Health Care Reform — A Historic Moment in US Social Policy

On March 23, 2010, President Obama signed into law the first U.S. comprehensive health care reform bill, the Patient Protection and Affordable Care Act (PPACA). After almost a century of failed attempts, the U.S. now has a national health care system which promises to increase access to care, increase consumer choice, and ban insurance discrimination for individuals with preexisting medical conditions. The PPACA is expected to expand insurance coverage to 32 million individuals by 2019 through a variety of measures. At a cost of $938 billion over 10 years, the PPACA is projected to reduce the deficit by$143 billion in the first decade and $1.2 trillion over the second. Almost everyone will be required to purchase health insurance by 2014, with certain exceptions, or face a penalty. The mandate is coupled with sliding scale subsidies to make the purchase more affordable, and it limits annual and out of pocket spending. If the penalty is strong enough, the mandate will be effective in expanding the pool of insured people, spreading the health risk, and eventually decreasing premiums. Key coverage expansions, such as expanding Medicaid benefits to individuals and families with incomes up to 133% of the federal poverty line (FPL), are critical, but access to providers must also be ensured. By 2014, states must set up exchanges where consumers can shop for health insurance at competitive rates. Subsidies will be provided to individuals and families under 400% of the FPL and not eligible under Medicaid to help purchase insurance in the exchange. Additionally, small businesses with fewer than 100 employees will receive tax credits for offering insurance. The PPACA reverses common industry practices that have, in the past, created barriers to coverage. It prohibits insurers from denying coverage to those with preexisting conditions and allows young adults to remain on their parents’ plans up to age 26. For Medicare patients, the Part D coverage gap is closed and cost sharing for preventative care is eliminated, while the amount of out-of-pocket costs paid per year is limited. This historic legislation takes great strides towards providing everyone with medical care, irrespective of income or health status. It will improve public health, and place more emphasis on primary and preventive care. However, issues still remain surrounding difficult choices on how to reduce increasing costs, improve quality, and ensure appropriate payment reimbursement for providers

Physician Assisted Dying: A Turning Point?

Physician Assisted Dying (PAD) has been lawful in some countries since the 1940s and in the United States since 1997. There is a body of social and scientific research that has focused on whether the practice has been misused and whether gaps exist in legislative safeguards. There are multiple concerns with physicians assisting patients to die: incompatibility with the physician’s role as a healer, devaluation of human life, coercion of vulnerable individuals (e.g., the poor and disabled), and the risk that PAD will be used beyond a narrow group of terminally ill individuals. Statutes in the United States have been drafted with these concerns in mind in an effort to mitigate the possible risks of PAD while still providing individuals with access. There seems to be a shift in attitudes towards PAD. Currently four states statutorily permit PAD and it is being discussed by multiple legislatures across the country. There also seems to be a shift in medical practice as demonstrated by a 2015 survey that showed for the first time that more than half of physicians surveyed favored medical assistance in dying. PAD is a deeply personal choice. The question is whether more states will authorize the practice and, if so, what safeguards will be put in place to ensure the practice is not misused and remains consistent with prevailing social and ethical thought

Health Care Reform in Transition: Incremental Insurance Reform Without an Individual Mandate

A major access problem exists in the private insurance market for individuals with preexisting conditions, who are either denied coverage or charged exorbitant premiums. In effect, individuals are denied coverage for exactly what they need, which jeopardizes their health and the financial security of their family. Before health reform passed, discussions surrounding incremental reform took place, including perhaps the most politically compelling – prohibiting insurers from denying coverage to those with preexisting health conditions. Insurance is based upon the principles of spreading risk of individuals across a population to ensure that everyone can afford medical care when he or she needs it. However, risk pools are functional only if they include enough healthy individuals to keep overall health care expenditures lower than premium costs so that high-cost individuals will be covered. Although providing access to health care for all is vital, in practice requiring insurers to accept more high cost individuals without adding more healthy individuals to the pool could result in adverse selection, increase costs, and a potential financial death spiral. If there are no incentives or mandates for individuals who are healthy to purchase insurance, risk pools become even more expensive and result in even more adverse selection and malfunctioning markets. A mandate to purchase insurance counteracts adverse selection by bringing more healthy individuals into the risk pool, thereby decreasing premiums. Moreover, mandates decrease the number of uninsured, lessening cost-shifting due to uncompensated care. A tax penalty would be levied on individuals who do not have qualifying insurance. Of course, adequate subsidies must also be provided for poor individuals and families to help purchase insurance. But while many support covering those with preexisting conditions, support for a mandate is still contentious, even after the health reform law, which includes a mandate. Conservatives frame the mandate in terms of personal freedom, compulsory contracts, and transfer of money to a private party. In actuality, mandates combined with prohibition of excluding those with preexisting conditions would prevent insurers from engaging in opportunistic marketing practices. The goals of health reform are to increase access to quality affordable care, while reining in costs. But preexisting condition coverage without an individual mandate may ultimately lead to insurance that is less affordable for everyone and make access problems even worse

