X-ing out Title X

Earlier this week, the US House of Representatives Committee on Appropriations released its 2016 budget proposal for funding the Department of Health and Human Services. As part of that proposal, the Republican-dominated Committee recommended eliminating funding for the Title X (ten) family planning program.

For those of you who may not be familiar with the Title X family planning program, it is the only federal program that provides family planning and reproductive health services for low-income Americans. Enacted in 1970 with broad bipartisan support and signed into law by Republican President Richard Nixon, the program subsidizes nearly 4,200 clinics nationwide. Those clinics provide contraception and family planning services at little to no cost for individuals who earn less than $25,000 a year. Most patients are women. A disproportionate number are women of color.

All told, over 5 million people use Title X-funded clinics annually. According to the Guttmacher Institute, a non-profit organization that works to advance sexual and reproductive health and rights, these clinics serve one in five American women who seek birth control counseling. Over 15% of all the contraceptive prescriptions written and a third of the family planning supplies used in the US come via these clinics, preventing an estimated 1.2 million unintended pregnancies yearly.

More importantly, these millions of women (and men) don’t just use these clinics for family planning. That’s because Title X-supported clinics provide more than just contraceptive services. They provide a variety of health-related services, including: screening for breast cancer, cervical cancer and testicular cancer; testing and treatment for sexually transmitted diseases; prenatal, postpartum and well-child care; and even preventative medical exams. Over the past 20 years, for example, these clinics have conducted nearly 60 million Pap tests, providing early detection of as many as 55,000 cases of invasive cervical cancer.

The services provided by Title X clinics don’t just prevent unwanted pregnancies, these services save lives. This comes at the modest annual cost of just $60 per patient. Last year, the federal government spent a mere $300 million on the Title X family planning program. That same year, the services provided by Title X clinics saved the government an estimated $2.1 billion in downstream health care costs. By contrast, the fiscal conservatives who control Congress appropriated over $4 billion for unnecessary pork barrel projects, including $120 million to upgrade the M1 Abrams tank despite the objections of military officials. Over 2,000 of those tanks are currently sitting idle in the California desert as the Pentagon has no use for them.

For many low-income Americans, Title X-funded centers may be the only place they receive care. One survey found that nearly two-thirds of women who received services at a Title X-supported clinic had no other source of primary medical care.

So why are Republicans so eager to do away with a modestly priced but widely successful program? The reason can be summed up with one word: abortion. Specifically, the Title X family planning program subsidizes some Planned Parenthood clinics that also offer abortion services. Planned Parenthood is the largest single recipient of Title X funding, and that is enough for conservative lawmakers to put the program to the hatchet.

Keep in mind that federal law prevents Title X funding from being used to pay for abortions. Also keep in mind that many Planned Parenthood clinics do not provide abortion services; abortion accounts for only 3% of the total number of procedures performed at all Planned Parenthood clinics. So the logic behind the decision to cut Title X funding is somewhat convoluted: the public money that is provided to a large number of clinics for family planning services frees up other private money at a small number of clinics that can then be used to pay for abortion. The absurdity of that line of reasoning makes my head hurt.

This line of reasoning is also flawed. If the goal of Republican congressmen is to prevent abortion, then they should increase funding for Title X rather than cut it. As I mentioned earlier, the family planning and contraceptive services provided by Title X-funded clinics prevent an estimated 1.2 million unintended pregnancies yearly. Should these unwanted pregnancies occur, statistically they would result in about 200,000 miscarriages, 600,000 births, and 400,000 abortions. The number of abortions in the US will actually increase should the Title X family planning program be scrapped.

There will be other deleterious effects as well. Many Title X-funded clinics provide desperately needed health care services to millions of poor men and women, including pregnancy testing and prenatal care, cancer screening, HIV testing and education, and testing and treatment for sexually-transmitted diseases.

Without these subsidies, many of these clinics will be forced to close. In those communities, we can expect to see increasing rates of maternal morbidity and of negative birth outcomes like low birth weight, premature birth, and infant mortality. We can also expect to see outbreaks of HIV and other sexually transmitted diseases, as recently happened in Scott County, Indiana when that county’s HIV testing clinic closed.

The personal and economic costs of cutting Title X are likely to be staggering, particularly at a time when conservative lawmakers are also actively trying to dismantle the Affordable Care Act, eliminate funding for comprehensive sex education and teen pregnancy prevention programs, and give employers the right to deny employees access to birth control. Unfortunately, these ideologues are likely to succeed, leaving 5 million Americans without care and the rest of us footing the tab.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on June 18, 2015, and is available on the WAMC website.]

Posted in Uncategorized | Tagged , , , | Leave a comment

There’s Something About Caitlyn

Unless you’ve been living under a rock or on a social media fast these past couple of weeks, you’ve undoubtedly seen the pictures of Caitlyn Jenner on the cover of Vanity Fair. No surprise that she appears in the June issue, the same month that celebrates lesbian, gay, bisexual and transgender (LGBT) pride.

