge region of Oregon improved food security and gave its residents a voice in the structure of Medicaid spending, and so on. There are dozens of stories like this around the country but sadly not enough.
Make the Prevention and Public Health Fund, currently part of the ACA, permanent and fully funded through standalone legislation.  
If we want to truly make a difference, here is a simple way to start. Make the Prevention and Public Health Fund, currently part of the ACA, permanent and fully funded through standalone legislation. We spend 75 percent of our health care dollars on preventable disease but only three percent on prevention. If we want to make a dent in spending, we need to focus on prevention (not just preventive services) and really mean it–by taking it farther from the political arena. This is only a first step. Building a Culture of Health will require bold action on housing, education, and other social determinants of health. However, before we can go there, we all need to agree that health is a shared value and understand how the social determinants of health shape our lives – only then can we begin to reshape federal policy and the budget to address health care spending. We both want what is best for America – taking this small step forward together and making public health a non-partisan issue is a smart investment in our future. Featured Image: U.S. Department of AgricultureUSDA Photo by Lance Cheung. Students saw, touched and sometimes tasted produce that was new to them at Nottingham Elementary School in Arlington, VA, on Wednesday, October 12, 2011. Farmers from Bigg Riggs Farm in Hampshire County, WV, and Maple Avenue Market Farm in Vienna, VA were very popular with the students. Today's menu included roasted chicken, roasted butternut squash with dried cranberries, farm fresh mixed lettuce salad, turkey wraps, pita wedges, hot muffins, carrots, Asian pears and more. Used under CC BY 2.0 license/cropped from the original [post_title] => Put People and Prevention Ahead of Politics [post_excerpt] => We're pleased to publish the winning essay in PHP's first essay contest "Dear Paul Ryan..." Congratulations and thank you to all the students who submitted essays! [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => put-people-and-prevention-ahead-of-politics [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:44:18 [post_modified_gmt] => 2017-08-27 03:44:18 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=938 [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 )

We’re pleased to publish the winning essay in PHP’s first essay contest “Dear Paul Ryan…” Congratulations and thank you to all the students who submitted essays!

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Viewpoint

Making a Case for a Public Option

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                    [post_content] => We're pleased to publish the second of two finalists in PHP's first essay contest "Dear Paul Ryan..."  Read our other finalist here. The winning essay will be published tomorrow (Thursday, January 18, 2017).

Dear Mr. Speaker,

I believe in the ability of public health initiatives to improve the lives of individual Americans as well as the country as a whole. Public health focuses on population health and preventative measures that improve health. Historical public health movements have resulted in providing clean water, creating sewage systems, and improving unsafe housing conditions in order to prevent epidemics such as typhoid, yellow fever, and cholera. Individuals are not equipped to deal with these systemic issues, thus the government must step in to provide the needed interventions. I ask you to prioritize public health as the Speaker of the House in order to ensure better access to health care, lower health care costs, and to improve both health and economic outcomes. The United States spends the most on health care per capita in the world but Americans often have worse health outcomes than individuals in the other countries. In 2015, the United States spent 16.9% of its GDP on all health expenditures. Switzerland, the Organization for Economic Co-operation and Development (OECD) country that has the second highest percentage, spent only 11.5% of its GDP that year. This number may be justifiable if the United States had the best health outcomes, but unfortunately we do not. Life expectancy at birth in the United States ranks 26th out of 38 OECD countries and the infant mortality rate in the United States is higher than the OECD average. If we are spending more, we should be getting more.
Keeping the Patient Protection and Affordable Care Act (ACA) is the most pressing way at the moment our federal government can promote public health.  
Many poor health outcomes are a result of social determinants of health and people not receiving the care they need.  Low socioeconomic status often means higher disease rates and premature death due in part to inadequate access to health care. It is morally wrong to deny people equal access to living a quality life, and it is also bad for society. Sick people are not able to give back as much as healthy people. A recent NBER working paper shows that children who were eligible for Medicaid at an earlier age had lower mortality and disability rates as adults, earned more income, and reduced overall governmental spending because of increased tax contributions and decreased benefit payments. Health and productivity are intertwined, thus better health for individuals provides a more stable bottom line for America. Keeping the Patient Protection and Affordable Care Act (ACA) is the most pressing way at the moment our federal government can promote public health. The ACA has successfully achieved its goal of providing greater access to health insurance. Twenty million more Americans are now more likely to get the care they need without suffering dire financial consequences. I realize the ACA is incredibly unpopular with you, despite its successes, but I urge you to reconsider your position on repealing and delaying. A report by the Urban Institute lists the disastrous ramifications of partially repealing the ACA, stating that uninsurance rates and health care costs would be even higher than before the ACA.
It is morally wrong to deny people equal access to living a quality life, and it is also bad for society.  
If the individual mandate is eliminated, whether through a full repeal or a budget reconciliation bill, healthy people will be less likely to sign up for insurance and premiums would continue to rise. If subsidies are also reduced, people will be unable to afford insurance on the exchange, meaning that the ACA will be effectively destroyed. I would like to propose a different option. You’ve heard this before but I would like for you to consider it and its benefits: the government-run public insurance option. I ask you to reconsider because the ACA and the public option have more support than you may think and providing a public option will mean that more people can stay insured and receive the preventative care they need. Republicans are backpedaling on their desire to repeal the ACA in its entirety and polls show that more Americans want to expand or keep the law as is compared to repealing or limiting the reach of the law. Similarly, more Americans are in support of a public option plan than not, and the majority of physicians support having a public option. Repealing parts of the ACA has already been shown to be unpopular, and maybe even impossible. The newly elected Governor of Kentucky ran his campaign on the promise of undoing Medicaid expansion in the state. When he got into office, he was unable to take the insurance away from 425,000 individuals and switched his goal to reforming instead of repealing. I realize people do not expect Republicans to consider this proposal and therefore look for other, and I argue more complicated, ways to improve the ACA. But I think this is the right thing to do and it should be considered. A public option would address some of the problems of the ACA, including private insurers leaving the market place since it would serve as an option in marketplaces where there are no other options. Since the government does not need to make a profit, it should provide an insurance option that is lower-cost that provides higher quality. It could be budget neutral if it served as a place for people to pool their premiums. Also the government could set its payments to providers lower as it does for Medicare and Medicaid, thus lowering health care costs. Perhaps the best way to do this is through Medicaid managed-care plans as suggested recently by Michael Sparer in New England Journal of Medicine, but either way, there must be a government-run option in the ACA marketplace in order to improve the health care system in the United States. Featured Image: LaDawna Howard#protectthelaw Rally in support of the Affordable Care Act in front of the US Supreme Court in Washington DC, can be reused under CC BY 2.0 license [post_title] => Making a Case for a Public Option [post_excerpt] => The second of three essays chosen in PHP’s first essay contest “Dear Paul Ryan…” [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => making-a-case-for-a-public-option [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:46:39 [post_modified_gmt] => 2017-08-27 03:46:39 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=923 [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 second of three essays chosen in PHP’s first essay contest “Dear Paul Ryan…”

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