We’re Waiting for the Paperwork

By PHS 795 student, Gabrielle Waclawik

https://www.theatlantic.com/politics/archive/2017/08/president-trump-declares-the-opioid-crisis-a-national-emergency/536514/

A few weeks ago, President Trump proclaimed he considered the opioid epidemic a national emergency. Our nation’s opioid crisis has been brewing over many years, really since the 1990’s when pain gained recognition as the fifth vital sign and opioids, the ‘wonder drug’ were utilized in response. But it really was not until the problem began to infiltrate and make noise in the more white and affluent communities in the last 5-10 years, that the opioid epidemic began to gain traction in the mainstream and popular media. Now, this is no longer an issue that we, as a society, can ignore, as non-prescription opioid use, addiction, overdoses, and preventable deaths have increased at such a dramatic and exponential rate over the last decade. Most importantly, we must not forget that much of this illicit drug use started as a routine prescription for opioids from a licensed health provider. In fact, according to the CDC, people who are addicted to prescription opioid painkillers are 40 times more likely to be addicted to heroin.

However, some still argue against the use of their tax dollars towards funding free needle exchange programs, or easier public access to a readily available antidote (Naloxone), claiming that this only propagates a message that illicit drug use is tolerated by our society. Others, perhaps, believe this is an isolated problem among the drug user community, that does not affect them, thus how can it be a public health issue of national concern requiring collective action? But in reality, beyond the addiction, the overdoses, and the preventable deaths, downstream effects have now become extremely evident, with increasing numbers of new Hepatitis C and HIV cases on the rise. According to the CDC, new Hepatitis C cases in the U.S. grew nearly 300 percent between 2010 and 2015. In 2015, the state of Indiana’s new Hepatitis C cases were increasing as such a rapid rate that the state declared it a public health emergency, immediately making syringe exchange programs legal for the first time ever in its state. Furthermore, the access to medication alone for Hepatitis C treatment has been a greatly debated topic due to its high costs, and whether state and federal medical programming should be bearing this burden. This does not even begin to include the preventable drain of numerous other resources such as hospital costs or decreased work force productivity.

The degree of complexity the opioid epidemic presents requires multi-disciplinary action on many levels, and has, more recently, finally forced a government response.  On a state level, Wisconsin has led the charge with republican Representative Nygren, whose own daughter experienced heroin overdose and continues to battle drug addiction. Rep. Nygren brought forth the HOPE Act, which was initially signed in 2014 but continues to have addendums up for vote. On a national level, while President Trump may have made a public verbal statement acknowledging the issue, weeks later he still has yet to officially sign the paperwork to formally declare the opioid crisis a national emergency. In fact, the Atlantic article points out that despite Trump’s efforts to repeal the Affordable Care Act, the failure to repeal avoided a dramatic cut to Medicaid and thus maintained states’ ability to respond to the opioid crisis through the broader coverage of treatment and substance abuse programs. By signing the declaration, it will allow us easier access to federal disaster funds and waiving of certain federal program regulations. So that we can more quickly and robustly respond to this growing opioid epidemic, please sign the paperwork, President Trump.

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Another look at soda taxes…

Using taxes to control the consumption of harmful products, including sugar-sweetened soda, is a matter of intense debate (see, e.g., http://www.nytimes.com/2016/11/26/well/eat/as-soda-taxes-gain-wider-acceptance-your-bottle-may-be-next.html)  A PHS 795 student points to a post on Kaiser Health News and questions the evidence on the effectiveness of soda taxes:

Last week, the soda-tax was brought up in our Epidemiology class. This Kaiser article discusses the passing of soda-taxes in many cities in the US in the November election. Based on our discussions on utility and marginal cost in class, I find it interesting that many cities are expecting to use a small increase in cost per soda to change the behavior of people in hopes of starting to solve the obesity epidemic and dental decay. Although there might be a causal relationship between sugary beverages and these poor health outcomes, there are many other contributing factors to these health problems. Further, the article doesn’t discuss whether implementing the soda-tax will actually decrease consumption. Instead the article focuses on the amount of tax revenue the soda-tax will bring in for the cities with the soda-tax. How high of an additional cost are people willing to pay before the cost forces a change in behavior? What other systemic issues are at play here that go beyond the cost of soda? The article only begins to touch on the other causes such as education, lack of access to alternative beverages, preference etc.

