Health Care Reform: Upheld by the Supreme Court

On Thursday, June 28, the Supreme Court upheld President Obama's Patient Protection and Affordable Care Act (ACA). The law seeks to make health insurance more affordable for all and provide increased consumer protections (e.g. prevent discrimination by health insurance companies against individuals with pre-existing health conditions). But what are some of the actual act's directives?


Since 2010, the law has already:

• ended discrimination against children with pre-existing conditions.
• extended coverage to younger adults (up to age 26) by allowing them to stay on their parents health insurance plan
• prohibited health insurance companies from dropping people's coverage when they get sick.
• increased federal matching funds for Medicaid.
• set forth initiatives to strengthen the primary care workforce.
• sought to bring down the price of health care premiums by requiring that at least 85% of all premium dollars collected by insurance companies be spent on health care services and health care quality improvement (rather than for profit).
• encouraged the use of integrated health systems (i.e. Accountable Care Organizations).
• required federal agencies to record a wider range of demographic data in an effort to understand health disparities.

In 2013, the law will:

• provide new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost.
• establish a national pilot program to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care.
• increase Medicaid payments for primary care doctors.
• provide additional funding for the Children's Health Insurance Program (CHIP).

In 2014, the law will:

•  require individuals to purchase health insurance (this is the "individual mandate" that was the subject of debate). If affordable coverage is not available to an individual, they will be eligible for an exemption.
• prohibit insurance companies from refusing to sell coverage or renew policies because of an individual's pre-existing conditions.
• prohibit plans from imposing annual dollar limits on the amount of coverage an individual may receive.
• provide tax credits to make it easier for the middle class to afford insurance.
• ask States to open health insurance exchanges to enable all Americans to easily shop for more affordable private insurance.
• increase access to medicaid for Americans who earn less than 133 percent of poverty limit.

Finally, in 2015 the law will:

• compensate physicians for the quality of care they provide to their patients rather than the volume of services they provide.

While many of these provisions will not be well-received by everyone, and some of these provisions admittedly do not do enough to reform the health care system, this is a step in the right direction.

LGBT Pride

We have come a long way since HIV was labeled the “gay disease.” This label was spawned from fear of HIV, and based on the observation that the first cases of HIV appeared in gay men in the early 1980’s. However, this label was not only discriminatory but also inaccurate as intravenous drug users also became infected. Furthermore, by the mid 1980’s children (usually those born to drug users) began to show symptoms of Acquired Immune Deficiency Syndrome (AIDS). Some people also contracted the virus via blood transfusions. Despite our best efforts and advances in medicine, HIV/AIDS still affects roughly 34 million people worldwide; people from many different ethnic groups and religions, with different socioeconomic backgrounds and sexual preferences. However, disparities still exist. According to AIDS.gov, in the United States, 61% of new HIV cases in 2009 were via male-to-male sexual contact; the ethnic groups most severely affected were Blacks/African-Americans and Latinos (even among females). What do all of these statistics tell us? We need to do a better job.

Lesbian, gay, bisexual, and transgender individuals (LGBT) experience various health disparities, not just those related to HIV/AIDS. This effect is compounded if the person belongs to multiple minority groups (for example, Latino and gay or female and transgender). Many studies have shown a direct correlation between the number of minority groups one belongs to and the discrimination he or she faces. This discrimination, in addition to identity issues and problems fitting in or strained relationships with unsupportive friends and family, can lead to many mental health problems. These problems include depression, anxiety, substance abuse and suicide. According to Youth Pride, Inc., gay and lesbian youth are three times more likely to attempt suicide and suffer higher rates of verbal abuse and isolation than their heterosexual counterparts. Additionally, LGBT youth are more likely to be isolated, homeless and be victims of physical and sexual abuse. All of this contributes to poor physical and mental health …and so the cycle continues.

Disparities surrounding access to proper medical care also exist for LGBT individuals. Bias or cultural incompetence within the health care system create barriers to care. Lesbian and bisexual women are not screened as often for breast and cervical cancer. Transgender individuals are less likely to have health insurance. Marriage inequality and a lack of equal rights for LGBT domestic partners (compared to married individuals) also exacerbates these problems. The Patient Protection and Affordable Care Act (ACA), seeks to alleviate some of these problems by improving access to health care for all Americans, guiding state Medicaid agencies on financial protections for same-sex couples and improving health data collection for the LGBT community and other minorities.

In commemoration of the Stonewall Riots in New York City in 1969, June is celebrated as LGBT Pride Month. Since the 1960’s the LGBT community has increased its visibility as a social group and successfully demanded rights it was not previously afforded. However, discrimination, inequality and health disparities still exist. Individuals from all walks of life can play a part in resolving these issues. Strive to be accepting of others and encourage leaders and lawmakers to enact legislation that will ensure equality for all.

Racism and Health Outcomes

 

Not long ago, I wrote about the role of race in predicting and treating disease. Recently, I had the pleasure of listening to David Chae, SciD, MA, professor at the Emory University Rollins School of Public Health, speak about racism and health outcomes—particularly cardiovascular risk and aging. While the two ideas sound similar, racism and its effect on people’s health is related to my last post but is a different concept.

