Category: Healthcare Reform

Medicaid Expansion and the Opioid Epidemic in the U.S.

As the United States continues to be embattled in an ongoing opioid overdose epidemic, new research is showing the benefits that Medicaid expansion has had under the Patient Protection and Affordable Care Act (ACA). According to a recent study out of the Center on Budget and Policy Priorities, the rate in which patients who were hospitalized due to opioid-related health issues, who were uninsured dropped in states that expanded Medicaid, from 13.4% in 2013 to 2.9% the following year. The same study also showed that Medicaid expansion had not contributed to the ongoing opioid crisis, showing that opioid-related hospitalizations were higher in states that expanded Medicaid three years before expansion occurred, and that the rates had been steady in expansion and non-expansion states. As we can see, Medicaid expansion has had a profound impact in reducing the rate of uninsured, and in the case of the ongoing Opioid epidemic, Medicaid plays a key and vital role in working to help curb the epidemic. For more information on this study from the Center on Budget and Policy Priorities, please check out the link below.


Center on Budget and Policy Priorities, Medicaid Expansion Dramatically Increased Covered for People with Opioid-Use Disorders, Latest Data Shows –

Wearable Health: Who Benefits and Who is Left Out?

By Shazia Manji

There’s no denying the ubiquity of wearable health technology. The global wearables market is expected to grow by more than 15% this year alone, with projected sale of 310.4 million devices worldwide and $30.5 billion generated in revenue. These technologies generate real-time personalized data with the promise to improve individual health by helping to track, manage, incentivize, and improve healthy behaviors and decision making. As wearable tech finds success in the market, it’s important to consider where they can be most effective and where do they face barriers in impact. For example, a device such as a FitBit may be helpful in motivating an individual to make small changes to their diet when they have the necessary resources to make that happen. But what happens if you can’t afford a gym membership and you don’t feel safe running around your neighborhood at night? How well will these devices work for people who live in food swamps, neighborhoods or areas with many fast food and liquor stores but few places to buy healthy foods such as fresh fruits and vegetables?

The overall efficacy and effectiveness of wearable tech is still being determined. A 2015 study published in the Journal of the American Medical Association noted that while these kinds of tracking devices were increasing in popularity, there has been little evidence to show that they are successful in actually changing behavior. Still another suggested that wearables are more likely to be purchased by those who already live a relatively healthy lifestyle, and are less in use by those who might most benefit from a shift in physical activity, or by those with an existing and related health condition. Few studies or initiatives have looked at connecting these mobile health technologies with lower-income individuals in the US or at increasing their prevalence across socioeconomic status. This is largely in part because cost can be prohibitive for those at the lower end of the spectrum. Low-income populations are most at risk for diabetic complications, and may be less likely to have easy access to a physician, but the tools to help improve compliance and self-care have not been made with them in mind. The digital divide in healthcare technology is yet another example of how opportunities and resources for health are inequitably distributed. If we truly want to increase the effectiveness and relevance of wearable health tech, there needs to be a shift in their development and distribution.

A great first step to reducing the cost barrier would be working to get more health tech to be covered by insurers – and not just more robust private or employer-provided insurance plans, but by the insurance plans used by targeted populations, including Medicare and Medicaid. Tech companies could forge partnerships with community-based initiatives working to understand and shift the more structural barriers to health in low-income neighborhoods as part of potential multi-level interventions that go beyond individual behavior change. Wearable health tech used in research studies could combine the tracking technology with forms of interviewing or survey collection aimed at better understanding the barriers to behavior change in the most vulnerable populations, to help collect participant data that can in turn inform chronic disease prevention efforts. At the very least, developers could recognize that tech developed and marketed towards more affluent populations will differ from tech tailored for the most vulnerable.

Perhaps most importantly, I think it’s important to approach investment in and development of wearable health technologies with caution. Investment in digital health technologies is rising tremendously – but it’s crucial to understand who benefits from these technologies and who is left out, and then work proactively toward decreasing the digital divide. Investment in new tech should not trump investment in people and investment in improving the places and conditions in which people live, the conditions which shape and constrain quality of life and health behaviors.

Image: Koolme, Andri. “Fitbit Blaze activity tracker / wristwatch / smartband / smartwatch / smartphone.” 16 July 2016. Licensed under Creative Commons Attribution 2.0 Generic (CC BY 2.0). Accessed 31 Jan 2018.