 1 Leading the Way? Northern California Cities To Embark On Soda Tax Spending

khn.org

Health advocates are expecting millions in new tax money for health education programs aimed at preventing obesity, diabetes and tooth decay. Other cities around the country are mulling similar mea…

Medicaid coverage for the incarcerated population

The incarcerated population faces numerous health challenges (see, e.g., http://www.annualreviews.org/doi/abs/10.1146/annurev-soc-073014-112326). A PHS 795 student draws our attention to a helpful overview of the role of Medicaid in caring for this population. They write:

Because incarcerated populations are so isolated from the general population, they are often overlooked in conversation. Given that incarceration rates are at an all time high and that incarcerated populations are particularly vulnerable to health disparities, I think it is important to understand how states are addressing their health management. Medicaid plays an important role in financing health care for criminal justice system involved individuals, a population with significantly lower socioeconomic status and disproportionately burdened by multiple health problems. Although very dense, this article discusses the guidelines for Medicaid spending on incarcerated individuals following introduction of the Affordable Care Act.

The expansion of coverage for criminal justice involved individuals has many benefits, as discussed in this article. This article brought to my attention the unique opportunity incarceration presents to effectively treat inmates for various health conditions. Treating them during incarceration decreases the chance of transmission of infectious diseases after release, decreases the risk of re-incarceration if mental health improves, decreases hospitalizations and emergency room visits, and lowers health care spending. It will be interesting to see how Medicaid funds are allocated to incarcerated populations and how total spending for this population changes over time if the ACA remains in effect for much longer.

http://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2016/08/how-and-when-medicaid-covers-people-under-correctional-supervision?utm_campaign=LM+-+GP+-+SFH+-+CHCS+-+Medicaid+Brief+08+01+16&utm_medium=email&utm_source=Pew

 

Sweet, sweet conflict of interest…

A PHS 795 student calls our attention to a recent NPR story on potential conflicts of interest associated with the soft drink industry’s funding of public health initiatives. They write:

The article and associated NPR story below discuss soda company sponsorship of U.S. health and medical organizations, along with corporate lobbying expenditures on public health legislation.

Listening and reading this made me think about the focus in our class on the economic aspects of population health, particularly operating in a world with limited resources. With budgets being cut or limited for health organizations, I think it is hard for organizations not to apply for or take money where they can get it, but it is important to keep the organization’s mission in mind.

It is not clear from the article, but I wonder if the organizations have to apply (e.g., for a grant) for the funding, and if they also do so from other companies (not just soda companies)? Does it matter whether money is just given freely, or if the organization has to apply for it? Was it a matter of getting a program or event funded in order to help individuals? If so, if that program or event supported the health and well-being of individuals, do the benefits of the program or event outweigh the potential conflict of interest issues?

On a related note, I’ve noticed increasingly that organizations are partnering with pharmaceuticals to offer grants funding. It might be interesting to see a similar analysis of the pharmaceutical industry.

I’d be interested to hear what others might have to say on this.

http://www.npr.org/2016/10/19/498582189/soda-industry-tries-to-woo-public-health-groups-with-sponsorship-deals

Here is a link to the study in the Am J Prev Med that motivated the story: http://www.ajpmonline.org/article/S0749-3797(16)30331-2/pdf

Life in Obamacare’s Dead Zone – The New York Times

A PHS 795 student writes about an article in the NYT about working, low-income Americans who are eligible for neither Medicaid nor subsidized insurance on the ACA exchanges:

Yesterday, an article was published on the New York Times regarding the coverage gap between Obamacare and Medicaid. I was moved by this poignant article, as it discusses the personal ramifications of being uninsured. This article discusses the innovative ways providers had adapted to the overwhelming demands of treating the uninsured and medically isolated, where the coverage gap exists. This article reemphasizes the fact that being uninsured is still costly. It is costly on the uninsured mental health, it is costly on community contributions, and it is costly to treat potentially preventable diseases that could have been managed if the uninsured had been able to see a physician on a regular basis.

Hypertension: It’s not just a rich men’s problem…

A PHS 795 student does something excellent — corrects an incorrectly held impression by observing data. They write:

I came across this article a while ago on a recent study – saying that more than 1 billion people are living with high blood pressure. Since the world has 7 billion, about 14% of the entire population! While I have had a(n incorrect…) perception that high blood pressure was more of a rich men’s problem, this latest study suggests that it is a condition of poverty, showing a completely inverse relationship with national income. On top of the well-known factors (e.g. high levels of salt and potassium in diet, lead exposure and pollution, lack of diagnosis and treatments), children who are undernourished are more likely to have higher blood pressure as they grow older. The researchers suggest that the global community take it as a condition of poverty – especially focus on the intake of healthy calories and not just enough calories! I have a mixed feeling of ‘relief’ that we have discovered a problem to be resolved for global health improvement as well as ‘frustration’ that we have ANOTHER problem on the endless list…..
http://www.cnn.com/2016/11/15/health/high-blood-pressure-global-statistics/

Stigma and mental health: not just a US issue.

