Category: Health Policy

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.

CHIP in or out?

When it comes to healthcare coverage in the US….well, let’s just say it hasn’t had a historically smooth path. Among the political debates have been to whom the government should provide aid, how much, and how for how long…but everyone agrees that children should be have health insurance. Politically speaking, they are an easy group to support.

CHIP, The Children’s Health Insurance Program, was  created in 1997 as part of the Balance Budget Act of 1997. By 2000, every state had enrolled in CHIP-financed coverage. The cost of the program is split between states and the federal government via a formula called the Medicaid Federal Medical Assistance Percentage. But the split is actually more 71-29ish than 50-50, as Congress had also enhanced funding to match 15% more than what a state would cover–basically giving states a bigger incentive to enroll in the program.

Funding for CHIP expired on September 30th. The Affordable Care Act extended CHIP and further enhanced the federal matching rate, which should have continued through September 2019. Many states relied on this in their budgeting, and will face huge shortage if Congress does not extend federal funding.While Congress tries to pass legislation to rescue the program, states like Minnesota and Utah have already applied for emergency funding, and 27 additional states are expected to need more funds by March.

Legislation went through the Senate earlier today, but financial negotiations will need to be sorted across party lines before the vote can pass in the House.

Kaiser Health News  is a reliable source to stay up-to-date on the progress of the bill. It’s unlikely that a final decision will be made before the end of this month, but the bottom line is–nearly 9 million children’s insurance status depends on a successful resolution of this bill.

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.

What is DACA?

There has been a lot of buzz around “DACA” the last couple days; which has left many of us wondering, “what is DACA?” The Deferred Action for Childhood Arrival program, or DACA, was enacted by the Obama Administration in June 2012. The program

The program had granted undocumented immigrant children, who entered the U.S. before their 16th birthday, a renewable two-year deportation protection and work permit while they either worked, attended school, or served in the military. However, it did not provide lawful status to those within the program.

DACA had nearly 800,000 immigrants enrolled in the program before President Trump ended the program this week. Survey data shows that 91% of those in the DACA program were currently employed and that number goes up to 93% for those 25 and older.

While some have thought President Trump did this to open up more jobs for American citizens, it is obvious there was not much thought given to those who are currently enrolled in DACA. Now, without DACA, the enrollees have to reevaluate everything they had planned for their lives. How will they be able to work to provide for their family? How will they pay for schooling? How will they be eligible to keep their position in the military?

 

Sincerely,

AB

Do you have an Advance Directive?

Everyone deserves the right to make their own decisions about their health. But sometimes we may found ourselves in certain circumstances in which we are unable to do so, such as during a coma, terminal illness, or serious injury. An important way that we can communicate our decisions during these times, however, is by having an “advance directive” in place.

Advance directives are written, legal documents that outline your decisions regarding medical care when you are unable to make them. They assist doctors and caregivers in making medical decisions on your behalf, and they can be written at any age.

There are several types of advance directives:

Health care power of attorney (also called “durable power of attorney for health care” or “health care proxy”). This is a type of advance directive in which you appoint a person you trust to make medical decisions on your behalf when you are unable to do so. This may be a family member, partner, or friend.

Living will. This is a written, legal document that outlines your wishes for certain medical or end-of-life care treatments. These may range from mechanical ventilation to tube feeding, to even organ and tissue donations.

Do-Not-Resuscitate Orders (DNR). This order informs health care providers not to perform CPR if your breathing or heart were to stop.

While advance directives are not required, it may be a good idea to have one in place so that you can have peace of mind knowing that you’re in control of your health care in the event that you are unable to make decisions for yourself.

It should be noted that state requirements regarding advance directives, such as living wills, may vary, so be sure to check your local state laws if you decide to create one for yourself. Also, be sure to keep a copy of your living will for yourself, as well as provide copies to family members, health care providers, and your health care power of attorney. Advance directives can be changed at any time, but just be sure to redistribute copies as necessary.

