Top Picks in 2010 Health Care Reform: Bill Passed!

I can't believe we've passed national, comprehensive health care reform! A first for public health. With all that I learned from the esteemed Bob Blendon in Political Strategies, I knew it would be a long shot. Presidential diplomacy likely played a strong hand in back deal negotiations, as well as the organizing and activity of pro-reform groups in putting pressure on key (read: moderate) legislators!

Here's what pumps me up about national health care reform:

1. Millions of uninsured (an estimated 32 million, to be exact) will now be covered! This means greater continuity of care and hopefully less late, untreatable conditions get prevented and treated early!
2. National menu labeling for chain restaurants! Calorie counts will be visible at point-of-purchase for most chain restaurant menu items across the United States (and the National Restaurant Association sings its praises in the Wall Street Journal blog...miracles do happen!).

There are tons of hurdles yet to be overcome when it comes to implementation and the elephant in the room is cost controls on skyrocketing premiums. I've heard it said that legislators want to "Tackle coverage first, then deal with cost." Whether that approach helps or hurts the health of Americans will be closely monitored, I'm certain!

Let's Move! ...to Prevent Childhood Obesity

It's no surprise that childhood obesity is drawing more public attention than ever before. Evidence is growing on the ill-effects and complicated origins of childhood obesity, making inaction impossible both for public health programs and politicians.

We can prevent childhood obesity. And that's precisely what the White House initiative, Let's Move!, intends to do.

Update: MA School Nutrition Bill

It took a little investigating (and some decoding) to figure it out: the School Nutrition Bill passed the House!

Thanks for calling and/or writing your Legislators. It does make a difference. I know there was a lot of movement on the ground Thursday morning among advocates for school wellness and nutrition policy even though I couldn't join them.

You can access the legislative history of the newly numbered bill (HB 4441) at the Massachusetts website. Each Amendment was adopted in turn, with a few hiccups (i.e. "referred to House Rules" and "Rules Suspended") along the way.

Need a little more information about what took place yesterday?? ...

Contact Your MA Legislator for School Nutrition!

Tomorrow may be a historic day for school nutrition in Massachusetts!

This Thursday, the Massachusetts House plans to vote on House Bill 4438 (previously HB 2092), also known as the School Nutrition Bill. This would be a milestone in Massachusetts school nutrition history, as no previous bill has set standards for the types and quality of food sold in school besides the VERY minimal federal regulations.

If you want our schools to be healthier places for our kids, then contact your legislator by TOMORROW!

You can find out more about the School Nutrition Bill and the Local Farm Products Bill (HB 2017), which will *hopefully* also be incorporated in the final document, at the Massachusetts Public Health Association website.

To find out who your State Representative is and how to contact them click here.

This is what I wrote to my Representative...

Health Care Reform Revisited: Brown Defeats Coakley

In yesterday's Senate race Scott Brown (Rep) soundly defeated Martha Coakley (Dem) by 5 percentage points, according to today's headlines in the Boston Globe. While Coakley proved she is knowledgeable and articulate during the debates it seems that voters' took issue with health care reform and probably a number of other issues related to the economy, taxes, and national security.

What I think this election came down to was Massachusetts' voters deciding to mark their ballot for the candidate that best represented their own interests. A likely case for voters in every region of America.

But when it comes to heath care reform, MA is in an interesting predicament.

Is "Healthier" Healthy Enough for School Vending?

Early on a Tuesday morning, while walking the halls of Winter Hill Elementary School in Somerville, Massachusetts, I was struck by the absence of an item that has become nearly ubiquitous in schools across Massachusetts: vending machines. Vending machines are the most convenient source of exactly what you tell your kids not to eat.

Mammography Guidelines Revisited

Reaction to the updated mammography guidelines -- see previous posts on the topic -- from the US Preventive Services Task Force (USPSTF), a panel of experts charged with determining guidelines for cancer screening, has reached partisan proportions. Republicans are trending toward outrage and Democrats sympathy.

APHA Day 1: Environment Matters for Health

Mayor Nutter described Philadelphia, "the city of brotherly love and sisterly affection," as a city of public health firsts during today's Opening Address at APHA. He and several other speakers talked about the many public health "firsts" that Philadelphia can pride itself with: the first medical school, the first water and sanitation bureau, the first city to require water flouridation.... 