A PHS 795 student writes about a recent piece on NPR:

This article touches on a health issue that we mentioned in an earlier lecture by Dr. Elizabeth Jacobs on health care disparities and cultural competency. In it, the article discusses how cultural awareness of what mental health is often ignored. In particular, it draws on an anecdotal story from an individual from Nepal and how they were not aware what depression was, let alone how to seek help for many years. Additionally, “in Nigeria,… only a third of those with depression knew they had a problem and that something could be done about it”. I found this very interesting because even talking to older adults in the U.S., it seems like there is still a large stigma about mental health and a gross misunderstanding as the causes and effects, particularly of depression. The individual in the article, Jagannath Lamichhane, even states “‘People believe that depression is the result of personal weaknesses…'”, and from my knowledge, this seems to be a misunderstanding across different parts of the world and different cultures. This relates back to the lecture on cultural competency and the burden that medical professionals, researchers, and policy-makers all have to continue raising awareness on mental health, the biopsychological factors related to mental health, and of course, services available. I’m not certain as to how much training people in these three spheres receive, but it certainly seems to be a global public frame of mind and cultural attitude that needs to be further developed and conversations that need to be had.

Gender equity and the “repeal/replace” question.

A PHS 795 student raises important questions about gender equity and intergenerational effects from potential repealing and replacing of the ACA:

In our past few lectures, we discussed the criteria for assessing health insurance policy as well as the Trump Administration’s impact on health care reform. A brief article from Kaiser Health News suggests that women may incur a disproportionate cost as a result of ACA reform (or dismantlement) because of foreseen policy changes regarding the coverage of maternity care.

 

According to the article, an estimated 13% of women who purchased health insurance on the individual market (not public insurance or employer-provided insurance) had coverage for maternity care in 2009. The ACA mandated that all plans must cover maternity care, endorsing it as an essential preventive service. With an incoming administration reevaluating what qualifies as preventive care, women who purchase health care in the post-ACA individual market may find few plans that cover maternity care.

We talked about “fairness” as a criterion for health insurance policy, and this piece raises questions on whether these potential changes in coverage are fair to women. I had one question that wasn’t addressed by this article: Is it fair to future children, and should we consider future children in evaluating health policy changes. If we recall Dr. Ehrenthal’s lecture on the life-course trajectory of health, early interventions when a child is in utero can affect birth outcomes and may impact early childhood development. When we evaluate health insurance policy changes, should we consider those affected aside from the single patient? If so, how do we evaluate “secondary” (non-patient) players in policy?

(Note: When I refer to a child in utero, I assume that the mother intends to carry the child to full term.)

CBPP: Medicare is Not “Bankrupt”

In a followup to our lectures on Medicare and Medicaid, a PHS student refers us to a useful posting on the Center for Budget and Policy Priorities blog about predictions of Medicare costs for the next generation. Notably, patterns of cost growth are sensitive to policy (including Obamacare, which has contributed to lower long-run cost forecasts).

Medicare has grown somewhat stronger financially in both the short and long term but continues to face long-run financing challenges

Source: Medicare Is Not “Bankrupt” | Center on Budget and Policy Priorities

It will be important to keep these projections in mind as policy alternatives affecting Medicare, Medicaid and Obamacare are rolled out under the Trump Administration.

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What constitutes a “health emergency”

A PHS 795 student makes an important point about the importance of clear communication in population health (and indeed all science of public interest):

Article: http://www.npr.org/sections/goatsandsoda/2016/11/18/502616422/zika-no-longer-global-health-emergency-who-declares

I initially was looking through NPR and what was in the headlines when this article caught my eye. I was going to summarize on the update of Zika that the article mentions, but as I read it, I actually noticed two larger populations health issues. In the first part of the course, multiple lecturers touched on the responsibility of researchers to make their work clearly understood to the public and our “academic oath” in doing good research that helps the greater good, or population health as the case may be. So when I read an article titled “Zika No Longer Global ‘Health Emergency,’ WHO Declares”, I assumed it meant that Zika had finally stopped spreading or was no longer as much of a crisis as it had been. So I was very surprised that when I kept reading, the third paragraph is:

“‘It is really important that we communicate this very clearly: We are not downgrading the importance of Zika,’ Salama says. ‘In fact, by placing this as a longer term program of work, we’re sending the message that Zika is here to stay. And WHO’s response is here to stay, in a robust manner.’ One thing is clear: Zika is still spreading. And microcephaly cases are still growing. ”

To me, these two things are contradictory. It appears the researchers made an effort to clarify their statements, but somehow it was still lost in the headline.  With respect to population health, when headlines like these make the news (that are somewhat the opposite of what the research says), public support for health programs often diminishes which just exacerbates the health issues in the first place. These leads to the second issue: when support for public health programs declines, it is often people who are most at risk that feel the effects first.

The article mentions that pregnant women are most at risk and from my prior knowledge, I believe it is often women from poorer areas So then people with low socio-economic status are the ones who will first and foremost feel the adverse effects of misreporting research. I believe this is one example of how there needs to be better communication between research and the rest of the world.