For more information about advance directives, check out the following resource links:

Advance Care Planning | UNC Health Care: UNC Medical Center

Living Wills and Health Care Powers of Attorney | North Carolina Bar Association

Living Wills and Advance Directives for Medical Decisions | Mayo Clinic

References:

Advance care directives. (2017, September 5). Retrieved from https://medlineplus.gov/ency/patientinstructions/000472.htm

Advance directives. (2017, July 24). Retrieved from https://medlineplus.gov/advancedirectives.html#summary

Creating advance directives. (2014, November 11). Retrieved from http://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/living-wills/art-20046303?pg=2

Living wills and advance directives for medical decisions. (2014, November 11). Retrieved from http://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/living-wills/art-20046303

 

GOP Bill Halts in Senate

Remember back in May when the GOP health bill passed in the House? The momentum stopped there.
The Senate failed to pass a GOP-proposed Health Law yesterday. Senate Majority Leader Mitch McConnell says they’re going to try again early next week, though it doesn’t seem like this will be a promising attempt either. Analysts attribute this to many deep-rooted factors:  the Republican party as a whole not unified behind an action plan other than repealing the ACA, the taking away of funding and resources without a viable exchange, and a severe lack of public hearings and drafting.
Provisions included in a draft of the bill last week including capping funding for Medicaid, and giving states the power to opt out of insurance regulations substantiated in the Affordable Care Act. This fielded much opposition from more moderate Republicans. They cite problems  such as too “deep cuts” to Medicaid, and an insufficient means to account for the expenses of changing the insurance system. This opposition was especially strong in Republican states like Ohio that had expanded Medicaid under the ACA.
Now, Republican Senators are working on re-drafting a “repeal and delay” bill that would phase out aspects of the ACA over a two year time frame–a version of this bill passed in 2015. Of note, the draft of this bill to be debated does not include an amendment proposed by Senator Ted Cruz. According to a report conducted by the Department of Health and Human Services, this amendment might actually result in broader coverage and lower premiums. The quality and correctness of this report is already under great criticism by healthcare and insurance analysts.
Sources: The New York Times, Kaiser Health News

Public Health Selling Souls to the Devil

By: Shauna Ayres MPH: Health Behavior candidate 2017

Today, approximately 2/3 of adults and 1/3 of children in the United States are overweight or obese (Odgen, 2012; Flegal, 2012). It is estimated that the country spends upwards of $190 billion per year treating obesity-related health conditions (Cawley, 2012). This trend is associated with the increase in marketing expenditures ($3.2 billion for carbonated beverages in 2006) and consequently the rise in consumption (US FTC, 2008). Americans are exposed to hundreds of ads each year; however, beverage companies adamantly deny their products and/or marketing tactics are correlated with the current obesity epidemic (HSPH, 2012).

Unfortunately, a study conducted by Daniel Aaron and Michael Siegal out of Boston University found that public health organizations may be enabling beverage companies to continue these detrimental business strategies. Aaron and Siegal discovered that 96 national health organizations accepted money from Coca-Cola and Pepsi and ironically included diabetes organizations such as the American Diabetes Association and the Juvenile Diabetes Research Foundation. Siegel and Aaron note that beverage companies “primary interest[s] [are] of improving profit, at the expense of public health.” It is demonstrated in the numbers. Between 2011 and 2014, the Coca-Cola Company spent more than $6 million annually, on average, on lobbying, while PepsiCo spent more than $3 million a year against 28 bills that established a soda tax or implemented advertising restrictions. Whereas the American Beverage Association spent a little more than $1 million a year (Aaron & Siegal, 2016). This hardly seems like a fair fight.

Siegel equates beverage companies to alcohol and tobacco companies and points out that “corporate philanthropy” is merely a “marketing tool that can be used to silence health organizations that might otherwise lobby and support public health measures against these industries.” The study recommends that health organizations reject sponsorship offers from soda companies and find alternative sources of funding (Aaron & Siegal, 2016; Chedekel, 2016).

Resources:

Aaron, D.G. & Siegal, M.B (2016). Sponsorship of national health organizations by two major soda companies. Am J Prev Med. http://www.ajpmonline.org/article/S0749-3797(16)30331-2/pdf

Cawley, J. & Meyerhoefer, C. (2012). The medical care costs of obesity: an instrumental variables approach. J Health Econ. 31(1):219- 230.

Chedekel, L. (2016). How health groups unwittingly help coca-cola and pepsico. Futurity. http://www.futurity.org/coca-cola-pepsi-lobbying-1272392-2/

Flegal, K.M., Carroll, M.D., Kit, B.K., & Ogden, C,L. (2012). Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 307(5):491-497.