School Nutrition Policies, MA on my mind

As I mentioned on Twitter this morning, french fries appear to be the lunch food of choice for students in a popular school in Queens, New York, according to the New York Times. That probably doesn't surprise anyone who works in a school or has visited one during lunch. Unfortunately, I have not.

Nonetheless, my memories of school lunch are not much different. I remember tater tots and pepperoni hot pockets being standard fare. By the time I graduated, there was a salad bar in place; it was not very popular. Occasionally, I opted for the food served as part of the National School Lunch Program (spaghetti comes to mind) and on days of cross-country meets I habitually ate a peanut butter and jelly sandwich, which was a pretty good choice thinking back on it.

Soda Tax To Combat Obesity, Will it Work?

Cigarettes are taxed, alcohol is taxed, why aren't soft drinks taxed?

One huge reason for the dirth of legislation levied against unhealthy foods including sodas is the enormous lobby of the food industry in DC and across the country. Whenever there is serious consideration of restricting access to unhealthy foods (such as in public schools) there is enormous resistance. Big Food has lots of money to manipulate (I mean influence) public opinion so that there is not enough momentum and public support for anti-junk food policies. The sad story is that public health professionals can have nearly the same trouble improving access to healthy, nutritious foods in these same places!!

The lead story of the Business section of today's New York Times was "Tempest in a Soda Bottle: Proposed Tax on Sugary Beverages Debated." It discusses the increased political open-mindedness to the idea of a tax on soft drinks and sugar-sweetened beverages in the US and the likely resistance to such a proposal.

Here's why I think this could be a good idea.

Smoking Outside, A Public Health Threat?

The New York Times has been impressing me recently with its coverage of public health issues. Sure, health care reform makes that coverage pretty much a no-brainer, but today's front page article on the proposal to ban smoking outdoors in New York City definitely peaked my interest. It is part of the "Take Care New York Plan 2012" and includes other public health proposals in addition to banning smoking in public parks and beaches.

New York City has long been an early adopter of public health initiatives, such as eliminating trans-fat from prepared foods, improving menu labeling in fast food chains to include calorie counts, and banning smoking from nearly all indoor spaces.

The proposal, launched by the NYC health commissioner, Dr. Thomas A. Farley, to ban smoking from public, outdoor spaces is not without precendence, as the article points out:

"A number of municipalities — particularly in California — have banned smoking at outdoor parks, playgrounds and beaches. In 2007, Los Angeles extended its smoking ban, which already covered beaches and playgrounds, to include municipal parks. Later that year, Chicago banned smoking at its beaches and playgrounds, though smoking is still allowed in many parks."

Nonetheless, there is much controversy over the need for such a ban. What are its objectives?

Obama Health Care Speech, Meat and Meaning

We know we must reform the system. The question is, 'How?'

- President Obama, Health Care Speech, September 9, 2009

Tonight at 8pm Eastern President Obama made his appeal for passing health care reform. Prescriptions columnist David Herszenhorn had a timely piece in the New York Times this morning, "How to Watch the Obama Speech." Where was Herszenhorn right? Where did he go wrong? This is my attempt at establishing whether, as my journalism professor put it, "it was worth the effort."

Health Care Reform: Canadian Comedy

My goodness. The US is not and never will be like Canada. Period. Certainly not in terms of health care. It is for better or worse depending on who you talk to.

I am sick and tired of all the news hype and political rants about health care reform turning the fractured US system into ONE giant government-run health care plan. That is just not going to happen. Canada has a single-payer, government-run health care system. There is no private health care in Canada. This is an exception and not a rule for strengthening and expanding health insurance coverage and service access.

For example, last month I was in Costa Rica. Costa Rica has a government sponsored health insurance plan that covers all citizens. Citizens are required to pay into the plan whether they use those services or not. Those who seek faster or more specialized health care services can pay more for private insurance and seek private health services, as well. While the system may not work perfectly, it leaves no one behind. In fact, I was asking my Costa Rican friend where she would go if she had a major medical problem (say a diagnosis of breast cancer). She said she would absolutely, hands-down have her surgery at the public, government hospitals because the physicians are better skilled and trained for those intense surgeries.