SNAPFresh Without the Fresh

This week the Trump administration released their proposed change to the longstanding SNAP (Supplemental Nutrition Assistance Program) which some would equate to delivery meal services such as HelloFresh, Blue Apron and Purple Carrot. These new delivery meal services have been tremendously popular and my first reaction was this might actually be a good idea. This type of service is more convenient and having groceries delivered without the hassle of going to a grocery store would be a nice perk for program shoppers. I further explored the details of this program and my mind quickly changed when I read about what was included in the boxes and more importantly what was not. These boxes would not contain fresh foods (milk, eggs, fruits and vegetables) and instead would provide canned fruits and vegetables and shelf milk. To be honest I had to do a quick web search to see what was actually shelf milk. Additionally, these Americans would have little to no say over what is included in the boxes versus the current program where they are issued a card and can purchase what they choose to at participating stores. While I could see benefit in this type of service as an OPTION for SNAP shoppers there is a lot of improvements that should be made before bringing this proposed idea into actual implementation particularly thinking about the foods included and would this truly be something that current SNAP shoppers find feasible and/or pragmatic.


Funding AMR Research Straight from the Source: Agriculture

By Raj Topiwala

Alexander Fleming’s discovery of Penicillin in 1928 is undoubtedly one of history’s crowning achievements in medicine. In the 89 years that have since followed, antibiotics have saved countless lives and reduced once fatal maladies to easily treatable diseases. However, with the list of antimicrobial resistant pathogens growing at an alarming rate, we risk soon encountering diseases that are resistant to every available method of treatment, regressing us back into the pre-antibiotic age (and its diminished life outcomes).

With that in mind, one would expect research and development (R&D) into antimicrobial resistance (AMR) to be a major objective in the pharmaceutical industry. However, it turns out that AMR innovation is a rather unattractive option for pharmaceutical firms. Because patents for new pharmaceuticals expire quickly, there is a narrow window of time for firms to make up the massive costs of R&D and turn a profit, a near-impossible task for new antibiotics. With the plethora of inexpensive generics already on the market, why would a consumer choose the new expensive antibiotic when they could get a generic for nearly free? To offset this lack of profitability, a prize-system that rewards new AMR innovation has been proposed. In searching for a way to fund the prize, I propose we focus our gaze on what is arguably the biggest contributor to AMR there is: the agriculture industry.

The largest consumer – and waster – of antibiotics is the agriculture industry. More drugs are used for animals that produce food than the people that eat them (CDC, 2013) and an estimated 75-90% of antibiotics used in feed is excreted from livestock completely unmetabolized (O’neil 2016). The industry is routinely exposing pathogens to antibiotics without killing them – directly fostering the development of drug resistance. Taxing this practice presents a win-win scenario for the health sector. If the industry opts to continue using antibiotics at such

a dangerous rate, the tax revenue generated would be more than sufficient to fund the prize. If instead, the industry responds to the tax by decreasing antibiotic use in feed, then an entirely different, but equally beneficial, victory in reducing the dangerous practice will have been achieved. On some level, it is fitting to have the very practices that are creating AMR enable to solving of it. Though the agriculture industry is clearly unequipped to “clean up their own mess” in this case, having them pay for the AMR prize comes in at a close second – one that is both feasible and effective.

Works Cited

CDC: Centers for Disease Control and Prevention. (2013). Antibiotic / Antimicrobial Resistance. Retrieved November 19, 2017, from

O’Neil, J. (May 2016). Tackling Drug-Resistant Infections Globally: Final Report and Recommendations. The Review on Antimicrobial Resistance.

Health Disparity in Alameda County

By Elleni Hailu

In Alameda county, African Americans have the lowest life expectancy, compared to all other racial groups [1]. This trend in adverse health outcomes is also correlated with income levels, as individuals with lower incomes have higher morbidity and mortality rates, not only in the U.S. but also everywhere in the world. Combined with biologic and behavioral factors, ensuring health care access can reduce health disparities. However, having access to a health care professional and adequate medical care is simply not enough for many individuals, as they are not able to follow through with their doctor’s recommendations to improve their health and to prevent adverse outcomes. This is because there are a number of underlying factors besides access to care that affect a person’s well being such as neighborhood effects (i.e. access to fresh produce and parks). Here in the Alameda county alone, 23% of the Black population lives in poverty, compared to 8% of White residents who live in poverty [1]. This gap in income is what affects the health status of many Americans and their ability to maintain their health. Hence, creating ways to ensure income equality, such as passing bills that encourage public and private sector partnerships to build more affordable housing, would be instrumental in promoting healthy living.


