Help! We\u27ve Fallen and We Can\u27t Get Up: The Problems Families Face Because of Employment-Based Health Insurance

Steve Tilghman of Birmingham, Alabama knows first-hand the health insurance problems American families face.\u27 Steve\u27s family had adequate health insurance until Steve decided to change careers. After expiration of the eighteen-month extension period COBRA provides, Steve\u27s family could not afford the one thousand dollar monthly premiums necessary to maintain their policy. Steve\u27s epileptic son further complicated his ability to find adequate health insurance. After having no insurance for two months, Steve ultimately was able to find health insurance for only part of his family. Steve had to acquire a separate, unrated policy for his epileptic son. Steve is uncertain about the value of this policy, fearing that under this plan the insurer will consider the epilepsy to cause any injury to his son, in which case the plan does not cover him. In short, Steve\u27s family is self-insured. Steve faces tension between protecting his family\u27s financial resources and not compromising his child\u27s health. The problems Steve\u27s family faced in acquiring health insurance largely are due to the fragmented health care financing system in the United States. The American health care financing system is a hodgepodge of private sources supplemented with public sector coverage. Theoretically, third-party health insurance is available to all American families: (1) Medicare for the aged and disabled; (2) Medicaid for the qualified poor or for specified disabilities;\u27 (3) employment- subsidized insurance for workers and their dependents; and (4) privately purchased insurance if ineligible under the previous three categories. Health care providers, individual patients, and philanthropic groups provide the remainder of health care financing. This fragmented financing system creates inequitable and inefficient results according to the insured\u27s financial status

Symposium: Federalism\u27s Future

Two years have passed since my predecessor, Mike Smith, sat in Professor Barry Friedman\u27s office to begin choosing a topic for the Symposium that now sits before you. Although choosing a topic for a symposium two years in advance of its occurrence can be a difficult task, the topic they agreed upon, Federalism\u27s Future, transcends the risk of becoming outdated. If the Supreme Court\u27s struggle to articulate a reasoned principle in balancing the powers and responsibilities of our state and federal governments in Garcia v. San Antonio Metropolitan Transit Authority, and later in New York v. United States,2 is any indication, the problems of modern federalism will remain with us for quite some time. Perhaps the Court\u27s concession in New York-that the struggle to protect judicially the states\u27 role in Our Federalism is too large a task for it to administer-was inevitable. After all, designating the proper governmental unit to respond to diverse problems such as the environment, civil rights, and health care is no small feat, and the task is made perhaps even more difficult by the Court\u27s intradynamics and personality conflicts. A federal response to these problems seems natural, at least in the post-New Deal era, and the increasing globalization of society and its problems appears to further necessitate a federal solution

Precise interpolar phasing of abrupt climate change during the last ice age

The last glacial period exhibited abrupt Dansgaard–Oeschger climatic oscillations, evidence of which is preserved in a variety of Northern Hemisphere palaeoclimate archives¹. Ice cores show that Antarctica cooled during the warm phases of the Greenland Dansgaard–Oeschger cycle and vice versa[superscript 2,3], suggesting an interhemispheric redistribution of heat through a mechanism called the bipolar seesaw[superscript 4–6]. Variations in the Atlantic meridional overturning circulation (AMOC) strength are thought to have been important, but much uncertainty remains regarding the dynamics and trigger of these abrupt events[superscript 7–9]. Key information is contained in the relative phasing of hemispheric climate variations, yet the large, poorly constrained difference between gas age and ice age and the relatively low resolution of methane records from Antarctic ice cores have so far precluded methane-based synchronization at the required sub-centennial precision[superscript 2,3,10]. Here we use a recently drilled high-accumulation Antarctic ice core to show that, on average, abrupt Greenland warming leads the corresponding Antarctic cooling onset by 218 ± 92 years (2σ) for Dansgaard–Oeschger events, including the Bølling event; Greenland cooling leads the corresponding onset of Antarctic warming by 208 ± 96 years. Our results demonstrate a north-to-south directionality of the abrupt climatic signal, which is propagated to the Southern Hemisphere high latitudes by oceanic rather than atmospheric processes. The similar interpolar phasing of warming and cooling transitions suggests that the transfer time of the climatic signal is independent of the AMOC background state. Our findings confirm a central role for ocean circulation in the bipolar seesaw and provide clear criteria for assessing hypotheses and model simulations of Dansgaard–Oeschger dynamics

Worsened outcomes of newly diagnosed cancer in patients with recent emergency care visits: A retrospective cohort study of 3699 adults in a safety net health system