Now, in many ways Costa Rica can be quite exceptional. However, it goes to show that government services do not have to lag behind those of the private sector. All too often we assume that government services will be below the standard of private insurance. My experience working at the Veterans Affairs in Palo Alto taught be otherwise. Sure, it wasn't perfect -- but it was light-years ahead of some other private providers.

If planned appropriately and with the right incentives, there should be no reason why US health care reform cannot maintain high quality health care (...and there is improvement needed in this area as well...) while lowering costs and covering all Americans. We should expect exemplary government-run health care (including Medicare, Medicaid, and VA health care) that creates a gold standard for private practices.

But we must not forget that good health is NOT simply a matter of medical care. Prevention is key to improving our health and lowering costs. We must promote health in our homes and in our communities. Without changes in our lifestyle and the societal pressures that surround us we will never be able to sustainably lower costs and increase our health outcomes. We can prevent heart disease, cancer, suicides, and HIV/AIDS without expensive medical technologies and overpaid specialists.

And when I say 'We' I mean 'We' and not 'Me' or 'You'. Because I believe health is a product not just of individual choices, but of social and community influences and environments. Steps to improve our nation's health and our health care system must proceed accordingly.

Political Will & The Fight Against Human Trafficking

The political will to combat trafficking and sexual exploitation could not be more different in Nicaragua and Costa Rica. As you may be aware, the US Department of State released its 2009 Trafficking in Persons Report where it demoted Nicaragua to the Tier 2 Watch List, a warning of sorts that Nicaragua is not doing enough to combat this problem. Costa Rica, on the other hand, remained ranked at Tier 2.

While I admit that I have not met the leader of the Nicaraguan National Coalition Against Trafficking in Persons in the Ministry of Government, I feel that I have a adequate perception of him through my various meetings with international organizations, local NGOs, and US state department affiliates. And to be frank, it was pretty clear that it would not be worth my time (...should I not have said that?).

There is a clear lack of government leadership in Nicaragua to prevent trafficking and assist victims, which is absolutely essential for any national effort to eliminate this 'modern day slavery'. There are no clear objectives for the Coalition, there is no action being taken by the government to address trafficking, and the NGOs and international organizations are left picking up the pieces and doing their best to work with (and around) the governments' inadequacies. (...here's a good article on this in El Nuevo Diario if you don't just want to take my word for it...)

On the other hand, while Costa Rica is by no means a perfect example of 'best practices' in the area of trafficking prevention and assistance they are light-years ahead of many other countries in the region. This is no doubt a result of substantial government efforts to prevent and combat trafficking in coordination with local, national, and international NGOs.

I met on Monday morning with the Costa Rican Viceminister of Internal Affairs and Police, Ana Durán, who also heads the National Coalition against Illegal Migration and Trafficking in Persons. She has a strong record of leadership and commitment to this issue, as evidenced by the high regard for her of local NGOs that work in this issue. It was clear from our conversation that her team is working hard to 'institutionalize' the improvements they have made, so that future administrations can easily continue the work that they are doing.

Training and education/awareness are essential tasks of the coalition (among others...). And it is clear that Lic. Durán takes the education and training of police and immigration forces seriously. She mentioned that one factor that may make the Costa Rican Coalition more effective other coalitions in the region is the orientation of the police within the same ministry as the anti-trafficking leadership. This means that there is one less beaurocratic/political hurdle in getting the police to take trafficking seriously. In Costa Rica, for example, all officers must be trained in best practices to investigate possible cases of trafficking and sexual exploitation in order to pass through the police academy. Nonetheless, she concedes that the police have a way to go and hopes one day of a police force specialized in trafficking cases.

There are so many other examples of the strengths and weaknesses of the two government approaches to trafficking. For example, Nicaragua still only recognizes trafficking of women and children for sexual exploitation in their Penal Code. Therefore, those trafficked into domestic servitude or children and men trafficked into forced labor are not protected under Nicaragua law. It was only in February 2009 that Costa Rica revised the Penal code to include pubnishment for labor trafficking, as well. However, there is still little protection or assistance for men who are identified as victims of human trafficking. Until 2005 they didn't even consider internal trafficking a crime!