Pandemic Influenza: Ethics, Law, and the Public\u27s Health

Highly pathogenic Influenza (HPAI) has captured the close attention of policy makers who regard pandemic influenza as a national security threat. Although the prevalence is currently very low, recent evidence that the 1918 pandemic was caused by an avian influenza virus lends credence to the theory that current outbreaks could have pandemic potential. If the threat becomes a reality, massive loss of life and economic disruption would ensue. Therapeutic countermeasures (e.g., vaccines and antiviral medications) and public health interventions (e.g., infection control, social separation, and quarantine) form the two principal strategies for prevention and response, both of which present formidable legal and ethical challenges that have yet to receive sufficient attention. In part II, we examine the major medical countermeasures being being considered as an intervention for an influenza pandemic. In this section, we will evaluate the known effectiveness of these interventions and analyze the ethical claims relating to distributive justice in the allocation of scarce resources. In part III, we will discuss public health interventions, exploring the hard tradeoffs between population health on the one hand and personal (e.g., autonomy, privacy, and liberty) and economic (e.g., trade, tourism, and business) interests on the other. This section will focus on the ethical and human rights issues inherent in population-based interventions. Pandemics can be deeply socially divisive, and the political response to these issues not only impacts public health preparedness, but also reflects profoundly on the kind of society we aspire to be

Forced Migration, The Human Face of a Health Crisis

Nearly 60 million refugees, asylum-seekers and internally displaced persons (IDPs) fled their homes in 2014, predominately from war-torn Syria, Afghanistan and Somalia. The global response to assisting this vulnerable group has been wholly incommensurate with the need given the profound health hazards faced by forced migrants at each stage of their journey. The majority of forced migrants are housed in lower-income countries that do not have the infrastructure to assist the significant numbers of individuals who are crossing their borders and the humanitarian organizations who seek to assist in the response are grossly underfunded and under-resourced. Countries have varying responsibilities to protect different classes of forced migrants based in international law, however there are significant gaps in existing agreements, leaving many individuals without protection or hope of assistance. There is a need to strengthen existing international agreements to ensure that all classes of forced migrants are entitled to protection and to ensure the enforceability of existing agreements where governments refuse to honor their existing obligations

Short time-scale optical variability of the dwarf Seyfert nucleus in NGC 4395

We present optical spectroscopic observations of the least-luminous known Seyfert 1 galaxy, NGC 4395, which was monitored every half-hour over the course of 3 nights. The continuum emission varied by ~35 per cent over the course of 3 nights, and we find marginal evidence for greater variability in the blue continuum than the red. A number of diagnostic checks were performed on the data in order to constrain any systematic or aperture effects. No correlations were found that adequately explained the observed variability, hence we conclude that we have observed real intrinsic variability of the nuclear source. No simultaneous variability was measured in the broad H-beta line, although given the difficulty in deblending the broad and narrow components it is difficult to comment on the significance of this result. The observed short time-scale continuum variability is consistent with NGC 4395 having an intermediate-mass (~10^5 solar masses) central supermassive black hole, rather than a very low accretion rate. Comparison with the Seyfert 1 galaxy NGC 5548 shows that the observed variability seems to scale with black hole mass in roughly the manner expected in accretion models. However the absolute time-scale of variability differs by several orders of magnitude from that expected in simple accretion disc models in both cases.Comment: 16 pages, 14 figures, 5 tables, accepted for publication in MNRA

Restoring Health to Health Reform: Integrating Medicine and Public Health to Advance the Population\u27s Wellbeing

The Patient Protection and Affordable Care Act is a major achievement in improving access to health care services. However, evidence indicates that the nation could achieve greater improvements in health outcomes, at a lower cost, by shifting its focus to public health. By focusing nearly exclusively on health care, policy makers have chronically starved public health of adequate and stable funding and political support. The lack of support for public health is exacerbated by the fact that health care and public health are generally conceptualized, organized, and funded as two separate systems. In order to maximize gains in health status and to spend scarce health resources most effectively, health care and public health should be treated as two interactive parts of a single, unified health system. The core purpose of health reform ought to be the improvement of the population’s health. We propose five criteria that would significantly advance this goal: prevention and wellness, human resources, a strong and sustainable health infrastructure, robust performance measurement, and reduction of health disparities. Although the Patient Protection and Affordable Care Act includes provisions addressing these criteria, population health is not a central focus of the reform. In order to guide health reform implementation and to inform future health reform efforts, we offer three major policy reforms: changing the environment to incentivize healthy behavioral choices, strengthening the public health infrastructure at the state and local levels, and developing a health-in-all policies strategy that would engage multiple agencies in improving health incomes. Adopting these reforms would facilitate integration and dramatically improve the population’s health, particularly when compared to the health gains likely to be realized from a continued focus on access to health care services

THE WHEAT AND STOCKER CATTLE ANALYZER: A MICROCOMPUTER DECISION AID FOR EVALUATING WHEAT PRODUCTION AND STOCKER CATTLE GRAZING DECISIONS

The Wheat and Stocker Cattle Analyzer is a microcomputer decision aid for evaluating interrelated wheat production and stocker cattle grazing decisions under yield, weight gain, and price uncertainty. An important feature of the model is that wheat commodity program provisions are incorporated into the analysis. A wide range of alternatives including wheat production for grain only, owned stocker cattle grazing, and wheat pasture leasing can be evaluated by the program.Crop Production/Industries, Livestock Production/Industries,

Sylvie

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Sweetie

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