“How does racism get under the skin?” Dr. Chae asked.  Discrimination is a process by which individuals are treated differently (and usually unfairly) on the basis of a particular characteristic (e.g. ethnicity, sex, sexual orientation, religion, age). Racism is a discriminatory ideology that extends beyond an isolated encounter; racism is often ingrained within society. The systemic discrimination that constitutes racism is thought to cause stress which can have serious health consequences, but how?

Scientists at Harvard developed the implicit association test (IAT) to measure a person’s racial bias, even if the person is unaware of any such bias. Respondents are first asked to associate images of faces to particular words (e.g. a Caucasian face with the word “white”). Then the subject is asked to associate words like “beautiful” with “good” and “horrible” with “bad.” The subjects are finally asked to associate words like “beautiful” or “horrible” with word clusters like “black/good” or “white/bad.” The rate of responding on each of these tasks is compared. If a subject takes longer to place a good word like “beautiful” with the word cluster “black/good”, then they are said to have an anti-black bias. It is also possible to have an anti-white bias. Take the test here and see where you stand.

In his talk, Dr. Chae quoted one statistic that reported 80% of Whites and 50% of Blacks have an anti-black implicit bias. Clearly, racism is not just about hating another group of people; Black people can have an implicit anti-black bias. This may be the result of a history of institutionalized racism prior to the civil rights movements in the United States, and cases of de facto racism that continue today. In 1939, Dr. Kenneth Clark conducted a test in which he presented Black children with two dolls and asked the child to choose the nicer doll. The dolls were identical in every way except one was White and one was Black. Most of the Black students indicated the White doll as nicer. This is evidence of internalized racism. Unfortunately, this test was repeated more recently, and the results were not different. Watch the video here.

In one study, Dr. Chae determined that Black men with an implicit anti-black bias, who reported more experience with racism and discrimination, also had a history of poor cardiovascular health. To quote Dr. Chae, “Internalized negative racial group attitudes themselves were associated with history of cardiovascular disease, and they moderated the impact of racial discrimination on these outcomes.” To measure negative racial group attitudes he used three items assessing whether the respondent agreed with negative statements regarding Blacks, specifically, whether Blacks are lazy, give up easily, and are violent. Dr. Chae will soon conduct a longitudinal study in which he will use the IAT as a tool to determine negative group attitudes and further explore the link to cardiovascular health.

But how does racism get under the skin and impact health? One measure scientists use is the level of c-reactive protein (CRP). CRP is found in the blood and levels rise in response to inflammation; it is also an indicator of poor cardiovascular health. Dr. Tene Lewis and colleagues at Yale University School of Public Health, found that while an African-American’s body mass index was positively correlated with the level of CRP in the blood, so was regular racial discrimination. The thought here is that perhaps stress from racism is putting biological stress on the body, causing CRP to rise.

Another measure of stress and aging can be telomere length. Telomeres are located at the end of our chromosomes. They are made up of repeating units and protect our chromosomes (which contain important genetic information) from being degraded. Over time, the telomeres themselves degrade and shorten in length. Dr. Chae noted a very nice analogy in which telomeres were compared to the plastic casing on the end of shoelaces; our chromosomes are the shoelaces. The plastic end of the shoelace, prevents the lace from fraying. However, eventually that plastic gets degraded and the shoelace begins to fray. Shorter telomeres are a sign of cellular aging (different from chronological age which is measured in years). Back in 2004, Dr. Elissa S. Epel from the University of California found that telomeres shorten at a faster rate in response to stress. Many scientists now explore whether stress resulting from racism also shortens telomere length.

Until recently, it has been hard to truly measure the impact of racism on health because racism is thought of as an intangible idea. It is important to find effective ways to measure racism, stress and aging so that we may keep exploring the link between racism and health. The sooner the links are untangled, the sooner we can devise a solution.

Federal Plan to Reduce Asthma Disparities Released

Yesterday, the President’s Task Force on Environmental Health Risks and Safety Risks to Children announced a new initiative to reduce asthma disparities among children, but especially children from ethnic minority groups and/or a low socioeconomic background. The U.S. Department of Health and Human Services, Department of Housing and Urban Development, Environmental Protection Agency and several other federal bodies have teamed up to execute a plan of action. Read the fact sheet here.

The initiative promotes collaboration among federal entities and streamlines resources and knowledge surrounding asthma health disparities among children. This partnership also encourages teamwork among individual, local, state and national leaders from various sectors. This forces us to think about asthma in a more holistic manner. Asthma disparities in the United States are not just a medical problem, but also the product of environmental and social inequities.


Asthma can be deadly if children do not seek routine medical care and do not regularly take the proper medication. Environmental factors such as air quality and allergens can also cause asthma attacks. Kathleen Sebelius, Secretary of the Department of Health and Human Services spoke yesterday in Washington D.C. about the new action plan. She said the following:

Minority children today are both more likely to have asthma and less likely to be prescribed or take recommended treatments to control their asthma...Without health coverage, you’re less likely to get the preventive medicine you need to keep the condition under control, making you more likely to suffer an attack...you can get great care for asthma at your doctor’s office, but it won’t do much good if they don’t know how to treat it at your school. And you can have a great community health center down the street, but it will be hard to stay healthy if the air in your neighborhood is polluted...If we’re going to reduce these disparities, we have to work together, not just across the federal government, but with state and local partners, and community and private leaders on every front.

Collaboration and leadership among governing bodies is important, and is just one of many partnerships needed to end health disparities. United, we can enact change!  

Read more about reducing health disparities here.