[1] Lee, T. (2017, September). Epidemiology as a Tool for Social Justice. Lecture presented at Seminar for MPH Students in UC Berkeley.

A Multi-Level Analysis of Barriers to Care: Micro Level (Individual)

I argued in a previous post that public health should look at factors impacting health using a multi-level approach. In this post, I attempt to outline the various multi-level barriers to medical care (specifically access to PrEP, HIV prevention, and AIDS care) for black queer men (or black men who have sex with men).

At the individual level (the micro level), queer men are skeptical of medication for healthy individuals and wary of the potential side effects caused by these medications (Philbin et al., 2016). These ideas seem to go hand-in-hand. If you don’t want to take medication as a healthy person, you’d be worried about the potential side effects that would ultimately make a health person sick in order to prevent something that you might or might not contract. In this sense, it might be important to make people recognize the real possibility of contract the disease. We’re treating risk here, but preventing the disease is important. Further, the side effects of PrEP are fairly uncommon.

Queer men might think that this medication would be useful for others but not for them. Here, we have to think about assessing the individual patient to decide whether or not PrEP is right for them (Philbin et al., 2016). We’re not treating someone because they’re black and queer, and black queer men have the highest rates of HIV. It’s obviously possible for black queer men to have low associated risk of HIV. Treating high risk means treating patients with high risk factors not treating everyone from a population that has high rates of the disease. However, this presents an added barrier for providers to convince patients with high risks that this is the right drug for them.

Philbin, M. M., Parker, C. M., Parker, R. G., Wilson, P. A., Garcia, J., & Hirsch, J. S. (2016). The Promise of Pre-Exposure Prophylaxis for Black Men Who Have Sex with Men: An Ecological Approach to Attitudes, Beliefs, and Barriers. AIDS Patient Care and STDs, 30(6), 282-290. doi:10.1089/apc.2016.0037



Public Health & Epistemologies of Ignorance

The field of public health has primarily thought about improving health by making changes for individuals. We try to get individual people to quit smoking, make dietary changes to combat obesity, and start using condoms or other safer sex practices to limit exposure to sexually transmitted infections (STIs). However, all of these interventions focus only on changes that individual people are supposed to make. They don’t think about barriers that impact an individuals ability to make these changes or other factors that could be affecting, positively or negatively, the health of individuals.

In thinking about public health interventions, we should think about a multi level analysis, including the micro level (individual), the meso level (interactional, community), and the macro level (institutional, structural). Factors at each of these levels can positively and negatively impact health; however, by only looking at the individual (the micro level), we miss a significant portion of the picture in terms of health, especially when we start thinking about health disparities.

Lisa Bowleg (2017) argues that this represents an epistemology of ignorance, specifically that the focus on the individual and on health as a characteristic solely of the individual (a very neoliberal position), “obscure[s] the role of social–structural factors (e.g., political, economic, institutional discrimination) that constrain the health of historically marginalized individuals, communities, and societies” (678). She continues to argue that “[e]pistemologies of ignorance illustrate that willful ignorance is functional (Alcoff, 2007; Mills, 1997, 2007). Neglecting the historical legacy of how race (as well as the other marginalized social positions that intersect with race) has structured social inequality for people of color in the United States serves to center the health experiences of White people as normative, “color blinds” White privilege to highlight positive health outcomes among White people as the product of their individual actions, and reifies negative stereotypes about the “irresponsible” health behaviors of people of color (Bowleg et al., 2017).” From a political perspective, she argues that this focus on the individual in public health, and in other spheres, limits the political imperative and pressure to conduct research and enact laws that would address the social-structural factors in order to alleviate health disparities.

Bowleg, L. (2017). Towards a Critical Health Equity Research Stance: Why Epistemology and Methodology Matter More Than Qualitative Methods. Health Educ Behav, 44(5), 677-684. doi:10.1177/1090198117728760

Are You Healthy? (Part 2)

Previously, I discussed changes to our model of health due to randomized control trials and the pharmaceutical industry, as discussed in Joseph Dumit’s Drugs for Life. Here are the three primary models of health as discussed by Donald A. Barr in his book Health Disparities in the United States: Social Class, Race, Ethnicity, & Health. 