Harvard T.H. Chan School of Public Health (HSPH) (2012). Fact Sheet: Sugary drinks and obesity fact sheet. The Nutrition Source. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/30/2012/10/sugary-drinks-and-obesity-fact-sheet-june-2012-the-nutrition-source.pdf

Ogden, C.L., Carroll, M.D., Kit, B.K., & Flegal, K.M. (2012). Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 307(5):483-490. US FTC, 2008

Corporate Integrity Agreements

Throughout the summer I’ve dedicated several posts to the ways that medical and pharmaceutical publishing should be ethically conducted, according to established requirements and guidelines.

However, I’m sure it comes as no surprise that pharmaceutical companies have consistently failed to play by these rules. Headlines such as “GlaxoSmithKline to Plead Guilty and Pay $3 Billion to Resolve Fraud Allegations and Failure to Report Safety Data,” and “Bristol-Myers Squibb to Pay More Than $515 million to Resolve Illegal Drug Marketing and Pricing Allegations,” are proof that these companies are not always committed to high ethical standards of practice.

Although industry standards such as the ICMJE and GPP3 guidelines are almost universally accepted, they are not laws and are therefore not usually enforceable.

However, when pharmaceutical and biotech companies fall under Federal investigation, the Office of the Inspector General (OIG) can make them agree to abide by a Corporate Integrity Agreement (CIA) as part of their legal settlement.

These CIAs legally obligate companies to abide by many of the tenets of the previously mentioned guidelines and ensure ethical practice by imposing requirements such as:

  • hiring a compliance officer/appointing a compliance committee
  • developing written standards and policies
  • implementing a comprehensive employee training program
  • retaining an independent review organization (IRO) to conduct annual reviews
  • restricting employment of ineligible persons (people who have been flagged for unethical behavior)
  • providing an implementation report and annual reports to OIG on the status of compliance activities

If a company is non-compliant with their CIA, they risk having their product pulled from the list of products that can be reimbursed through Federal health care programs such as Medicare and Medicaid. This loss would be a crippling financial hit to most companies, making compliance with these agreements a high priority.
In this way, the industry can be kept in check and forced to behave in a more ethical manner.

Considerations for Ethical Research and Medical Publishing: Part II

Last week I touched on the way in which pharmaceutical marketing and research activities are separated to decrease the chance of bias or unethical practices in medical research. Today I want to briefly introduce some other guidelines that exist to regulate and guide medical research and publishing.

The International Committee of Medical Journal Editors (ICMJE) is one of the leaders in establishing guidelines and recommendations for ethical medical research practices, including both the way the research is conducted, as well as the way in which the results are reported and published. Major medical journals, such as JAMA, the New England Journal of Medicine, the British Medical Journal, and more, require that studies published in their journals abide by these ethical guidelines.

Contrary to what had previously occurred throughout the history of medical research and publishing, individuals and organizations that conduct medical research are now obligated to publish all of their results (even if they’re negative). This newer industry norm was implemented in response to critiques of companies who selectively published only the studies or trials that showed their product in a positive light, a practice that is now considered biased, misleading, and incredibly unethical.

Anti-bribery statutes and requirements to disclose payments and other transfers of value from industry to health care providers, as well as the required disclosure by all authors of their potential conflicts of interest, such as being employed by the pharmaceutical industry or being in some other position to gain financially from the success or sale of a drug, are additional safeguards against biased and unethical practices.

 

For more information about the guidelines and recommendations guiding medical research and publishing, check out these resources:

The War on Condoms in the Porn Industry

Last week, a California safety board rejected a proposed regulation that would have required porn actors to wear condoms, after only three members of the board voted in favor of the law (four votes were needed for it to pass).

Prior to the vote, industry officials and actors pleaded to the board to reject the regulation, arguing that passing it would either destroy or drive the industry underground. They also argued that pulling the industry underground would essentially eliminate the industry’s own requirement of actors being tested for STDs, putting actors safety at a greater risk.

However, the issue still remains a timely public health concern, especially because a recent CDC report found a porn actor likely infected another performer with HIV while having condom-less sex on a gay porn set, proving that testing alone is inadequate for preventing the spread of STDs.

Because of this, the panel that voted on the regulation is now considering a new worker-safety measure for the porn industry, but the push back from the industry has helped this be an easy task.

What are your thoughts about the regulation? Do you think the two industries can work together to find a happy medium, or is the required use of condoms the only solution?