While Nicaragua relies exclusively on NGOs to provide victim assitance and to lead prevention efforts, Costa Rica also relies heavily on the provision of serivces by local and international NGOs. The difficulty is in the provision of funding for these services which waxes and wanes. Currently, I would expect funding for trafficking to be flowing pretty freely. However, who is to tell when the international interest in this issue will decline? In fact, the NGOs that seemed to be most effective and growing were the ones receiving funding from the US State Department G/TIP office -- go figure!

These past three weeks have given me an incredible education on the politics and governance around trafficking issues. The strategies needed are complex and require extreme cooperation and collaboration between the civil and government sectors.

I am thankful that our current administration takes this topic so seriously. Especially as we hear more and more about trafficking and sexual exploitation taking place in cities all across the US. Hopefully we have an eye to the problem at home, as well as abroad.

Big Food: Bad News?

Here are two articles I came across in Consumer Affairs this morning:

FDA Warns General Mills About Cheerios Claims

According the the Food and Drug Administration (FDA) Cheerios has stepped out of bounds in its recent campaign to market that "Cheerios may reduce your cholesterol!". GM also promotes other scientific claims such as the ability of Cheerios to lower LDL cholesterol (the bad kind) and to lower cholesterol 4% over 6 weeks. FDA officials feel that these statements market Cheerios as a drug, not food because of these claims.

I applaud the FDA efforts in this area. GM and other large food companies are itching to show just how "healthy" their foods really are -- when really, their foods are not all that healthy. In fact, they would love to play up the RELATIVE advantage of sugary cereal over no cereal or the benefits of diet soda over regular soda. 

Come on! Leave out the sugar, cut back the sodium and use less refined products. Then you might not have to try so hard to prove that your food is good for the public.

Nothing beats a home cooked meal. We all should try it some time.

Senate Studies Soda Tax

The Center for Science in the Public Interest, a public health advocacy group, has finally gottenthe attention of Congress in efforts to pass a national tax on soft drinks and sugar-ladenbeverages.

According to the article a study conducted by the Harvard School of Public Health in 2006 found that added sweeteners contributed to 1/3 of all carbohydrate calories that Americans consume, and that the sugar from sugar-sweetened drinks is a full 1/2 of that caloric amount.

We have been down this road before without much success. Even in Massachusetts we have a law that explicitly exempts CANDY and SODA from State sales tax. How can this be?! Our Stateneeds money and this sort of sales tax on absolutely, undeniably, unhealthy food seems likelow hanging fruit, right?

How many of our politicians are in bed with the food and beverage industry to block this votefrom passing? We will know in due time.

Candidates Health Plans: Revisted

The NY Times just ran a series of letters to the editor that critiqued the candidates' so-called "solutions" to our health care woes. Below is one that sums up many of the readers' positions quite well. 

Most letters are written by physicians and lawyers -- I hope that public health professionals continue to be an active voice in the debate. We bring the perspective that access to health care is only a part of the solution -- prevention of poor health and improving peoples' built and social environment is essential to improving our nation's health.

NY Times: Letter to the Editor published November 1, 2008

“The Candidates’ Health Plans” (editorial, Oct. 28) reveals the critical flaw in both candidates’ proposals. Both merely redistribute the cost of health care; neither actually lowers the cost. Their common flaw: continued dependence on insurance companies.

Here’s a better plan: a single national nongovernment not-for-profit health insurance company financed by a payroll tax. By eliminating the profit margin and cost of marketing, we can reduce the cost of health insurance, and thus health care, dramatically.

Glenn Alan Cheney
Hanover, Conn., Oct. 28, 2008

The Looming Health Care Crisis

An Op-Ed submission by three Harvard School of Public Health students: Alana Wooley, Katelyn Mack and Jamie Zwiebel. For your reading pleasure. Comments welcome!

