United States Health Care Reform:  Progress to Date and Next Steps | JAMA | JAMA Network

The president got published in JAMA! This is a lovely, academic, chock-full-of line graphs sum up of the past 6 years of changes. Uninsured rates are way down, access and quality measures improving. The economy has responded positively. The health care world is topsy-turvy, and it is undeniably rough in the ranks of hospital management. But in spite of the challenges to the health care industry, the protections that the Affordable Care Act legislation provided make me as a believer in health care as a human right happy. And very frustrated with my home state and others that have declined to expand Medicaid.

It’s strange and sad that I celebrated the upholding of the ACA in the office of a Free Clinic where I volunteered, thinking it might be the end of clinics covering adults below the federal poverty level with a patchwork of volunteer services, state funds, and grants. I’m sorry that virtually nothing has changed for the patients we saw at that clinic. Hospitals in non-expansion states are still going uncompensated for millions of dollars of care. The federal government DSH (disproportionate share hospital) dollars that used to support public hospitals with large numbers of uninsured have declined as that money was plowed into ACA program support. One last insult: if you are paying federal taxes in a non-expansion state, your money is fed into Medicaid for adults in other states, while your health infrastructure is starving. But that is not the main focus of the article. This is a celebration. A statistically-backed victory lap. But don’t take my word, listen to Barack Obama, JD:

The United States’ high uninsured rate had negative consequences for uninsured Americans, who experienced greater financial insecurity, barriers to care, and odds of poor health and preventable death; for the health care system, which was burdened with billions of dollars in uncompensated care; and for the US economy, which suffered, for example, because workers were concerned about joining the ranks of the uninsured if they sought additional education or started a business.

Source: United States Health Care Reform:  Progress to Date and Next Steps | JAMA | JAMA Network

Cancer: The Emperor of All Maladies and My Cancer: The Wrecker of All Normalcy

Video: Cancer: The Emperor of All Maladies Trailer | Watch Cancer: The Emperor of All Maladies Online | PBS Video.

You’re all watching this, right? You’ve already watched it?

Good. I need to re-watch a time or two more before I give you my bullet points, but wow.

Hot off the press for my policy class about being a patient and looking at treatment options and statistics. No good choices yet.

The Fear & The Data

I’m the kind of patient who wants to, no insists, on knowing the numbers. When I was diagnosed with melanoma a little bit more than a year ago the sentence after “the tumor is malignant” was me asking “how deep.” I already had the tumor staging chart in front of me. That’s not true. It was dark, I was outside, and I had that thing memorized. My tumor was staged 2B, my stats are 60% survival at 5 years. I absolutely consent to a wide tumor excision and sentinel node excision. I am unable to undergo the recommended course of immunotherapy (12 month course) for adjuvant treatment that would have got me an additional 7% survival, due to my comorbid Lupus. I look for second and third and fourth opinions, and find a reputable oncologist with specific experience in my sub-type of melanoma who recommends adjuvant cutaneous radiation. The doc, my radiation oncologist, and I pull the best studies we can and make a good argument for radiation therapy in reducing recurrence of melanoma at the site (and more than 80% of melanomas of my subtype reoccur at the site) by 12-15%. SOLD! For $6,000 out-of-pocket, 6 weeks of my life, and 2 months of healing third degree burns and radiation toxicity. Steep. But fear is a powerful motivator. And fear of abandoning your young child? I mean I don’t have to tell you.

Would I have done the radiation for 5% reduced recurrence? I am aware that radiation can cause late malignancies. But REGRET. I could never forgive myself a lost chance to raise my child. Despite my lack of faith in integrity of studies in general, my non-surprise at aberrant results, and my belief that as a young person I may have more bounce back in me, I cling to the numbers with fear and with hope. Some people see themselves as the exception. I can’t help but see myself as the rule.

CDC Recommends Antiviral Drugs For At-Risk Patients : NPR

CDC Recommends Antiviral Drugs For At-Risk Patients : NPR.

The flu is awful this year. I’m in the bathroom washing my child’s hands all Lady Macbeth the second he gets home from school. In this interview Tom Freiden, Director of the CDC, explains plainly why the flu is so bad right now and why people who have gotten the flu shot are still getting sick. He also talks about antiviral use in flu patients.

I’m concerned for public health and the future success of flu shot campaigns. The strain that is infecting people despite vaccination was chosen for the vaccine, but between it’s selection and the beginning of our flu season it mutated. ARGH. This wasn’t a failure on the part of the CDC but it will lose them good faith in a year where we already had our eyes set to roll at their very next press release. So now add to the giant list of reasons people won’t get their flu shot “they messed it up last year.” Which is bad for community immunity.

