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.

Primary Care Physician Shortage

By 2014, the Patient Protection and Affordable Care Act (ACA) will expand the Medicaid health insurance program to over 15 million people. Among many things, this expansion will allow millions of people access to regular primary care. But is the field of primary care prepared to deal with such an expansion?

Primary care physicians (PCP's) serve as the initial contact person for a patient’s health issue. PCP's work with the patient over a long duration of time, treating routine conditions and providing preventive services like vaccinations. PCP's also refer the patient to specialists (e.g. cardiologists, endocrinologists) when necessary. Depending on the scope of the physician’s practice, primary care providers are internists and pediatricians, but can also be geriatricians or obstetricians and gynecologists. Nurse practitioners and physician’s assistants are increasingly providing primary care to patients as well.

For many years there has been talk about a physician shortage in the field of primary care. At one time, primary care physicians constituted the bulk of American physicians. However, advances in technology, increased medical educational debt, lower reimbursements and higher patient loads for primary care physicians have caused most doctors in training to enter a specialty field. The Association of American Medical Colleges predicts that in the decade that began in 2010, nearly one-third of all practicing physicians will retire. As a result, Americans will need an estimated 45,000 primary care physicians by 2020.

This trend has far-reaching consequences. Many ethnic minorities, people with low socioeconomic status or no health insurance may use primary care physicians and/or community health centers as their only source of health care; however, access to these providers is already limited for some patients because of factors like geography and a lack of transportation, or more complex issues like language barriers. The actual shortage of physicians and lack of funding for community health centers only exacerbates this problem.

Also, one statistic from the Kaiser Family Foundation says that 56% of patient visits in America require primary care, but only 37% of physicians practice primary care medicine, and only 8% of the nation’s medical school graduates go into family medicine. Furthermore, a higher ratio of specialists to patients has been correlated with higher mortality rates overall. This suggests that a higher ratio of primary care physicians will contribute to better health. With better access to primary care, patients can prevent disease and receive early treatment in the event of an illness.

The ACA has proposed several pieces of legislation to help solve the primary care physician shortage (the following was summarized from a Kaiser Family Foundation brief):

• Add 15,000 new primary care providers to the workforce by 2015
• Allocate $300 million for the National Health Service Corps which recruits the primary care workforce in underserved areas 
• $230 million in award grants will go to “teaching health centers” to start primary care residency programs 
• 10% bonuses for primary care providers under the Medicare fee schedule (started in 2011)
• Increase PCP reimbursements at the state level from Medicaid rates to Medicare rates by 2014 
• Increase the number of Accountable Care Organizations (ACO's) which thrive on the quality and not the quantity of patient care. ACO's encourage collaboration among physicians and allied health professionals rather than overuse of medical services
• Increase the number of community health centers 

Lastly, medical education institutions are charged to shape medicine’s leaders of tomorrow. This means medical schools should continue to educate students about issues related to primary care and the state of the health care system. Shadowing and networking with primary care physicians may increase interest in the field. Curricula should include such activities. Also, the number of residency programs must increase in order to accommodate the growing number of medical school graduates.

Race and Disease

What is the difference between health inequality and health disparities? Dr. Olivia Carter-Pokras, Associate Professor at the University of Maryland School of Medicine and the School of Public Health, said that health inequality is just a difference in health; health disparities are marked not only by a discernible difference in health, but also an injustice that can be changed. Dr. Carter-Pokras has over 25 years of health disparities research experience within the Federal government and academia, and was previously the Director of the Division of Policy and Data, Office of Minority Health, Department of Health and Human Services. Here at the National Institute on Drug Abuse (NIDA), I attended a presentation Dr. Carter-Pokras gave about health disparities.

After the seminar, I began to think about race in general. When I first arrived at NIDA, research fellows were invited to the Smithsonian National Museum of Natural History in Washington, DC. The museum held an exhibit called “Race: Are we so different?” One idea the exhibit emphasized over and over is that race is a social rather than a biological construct. This means that we created the idea of race to distinguish one human from another. However, someone on the other side of the world is only 0.1% different from me at the genetic level. This may be hard to believe considering that humans come in many different shapes, sizes and colors. The exhibit had strong scientific and historical evidence to support the idea that race is purely a man-made idea.