As our government leaders grapple with the current economic crisis, another crisis is gaining momentum. We can no longer ignore its symptoms: rising rates of preventable, chronic illnesses; Americans facing trade-offs between doctor visits, prescription drugs, mortgage payments, gas or food; financial concerns determining patient treatment for catastrophic illnesses; and an inability to obtain insurance with a pre-existing illness, among others.  In 2007, 45 million Americans were uninsured.  These numbers will no doubt continue to climb as families and employers alike increasingly feel the direct impact of rising unemployment and inflation.  If we do not address the looming health care crisis, we will undeniably face yet another bailout, this time for health insurance companies and the health care community.

In the most recent presidential debate, Senator Barack Obama (D) told the nation he believed health care is a right and Senator John McCain (R) believed health care is a responsibility.  Whether it is a right or a responsibility, both candidates believe that access to and affordability of health care are important.  While we may disagree about solutions to and responsibility for the health care crisis, 51% of Republicans and 79% of Democrats believe that our nation’s broken health care system is in need of repair (Blendon et al. 2008). While the Presidential candidates agree that something needs to be done, their health care proposals are in vast opposition to one another. 

Senator McCain offers a short-term solution to this imminent crisis.  His health care plan proposes a $2500 and $5000 tax-credit for individuals and families, respectively, to help absorb the rising costs of health insurance.  However, not only is this credit, which is payable only to the insurance companies, considered taxable income, it does not address rising premium costs and treatment expenses.  While this tax credit may be beneficial for young, healthy adults, it would exacerbate the financial burden of health insurance for families and adults living with chronic or catastrophic illnesses. Simply offering a tax-credit to help deflect expenses for an already expensive health care system is not a sustainable solution and one that will be ineffective in reducing the rising numbers of uninsured Americans. 

Senator Obama offers a more comprehensive, long-term solution to the health care crisis. He proposes allowing individuals and families to keep their current employer-offered health care, or opt into a public insurance or obtain private insurance coverage through an insurance clearinghouse. The public insurance would offer coverage similar to that which Senator Obama and Senator McCain have as government officials. Contrary to rumors of socialized health care and fines for not obtaining insurance, this proposal only mandates health insurance coverage for children.  Senator Obama offers a more comprehensive plan that would extend insurance access to those whom the current system does not capture.  While this plan would reduce the number of uninsured Americans and improve coverage for children and families, Senator Obama’s plan would not cover everyone.

The health of our nation is central to the health of our workforce, the strength of our families and communities, and our national security. This election is an opportunity to ensure that the housing and credit woes we now face do not similarly beset the fragile US health care system.  As voters, we must elect someone with sound judgment and visionary thinking.  We can no longer afford short-term solutions.  Our next President must offer long-term, sustainable solutions to the long-standing dysfunction and discord of the US health care system. Let us enter the polls with the economy, health care, and education on our minds, all of which are inextricably linked together. Now is the time.  It is our responsibility to avoid another bailout blunder by electing the candidate with the best solution to improving the health and well being of all Americans.

Health Care: Head to Head

The Wall Street Journal recently assessed Obama and McCain's health care plans (October 23, 2008; Personal Journal Section, D1). Depending on your income, health status and what kind of insurance you currently have the plans may have different effects on your insurance situation. The WSJ concluded that Obama's plan would tackle the large (and growing) uninsured population, but both plans could reduce out-of-pocket spending for Americans in the short-term.

How much will each candidates' health insurance programs cost? The Tax Policy Center has suggested both plans will cost between 1.3 (McCain) and 1.6 (Obama) trillion dollars over 10 years; however, the Lewin Group determined McCain's plan would cost almost twice as much as Obama's plan ($2.1 vs. 1.2 trillion). 

Both candidates plan to use money from taxes (by rolling back the Bush tax cuts) or other incentives (taxing employer health benefits) to offset the costs of their health care proposals. I encourage you to read the full article if you have a chance.

Health Care: A Right?

In the second Presidential debate of the season, the two Presidential candidates were asked whether they believe that health care is a privilege, a right, or a responsibility. 

Senator McCain responded:

"I think it's a responsibility, in this respect, in that we should have available and affordable health care to every American citizen, to every family member. And with the plan that...I have, that will do that. But government mandates I -- I'm always a little nervous about. But it is certainly my responsibility. It is certainly small-business people and others, and they understand that responsibility. American citizens understand that. Employers understand that."