Below, data for health districts reporting in VA (two weeks old). The red is the sub-type of flu the vaccine does not cover.

flu data
http://www.vdh.virginia.gov/Epidemiology/flu/WklyPhysReport.pdf

Knowledge cures ignorance so here is the back story of the flu vaccine and why this year was a one-off to convince you to please get your flu shot next year, too:

How are the viruses selected to make flu vaccine?

The influenza (flu) viruses selected for inclusion in the seasonal flu vaccines are updated each year based on which influenza virus strains are circulating, how they are spreading, and how well current vaccine strains protect against newly identified strains. Currently, 141 national influenza centers in 111 countries conduct year-round surveillance for influenza and study influenza disease trends. These laboratories also send influenza viruses to the five World Health Organization (WHO) Collaborating Centers for Reference and Research on Influenza located in Atlanta, Georgia, USA (Centers for Disease Control and Prevention, CDC); London, United Kingdom (National Institute for Medical Research); Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory); Tokyo, Japan (National Institute for Infectious Diseases); and Beijing, China (National Institute for Viral Disease Control and Prevention) for additional analyses.

The influenza viruses in the seasonal flu vaccine are selected each year based on surveillance-based forecasts about what viruses are most likely to cause illness in the coming season. WHO recommends specific vaccine viruses for inclusion in influenza vaccines, but then each individual country makes their own decision for which strains should be included in influenza vaccines licensed in their country. In the United States, the U.S. Food and Drug Administration (FDA) determines which vaccine viruses will be used in U.S.—licensed vaccines.

Think globally, outrage locally.

One of the volunteers at our tiny county’s only food bank/emergency assistance provider/shelter is always wearing a t-shirt that says IF YOU AREN’T OUTRAGED YOU AREN’T PAYING ATTENTION. He’s one of the gentlest guys I know–a middle aged black man living in rural poverty who relies on the food bank and is its most faithful volunteer. I used to give his son a lot of (unsanctioned by my employer) rides back when I was working in our nearby town. Also soft-spoken and kind. And tall and broad and one of those kids whose stupid luck ends him up in the wrong place sometimes. I worry.

But that t-shirt, oh man it makes me like that guy.

So here’s something I wasn’t paying attention to before one of my nursing colleges (Michael Swanberg, a member of ACT UP, certified nurse midwife, and enchanting human being) brought it to light. This data is pulled from the Thomas Jefferson Health District’s community health assessment, 2012. Page 54. The image quality is terrible but the dark blue is TJHD black infant mortality, teal is TJHD white infant mortality.

infant mortality image

An examination of infant mortality stratified by race demonstrates the same phenomenon in Virginia and TJHD as in the nation — African-American babies die more frequently than white babies. In 2007-2011, the rolling average IMR in TJHD was 4.5 infant deaths per 1,000 live births among white infants, lower than the Virginia (5.4) and U.S. rates; it was 17.3 among African-American infants, which was higher than the Virginia (13.8) and the U.S. rates (Figure 109).

Check my math but that means that African-American neonates in our health district are nearly four times more likely to die than their white counterparts. Brand new no-jackass-on-earth-can-say-their-deaths-were-deserved babies. Are you feeling the outrage? The black neighborhoods in Charlottesville are literally in the shadow of the towers of an academic health center. Tell me how this can be.

A seat at the table. Psst this is a feminist issue.

I spent all day yesterday and half of today at the hospital, then the other half of today writing a paper about my profession, then came home and watched this 26 min documentary about the future of nursing. I am so thoroughly in brainwashed/in love (that’s the same thing, right?).

I’m on board with all of this nurses are the answer messaging. But the very last line hits a sour note:

“Wake up public, you vote us most trusted profession but we need your support to be all that we need to be.”

THUMBS DOWN. Don’t spend twenty minutes talking about how we are natural fixers of problems then lob the biggest one we have, our fractured image, into the lap of the public.

Wake up faculty. Teach young nurses that it is absolutely their professional obligation to speak up for their patients. Not just in the hospital. Take that noise to the press, the internet, the state house.

Wake up nurses. That trust we get from the public is sacred. Earn it by being conscientious, whip-smart, and brave. And be public about it.

Price Tags On Health Care? Only In Massachusetts | Kaiser Health News

image

Let us be doubly thankful to Massachusetts.

Anyone with private health insurance in the state can now go to his or her health insurer’s website and find the price of everything from an office visit to an MRI to a Cesarean section. For the first time, health care prices are public.

via Price Tags On Health Care? Only In Massachusetts | Kaiser Health News.

If you have health insurance you’re likely used to making two types of price-based decisions when it comes to care:

1.) Primary care problem: How much sinus infection misery warrants a $35 copay to my doc? Answer (for me) 3-4 days.

2.) Emergent care problem: How much money am I willing to pay to have my burst appendix removed? Answer: ALL OF THE MONEY WHAT IS MONEY PAIN MEDS STAT.