If race cannot be defined by our genes, why do health care professionals use race to infer other characteristics about their patients? Why does the new Patient Protection and Affordable Care Act (ACA) require the Federal government to collect racial data?

There are a few instances in which race (heritage, to be more accurate) may help physicians and allied health care professionals better treat their patients. However, this is a line that must be walked carefully. For example, some ethnic groups do have a higher prevalence of certain diseases (e.g. Ashkenazi Jews have a higher prevalence of Tay-Sachs disease and African-Americans have a higher prevalence of Sickle Cell Anemia). If a physician understands these links, a diagnosis may be made sooner. However, sometimes making assumptions about race and disease can hurt a patient. The Race exhibit at the Smithsonian featured a video of a father whose infant daughter was not quickly diagnosed with Sickle Cell Anemia. The parents were both white and Sickle Cell Anemia seemed like an unlikely cause of the baby's illness. However, the father was of Sicilian ancestry. A simple blood test confirmed the baby had Sickle Cell Anemia. This was an example in which generalizations about ethnicity and disease can be harmful. Though it may not be commonly known, Sickle Cell Anemia spread to places in southern Europe as well as throughout Africa.

The ACA is working to eliminate health disparities. In a 2011 report, the American Medical Association says the first step to eliminating disparities is to detect them. If this is true then the collection of racial is data is justified. However, a closer look at what we define as race may actually be an indicator of the greater disparities that exist among social determinants of health. For example, while it is true that many minorities endure numerous health disparities, this is often due to the environment in which minorities live and inequities in education, socioeconomic status, and other factors—not race. Poor whites have similar health outcomes to those of ethnic minorities. Similarly, ethnic minorities with higher socioeconomic status have better health outcomes than their poorer counterparts. Race should not define who we are nor how healthy we can be. We should focus on improving the conditions in which many disadvantaged people live which will result in an improvement in health.

Three CCNY Students Named 2012 Salk Scholars

This press release was taken from the City College of New York's website. The following was released on May 16, 2012.

 

Lisa Brandt and Julian Flores, members of The City College of New York Class of 2012, and Alexa Mieses, a 2011 graduate, have been selected to receive the 2012 Jonas E. Salk Scholarship awarded by The City University of New York.

The awards recognize the high ability and scholarship of students who plan careers in medicine and the biological sciences and who are judged likely to make significant contributions to medicine and research. They are selected on the basis of original research papers undertaken with prominent scientist/mentors.

“Congratulations to Lisa, Julian, Alexa and the winners from the other CUNY Colleges,” said CCNY President Lisa S. Coico. “Their achievements are a testament to their hard work, dedication, and perseverance as well as to the support of the faculty.”

The Salk Scholarship provides a stipend of $8,000 per scholar, to be appropriated over three or four years of medical studies. Salk Scholars also receive achievement citations and diagnostic kits that include an otoscope and ophthalmoscope. The scholarships will be presented at a ceremony Wednesday, May 16, in the William and Anita Newman Conference Center at Baruch College.

Dr. Jonas Salk, a 1934 graduate of City College, developed the polio vaccine in 1955. He turned down a ticker-tape parade in honor of his discovery, asking that the money be used for scholarships instead. New York City provided initial funding for the Salk Scholarships in 1955.

Ms. Brandt, Mr. Flores, and Ms. Mieses were all inspired to become doctors to aid their communities. After graduation, Ms. Brandt will attend either Columbia University Medical School or Mount Sinai School of Medicine, while Mr. Flores plans to attend Harvard Medical School. Both want to become pediatricians. Ms. Mieses will attend Mount Sinai School of Medicine. Brief profiles of the students follow:

Lisa Brandt
Ms. Brandt, born in the Dominican Republic to a Dominican mother and an American father, wants to become a pediatrician to provide free and affordable care to her community. “I wanted a career that had a purpose for me, a versatile career where you’re a student, teacher, and guide, and can be a pillar to your community.”