I had trouble figuring out what McCain meant by saying health care is a responsibility since he followed that up with "we should have available and affordable health care to every American citizen." After going through his health care proposal I have come to understand his response as: it would be his responsibility as President to encourage the market (employers and insurance companies) to provide health care for American workers. He does not believe that increases in health care accessibility and affordability should result from increases in government spending on health care. But what about the people who cannot afford to work enough hours to be eligible for employer-based insurance (due to economic turmoil, layoffs, or family responsibilities)? What about the elderly? The disabled? What about the hard-working Americans who are working double-duty shifts and yet still earn less than half the median income-- not enough to pay $5-8,000 out-of-pocket for quality health care coverage for their family? Whose responsibility is it then? If it is the government's responsibility to provide access in these cases, the government is not doing enough.

On the other hand, here is Senator Obama's response:

"Well, I think it should be a right for every American. In a country as wealthy as ours, for us to have people who are going bankrupt because they can't pay their medical bills -- for my mother to die of cancer at the age of 53 and have to spend the last months of her life in the hospital room arguing with insurance companies because they're saying that this may be a pre-existing condition and they don't have to pay her treatment, there's something fundamentally wrong about that."

That health care is a human right is widespread belief. The preamble to the World Health Organization Constitution declares "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Recently, the Office of the United Nations High Commissioner for Human Rights and the World Health Organization released "The Right to Health," a fact sheet that seeks to outline the basic understanding of what "the right to health" is and "its implications for specific individuals and groups." 

While no country has a perfect health care system, some certainly have achieved more equity and better health outcomes than what we observe in the US. Ours is a system driven by capitalist principles for all but the most impoverished families (who are eligible for Medicaid and SCHIP). While I have heard it argued that no one can be turned away from medical services for immediate life-threatening illness or injury, we all know that chronic health conditions are increasingly placing a burden on our system in terms of human and financial resources. Plenty of studies (including an upcoming publication in Journal of Women's Health -- woohoo!) support the notion that men and women without health insurance are less likely to access and receive preventive health services. This results in later disease complications and even (preventable) death. I will readily acknowledge, however, that providing health insurance to everyone is not a magic bullet solution to the current state of (ill-) health  in our country.

What are your thoughts on health care as a right or a responsibility? Do you think health care rights include social conditions such as safe drinking water, adequate nutrition, proper housing, and gender equality? What about access to essential medications, preventive health services (screening, education, vaccinations), reproductive health services? Why?

Finally, will the country's looming health care crisis factor into your vote on November 4th? 

Comment! I know you want to.

Update: America's Health Insurance Plans investigated the average cost of health insurance. While premiums for families varied widely depending on the State in which you live, the average cost was $5799. In Massachusetts, the average cost was over $13,000. Obviously, there are huge differences as well in what you get for $6000 family insurance in terms of deductibles, preventive care, and copayments. 

Bailout: the $810 billion bombshell

There was a great op-ed written by Joel Berg in last week's Washington Post. He wrote from a social services advocate's perspective on the looming government bailout of failing financial institutions. While I acknowledge that some remedy is needed for the mess that lenders have gotten themselves into by thinking the housing bubble would never burst. I am nonetheless baffled by the shear magnitude of the cost. Now, we are learning that the $700billion initially proposed has grown to $810billion (...because of pork?!) -- I am forced to reflect on what this money actually means. Our politicians can talk about the need for social protections, serving "the people", providing for families, communities, and the country. But talk is cheap. True values are revealed by where we spend our money (and our time). Thus, this bailout may (I hope) mean more than rescuing troubled Wall Street investors; rather, it represents a greater value of protection of our livelihoods and lifestyles -- being able to own and keep one's home, start a new business, invest in our children's future education. The details and implementation of this bailout bill will further reveal the underlying values and priorities of those whom we entrust the future of our nation. 

Back to reflection upon this $810billion. What would I do with $810 billion? Would I provide food for the hungry? Legal counsel for the oppressed? Food for the malnourished? Mobile technology for the isolated? Job training for low-wage workers? Bed nets in malaria territory? Funds for non-profit organizations? 

What would you do with $810 billion dollars?