The first model is the medical model or physical health model that focuses on the absence of symptoms or other signs of disease or illness. However, Barr mentions several issues with this model of health, noting “that this approach to defining health tells us what the concept of health is not. . .It does not tell us what health is” (2014, pp. 15). He expands on this later:

“What are we to make of a condition that has no abnormal symptoms? An important example of this is high blood pressure, also referred to as hypertension; persons with hypertension develop symptoms only after a number of years. Should we consider a person with somewhat elevated blood pressure to be unhealthy based on our knowledge that his blood pressure will eventually lead to further problems? What might be the consequences of labeling such a person as ‘unhealthy,’ even if he feels fine?” (Barr, 2014, p. 16)

These are the questions that Joe Dumit attempts to answer, looking beyond hypertension to guidelines about pre-hypertension and the prescriptions of statins with no understanding of when patients can stop taking them.

The second model is the sociocultural model or the model of health as functioning at a normal level. Barr looks at it in contrast to the medical model, which looks at absence, because the sociocultural model looks at the presence of an ability to function at a level that has been deemed normal (2014, p. 17). The ability to functional normally is defined in regards to one’s ability to completed five “activities of daily living (ADLs),” which are roughly, (1) eating, (2) bathing, (3) dressing, (4) using the bathroom, and (5) moving on one’s own (2014, p. 17). Of course, the entire premise of “normal functioning” is subjectively predicated on societal ideas of self-sufficiency that might vary from culture to culture or community to community.

The third model is the psychological model or the model of health as a feeling of well-being. In this model, individuals are able to assess themselves and their own health with the help of several developed measures (Barr, 2014, p. 18). However, Barr notes that these tests are often “time-specific” (Barr, 2014, p. 18). I would argue that health is always time specific and temporal. I may be healthy today, but I can quickly develop a health problem or injure myself, perhaps even resulting in a temporary or life-long disability, reaffirming the temporality of both health and disability.

According to Barr, these models can be combined to create a multidimensional model of health that presents a better picture of the health of an individual.

Trans Youth, Ethics, & Access to Healthcare

There are four primary principles for ethical decision-making in health care (respect for autonomy, 2. justice, beneficence, and non-maleficence); however, these four principles do not necessarily yield the most beneficial results for trans youth or bodies that exist in contradistinction to state controlled modes of life. Medical practice is able to manage the modes of life for trans youth, relying on non-maleficence and a paternalistic notion of future expectations to continually withhold medical intervention.

The duality of beneficence and non-maleficence has often been presented as the double effect, where a single action may have both positive and negative effects that must be weighed against one another (Veach, 2007). A common example is when providing morphine to a dying patient. The patient’s suffering will be limited, causing a beneficial effect; however, the morphine simultaneously slows the respiratory system, causing the patient to die more quickly, the harmful double effect.

In the case of trans youth, this double effect is often used as a way to withhold hormone treatment or other medical intervention because the state and the medical institution see the greater harm if trans youth “change their minds” about their gender. Further, medical professionals discuss the potential harms within a framework of compulsory reproduction. The harm of hormones is seen as an inability to reproduce later in life, which maintains the assumption that biology is destiny (Adkins, 2017).

As we approach these ethical issues, there are difficult power dynamics inherent in the biopolitical state that limits what modes of living are seen as livable. For instance, an inability to reproduce is seen as unlivable or unruly. To provide better care for trans youth, we need to deconstruct current notions about the lack of autonomy for young people broadly, and especially for trans youth.

Adkins, Deanna (2017). “Transgender medicine: A wealth of ethical dilemmas.” Presentation.

Veatch, Robert M. (2007) “How many principles for bioethics?” In R. Ashcroft, A. Dawson, H. Draper, and J. McMillan (Eds.) Principles of Health Care Ethics, Second Edition. Chichester: John Wiley & Sons.

Thank you to Dr. Marshall for the fascinating presentation!

Last week, we were excited to have Dr. Laura Marshall discuss her dissertation research with us. Her work looked at the different types of comments posted online under an article for Breitbart and for Huffington Post, both on the subject of healthcare reform. Identity seemed very important to establish in both comments sections with “othering” used as the most common social process, i.e. invalidating a differing opinion typically through name-calling and questioning of intelligence. Main distinctions between the two sets of comments included Breitbart comments focusing on personal responsibility and a distrust of government actions or programs, and Huffington Post comments emphasizing social justice and hopeful solutions.

What is the purpose of these comments sections and, ultimate goal, how can communication professionals utilize them? Dr. Marshall’s theory is that users of comments sections establish identity through “othering,” then seek or offer information within their group, and propose solutions.