These are, of course, the first public photographs of Ms. Jenner since March 15, when she underwent facial-feminization surgery as part of her gender transition process. Olympic medalist and former Kardashian patriarch Bruce Jenner is now living her life as a woman.

The pictures, taken by famed celebrity photographer Annie Leibovitz, are stunning. Accompanying a 22-page interview that chronicles Ms. Jenner’s lifelong struggle with her gender identity, those images portray her in a way that no one expected: as a beautiful Hollywood starlet who looks not unlike actress Jessica Lange or former supermodel Janice Dickenson. Caitlyn is now the cover girl for many transgendered individuals, providing a very public face to an often ridiculed, stigmatized and maligned group.

Sadly but not unexpectedly, public reaction to the photos has been mixed. While many people have written, recorded, posted and tweeted messages of support, a few others have been less kind. Controversial pundit Bill O’Reilly and others who appear on the conservative Fox News network, for example, were quick to fire off all sorts of derisive comments and make numerous transphobic jokes. Similarly, former Arkansas governor and Presidential candidate Mike Huckabee told a campaign crowd that he’d wished he’d found his transgender side in high school so that he “could have used the showers in the girls’ locker room.”

Despite dismissive, mocking and even hostile comments like these, this open and largely public discussion of Caitlyn Jenner’s transition is, mostly, a good thing. Until recently, the transgender community was largely relegated to the margins of American society.

The actual number of transgendered people living in the US is still largely unknown. This is in part because most surveys of LGBT individuals ask about sexual orientation rather than gender identity, and in part because many transgendered people still live their lives in the shadows because of the stigma and discrimination that they would otherwise face.

Only a few states have laws that protect the rights of transgendered men and women. Most live in areas of the country where they can be fired from their jobs or denied housing simply because of who they are, resulting rates of unemployment and poverty that are nearly four times the national average. They can also be denied access to the basic services that many of us take for granted, including medical care, dental care, service in shops and restaurants, and even the use of public restrooms.

Worse yet, as the National Transgender Discrimination Survey found, transgender men and women experience epidemic rates of violence and assault. All most transgendered people have been verbally assaulted, more that half have been physically beaten, and over a quarter have been raped. No surprise then that the transgendered community has some of the highest rates of alcoholism, substance use, depression and suicide.

Caitlyn could help change that. By joining other transgendered individuals in the public limelight — such as Emmy-nominated actress Laverne Cox and musician Chaz Bono — Ms. Jenner provides yet one more positive role model for closeted transgendered individuals. She may even inspire some of them to “come out.”

She may also encourage many Americans to reconsider their open hostility to the transgendered community. We need to start recognizing and respecting the rights and dignity of our transgendered brothers and sisters, rather than proposing and passing local and state ordinances that allow discrimination against members of the LGB and particularly T community under the banner of religious freedom and family values.

That said, I want to caution us all against thinking that Ms. Jenner’s experience is typical. It’s not. Her story is not representative of the challenges and barriers that most transgendered individuals face. As Kris Hayashi, Executive Director of the Transgender Law Center, recently commented, “Any time someone is able to live fully and safely as their authentic self, it is a beautiful thing that we should celebrate. We can celebrate, though, while recognizing that Caitlyn’s experience is dramatically different from that of most transgender people.”

Caitlyn’s (nee Bruce’s) celebrity — extending many decades into the past as an Olympian, actor, spokesman and most recently as a reality television star — gives her a level of cachet and prestige that most people (transgendered or not) lack. She lives a life of privilege. She will never experience, for example, the challenges in finding employment and housing that the majority of transgendered people face.

She similarly has the money to access medical treatments and resources that allow her to live as a woman while meeting socially-established stereotypes of femininity, as evidenced by the numerous comments on her newfound beauty. Thanks to her wealth and celebrity status, Ms. Jenner is largely insulated from the insidious discrimination and harassment that other transgendered men and women deal with on a daily basis.

This is not to say that we shouldn’t, as Mr. Hayashi of the Transgender Law Center suggests, “celebrate” Caitlyn’s transition. We should, and we should encourage others like her to live openly and without fear. But the way to do that is not to remark on Ms. Jenner’s beauty or to talk about our love of the hit TV show Transparent.

Rather, we need to have an honest and public dialogue about what it means to be transgendered in America, and take a long hard look at our preconceptions and our prejudices towards those who struggle with gender identity. Only then can we achieve the social and political change that will allow people like Caitlyn to flourish.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on June 4, 2015, and is available on the WAMC website.]