But, for expensive and not especially time sensitive diagnostics and procedures transparency in pricing is so pleasingly sensible. The article makes the point that health care is not a commodity to be bought on price alone and I totally agree, but up ’til now we’ve had no way to collect data connecting price and quality. This is a step in the right direction.

Pro tip on buying your health care based on price–If you are buying on the exchanges/marketplace please do not make the Travelocity sort by cheapest yup I’ll take that one mistake. That is how you end up with a $10,000 deductible and 40% coinsurance on everything. You will not be happy. As I was not happy when I picked a hotel in Richmond that way. Hourly rates. Somehow under I95. Feral tomcats.

Choose a better fate.

Whooping cough outbreak at Grand Traverse Academy nearly doubles to 161 probable cases

Image NIAID

Whooping cough outbreak at Grand Traverse Academy nearly doubles to 161 probable cases | MLive.com.

Herd immunity/community immunity: when enough people are immune to a disease, that disease will not spread through the population. As a result those who are not or cannot be vaccinated (pregnant women, infants, immunocompromised) are protected from the disease as well.

Infants are eligible to receive their first pertussis immunizations at 2 months. Pertussis/whooping cough in the first three months of life is frequently severe and often fatal. Pertussis is a respiratory disease that in early stages has the same symptoms of a cold. Babies are most likely to get the disease from a parent or a sibling. (American Academy of Pediatrics)

I’m not going to ruin my night by getting on the soap box because it’s Saturday and ACA open enrollment is not a total disaster so far and I was just destroying at Jeopardy, but y’all are picking up what I’m putting down, right?

Between Two Lives – Features – Fall 2014 – Johns Hopkins Public Health Magazine

via Between Two Lives – Features – Fall 2014 – Johns Hopkins Public Health Magazine.

Does fleeing family violence and the nation with the world’s highest murder rate qualify Wilter as a refugee?

Though it’s been bobbing in and out of the news cycle, there is still a Central American migrant crisis. I got into the weeds on immigration policy, then deleted it all because jeez it may be the one thing more complicated than health policy. For reference: UNHCR definition of refugee, US Citizen and Immigration Services definition of refugee.

But this current event is germane to public health. By not having a comprehensive policy in place we are unable to mobilize resources to address the health and safety needs of a large group of immigrants, mostly children. The humane thing to do would be to accept and give the best care we can possible to these refugees. At bare minimum, to protect our native population we should ensure screening for infectious diseases (TB, measles, mumps, rubella, Hep A-C, pertussis), treatment, and vaccinations.

If you have the time and the inclination to have your heart broken, watch the film Sin Nombre. It was done more than five years ago and is of course fiction, but by all accounts captures the migrant journey well. What keeps me up at night is thinking of what home must be like if this voyage is the better option.

Panic, Paranoia, and Public Health — The AIDS Epidemic’s Lessons for Ebola — NEJM

Panic, Paranoia, and Public Health — The AIDS Epidemic’s Lessons for Ebola — NEJM.

Please read this because we have to remember our history to learn from our history.

Various politicians called for quarantining of anyone who tested positive for HIV, and commentator William F. Buckley infamously penned an op-ed in the New York Times saying that “everyone detected with AIDS should be tattooed.”

Let us pump our collective brakes.

I mentioned in an earlier post that as an infectious disease, Ebola is a slam dunk for a country with a robust public health system. It poses far fewer challenges then, say, a really bad respiratory virus. This technically-but-really-not-an-epidemic has shown that there are some weakness in public health. Particularly in leadership. I’ll leave you with a parting tweet:

I want to kiss the lawyer who defends this case.

Two Courts, Two Strategies: A Guide to the Recent Decisions on the ACA – The Commonwealth Fund.

The only reason I am reading the news this weeks is to keep up this blog, and I would like for everyone to know that I am now out of Tums and Pepto.

The above article describes the latest legal challenge for the ACA rising through the courts. It is great if you need some neck exercise. SMH SMH SMH SMH SMH. I just learned what that means.

Here is the meat of the case:

For the plaintiffs, that strategy (referred to by lawyers as “the theory of the case”) lies squarely in convincing the courts that a handful of words in the tax-code provisions of a 900-page law (in this case “Exchange established by the State under §1311”) means exactly that. If a state does not establish an exchange, there can be no subsidies.

Semantics! At stake for the states that have defaulted to the federal marketplace (instead of facilitating their own) are the federal subsidies offered to make insurance bought on these marketplaces more affordable. Which would be a BIG TIME BUMMER for people making under 400% of the federal poverty level ($95,400 for family of four) in Alabama, Alaska, Arizona, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana Nebraska, New Hampshire, New Jersey North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Virginia, West Va, Wisconsin, and Wyoming.