Introduction: Many patients receive a suspected diagnosis of cancer through an emergency department (ED) visit. Time to treatment for a new diagnosis of cancer is directly associated with improved outcomes with little no describing the ED utilization prior to the diagnosis of cancer. We hypothesize that patients that have an ED visit in proximity to a diagnosis of cancer will have worse outcomes, including mortality. Methods: This study is a retrospective cohort study of all patients with cancer diagnosed at Eskenazi Health (Indiana) between 2016 and 2019. Individual health characteristics, ED utilization, cancer types, and mortality were studied. We compared those patients seen in the ED within 6 months prior to their diagnosis (cases) to patients not seen in the ED (controls). Results: A total of 3699 patients with cancer were included, with 1239 cases (33.50%). Patients of black race had higher frequencies in the cases vs. controls (46.57% vs. 40.68%). Lung cancer was the most frequently observed cancer among cases vs. controls (11.70% vs. 5.57%). For the cases, 232 patients were deceased (18.72%) compared with 247 patients among the controls (10.04%, p < 0.0001, OR 2.06 95% confidence interval [CI] 1.70-2.51). An ED visit in past 6 months (OR = 1.73, 95% CI 1.38-2.18) and Medicaid insurance type (versus commercial, OR = 4.16, 95% CI 2.45-7.07) were associated with of mortality. Female gender (OR = 0.76, 95% CI 0.67-0.88), tobacco use (OR = 1.62, 95% CI 138-1.90), and Medicaid insurance type (versus commercial, OR = 2.56, 95% CI 2.07-3.47) were associated with prior ED use. Conclusions: Over one third of patients with cancer were seen in the ED within 6 months prior to their cancer diagnosis. Higher mortality rates were observed for those seen in the ED. Future studies are needed to investigate the association and impact that the ED has on eventual cancer diagnoses and outcomes

The current state of acute oncology training for emergency physicians: a narrative review

Patients with cancer represent a growing population of patients seeking acute care in emergency departments (ED) nationwide. Emergency physicians are expected to provide excellent, consistent care to all ED patients; however, emergency medicine (EM) education and training of acute oncology is lacking. To explore this topic, the Society for Academic Emergency Medicine Oncologic Emergencies Interest Group recruited experts in the field to provide a narrative description of the current state of EM education relating to acute oncology. This review of expert opinions explores the current state of acute oncology education in EM and identifies key content gaps that merit early investment. Current emergency physician training and knowledge relating to acute oncology likely reflects the American Board of Emergency Medicine Model of Clinical Practice. Key topics such as immunotherapy are absent from the most recent revision of the Model of Clinical Practice and consequently represent a knowledge gap for large numbers of emergency physicians. Additionally, there is limited penetration of guideline-based care for symptom management in the ED setting. As such, additional attention should be provided to training programs and research efforts to address these knowledge gaps. In conclusion, the current state of acute oncology education and training of emergency physicians is lacking and merits significant investment to assure the ability of emergency physicians to provide superior care for the growing population of patients with cancer

Multi-Center Study of Outcomes Among Persons with HIV who Presented to US Emergency Departments with suspected SARS-CoV-2

Background: There is a need to characterize patients with HIV with suspected severe acute respiratory syndrome coronavirus 2 (SARs-CoV-2). Setting: Multicenter registry of patients from 116 emergency departments in 27 US states. Methods: Planned secondary analysis of patients with suspected SARS-CoV-2, with (n=415) and without (n=25,306) HIV. Descriptive statistics were used to compare patient information and clinical characteristics by SARS-CoV-2 and HIV status. Unadjusted and multivariable models were used to explore factors associated with death, intubation, and hospital length of stay. Kaplan-Meier curves were used to estimate survival by SARS-CoV-2 and HIV infection status. Results: Patients with both SARS-CoV-2 and HIV and patients with SARS-CoV-2 but without HIV had similar admission rates (62.7% versus 58.6%, p=0.24), hospitalization characteristics (e.g. rates of admission to the intensive care unit from the ED [5.0% versus 6.3%, p=0.45] and intubation [10% versus 13.3%, p=0.17]), and rates of death (13.9% versus 15.1%, p=0.65). They also had a similar cumulative risk of death (log-rank p=0.72). However, patients with both HIV and SARS-CoV-2 infections compared to patients with HIV but without SAR-CoV-2 had worsened outcomes, including increased mortality (13.9% versus 5.1%, p<0.01, log rank p<0.0001) and their deaths occurred sooner (median 11.5 days versus 34 days, p<0.01). Conclusion: Among ED patients with HIV, clinical outcomes associated with SARS-CoV-2 infection are not worse when compared to patients without HIV, but SARS-CoV-2 infection increased risk of death in patients with HIV