Ms. Brandt was so impressed by City College’s affordability and high quality of education, that it was her only choice when she applied to college. “I knew I wanted to go to medical school for a long time, and I knew I didn’t want to come out with debt. I wanted to go to a school that would give me a high quality education,” said the biology major.
Currently, she is working in the lab with Professor Jonathan Levitt, using a ferret as an animal model to examine the postnatal development of the brain. She is also volunteering at Morgan Stanley Children’s Hospital of New York-Presbyterian and has volunteered at numerous health fairs.

At CCNY, Ms. Brandt received a myriad of honors such as the 2010 Annual Biomedical Research Conference for Minority Students Presentation Award, and the 2011 Collegiate Science and Technology Entry Program Honorable Mention Award in the Natural Sciences.

She also received the Zeldin-Sviridov Scholarship, Edmund Baermann Scholarship in Natural Sciences, Associated Medical Schools of New York Stipend and Student Support Services Program Outstanding Academic Award. Additionally, she shadowed a pediatric endocrinologist, and gastroenterologist in private practice. Outside of school, she enjoys drawing.

Julian Flores
Mr. Flores, the son of Costa Rican immigrants, believes he has an obligation to help the Hispanic community, since he has an opportunity to make an impact. “Being Hispanic, makes me want to want to give back to the Hispanic community to bring about longstanding change.”

That opportunity is a scholarship to Harvard Medical School, where he will pursue his dream of becoming a pediatrician. “It is a great honor to come from City College and to represent both CCNY and CUNY at Harvard,” the Flushing, Queens resident said.

Mr. Flores, who is receiving a BS in biology, came to City College on full scholarship as a Macaulay Honors College student. He used the resources of Macaulay to go beyond the textbook and the classroom.

He counseled parents in a family health intervention program run by Columbia University and also participated in a summer undergraduate mentorship program between his junior and senior years at Albert Einstein College of Medicine. Currently, he is using Drosophila Melanogaster, the common fruit fly, as an animal model to study autism spectrum disorders as a research assistant to Professor Tadmiri Venkatesh.

At City College, Mr. Flores received countless awards including: best poster in neuroscience at both the Annual Biomedical Research Conference for Minority Students and the 2012 Collegiate Science and Technology Entry Program Conference. He also received a Weston Scholarship, in addition to the scholarship from Harvard. Outside of school, he enjoys playing soccer and baseball as well as dancing and listening to music.

Alexa Mieses
Ms. Mieses already had dreams of becoming a doctor as a junior in high school. While she attended Bronx High School of Science, three students died of drug-related causes.  A sophomore she mentored was one of them, a victim of a heroin overdose. “The experience definitely inspired me to learn more aggressively about the effects of drug abuse on the brain and the body. It increased my awareness of it,” said Ms. Mieses.

She volunteered at Montefiore Medical Center in the Bronx and tutored low-income children at the Champion Learning Center in Lower Manhattan.  As the coordinator for the CCNY Minority Association of Pre-Health Students’  “Harlem Take Care of Yourself” health fair, she helped increase attendance twenty-fold. She also interned at the Bronx Zoo, the Gay Men’s Health Crisis Center and worked with autistic children in Chile, as a Watson Fellow.

A Queens resident of Dominican and Italian heritage, Ms. Mieses graduated magna cum laude with a BS in biology in 2011. She deferred medical school for a fellowship with the National Institute on Drug Abuse in Baltimore, where she examined behavioral and genetic correlates of drug addiction. The fellowship provided professional growth and gave her access to new lab techniques.

After the fellowship, she will attend Mount Sinai School of Medicine in August and hopes to become a primary care physician in an underserved community. “In addition to practicing medicine as a clinician in New York City, I am also committed to mentoring aspiring medical students and students from underrepresented minority groups.”

At CCNY, Ms. Mieses was awarded a J.K. Watson Fellowship and Outstanding SEEK Graduate of the Year Award; she was a SEEK Scholar and tutor, and belongs to three honor societies. In addition, she shadowed a surgeon in private practice as well as conducted neuroscience research on eye movements and studied Spanish and art history in Spain. Outside of school, Ms. Mieses writes poetry and loves singing. She hopes to incorporate her love of writing into her career.

Media Contact
Ellis Simon     P | 212-650-6460     E | esimon@ccny.cuny.edu