Posted in Uncategorized | Tagged , , , | Leave a comment

Patents over People

At a press conference in New York City yesterday, a group known as the Initiative for Medicines, Access and Knowledge (I-MAK) announced that it was filing legal challenges in Argentina, Brazil, China, Russia and the Ukraine to invalidate patents on the hepatitis drug Sovaldi. That drug was developed and is sold worldwide by the pharmaceutical company Gilead Sciences.

The disease that Sovaldi treats, hepatitis C, is a life-threatening illness caused by a blood-borne virus of the same name. Approximately 150 million people worldwide are infected with hepatitis C virus, with most of those living in poorer regions of the world, particularly Asia and Africa. This is more than five times the number infected with HIV. Most of those living with hepatitis C are undiagnosed. Fewer still have access to care and treatment.

This is in part because acute infection by the hepatitis C virus is usually asymptomatic, although some people may develop fever, fatigue, nausea and, in a few cases, the jaundice (or yellowing of the skin) characteristic of hepatitis. About of quarter of patients will clear the virus from their bodies, but the majority of those exposed will develop chronic hepatitis C infection. In individuals with chronic infection, the virus slowly causes long-term damage to the liver. Around one third of those with chronic infection will develop liver cirrhosis or cancer within 20 years.

Until recently, the only cure for hepatitis C was treatment with a combination of antiviral drugs like ribavirin and interferon, often given as injections or intravenous infusions three times weekly over the course of a year. This course of treatment was effective in less than 50% of patients, and many suffered from debilitating side effects. Moreover, the nature and intensity of treatment made it impractical for most patients living in the countries with less developed health care systems. For the vast majority of people infected with hepatitis C, both in the US and in other parts of the world, a cure was thus largely out of reach.

In that context, the development of Sovaldi (and more recent drugs like Harvoni and Viekira) was a godsend. Sovaldi is a once a day pill which, when taken in combination with oral ribavirin for twelve weeks, effectively cures 90% of patients. Many doctors also prescribe Sovaldi in combination with another oral antiviral drugs, with similar effectiveness and fewer side effects. In addition to being more effective, the use of oral-only formulations also makes this drug more accessible to patients who live in less developed regions. Patients no longer require intravenous treatment with hard-to-procure and hard-to-deliver drugs like interferon.

So why is there a brewing controversy about this miracle drug? Why is I-MAK challenging Gilead’s patents on Sovaldi in Argentina, Brazil, China, Russia and the Ukraine? The answer is quite simple: money.

Sovaldi is an incredibly expensive drug. Gilead charges nearly $1,500 for a single pill, so a twelve-week course of treatment can cost a patient (or their insurance company) over $100,000. This is well beyond the means of most of those living with hepatitis C worldwide.

Recognizing this, Gilead does allow drug manufacturers in India to make a generic version of Sovaldi, which is sold for less than $10 a pill to patients in 91 low-income countries. However, Gilead does not allow generic Sovaldi to be sold in Argentina, Brazil, China, Russia and the Ukraine, relatively wealthy countries where nearly 40 million people infected with hepatitis C currently live. Rather, in those countries, Gilead sells the brand-name drug to patients and health agencies at a slightly reduced cost of approximately $100 a pill.

That is a generous discount, but one that would still cost the cash-strapped governments of those five countries over $250 billion if they were treat all of the 40 million people who need care. Given this, physicians and policymakers in Argentina, Brazil, China, Russia and the Ukraine instead have to make tough decisions about who to treat and who to let die from hepatitis C-related liver failure.

This is why I-MAK, in collaboration with local patient advocacy groups, is pushing those governments to break Gilead’s existing patents on Sovaldi. This would allow drug manufacturers in of Argentina, Brazil, China, Russia and the Ukraine to make and sell their own generic version of Sovaldi.

But is this fair? It costs billions of dollars for a company like Gilead to develop, test, and get approval to sell a single drug like Sovaldi. That money has to come from somewhere, and it is the profit from selling these blockbuster drugs that allows pharmaceutical companies to recover those costs. These profit also provide drug manufacturers with the financial incentive to develop the dozens of miracle drugs that have come on the market over the last thirty years.

At some point, however, those costs (and more) have been recouped. Gilead has earned over $15 billion this year alone from selling Sovaldi in the US and overseas, more that enough to cover the costs of developing and testing this drug. There’s a fine line between maintaining a healthy profit margin versus exploiting the misery and suffering of those living with hepatitis C.

I have a good deal of respect for pharmaceutical researchers (and the companies they work for), and I believe that intellectual property rights should be recognized. But sometimes it takes a threat like this to get those companies to do the right thing.

I-MAK’s efforts to invalidate Gilead’s patents may not be fair, legal or even successful, but they may force that company to offer better price reductions on Sovaldi to patients who live in resource-poor regions of the world. This same approach was used successfully some years back to get companies like Gilead to drop the price of anti-HIV medications, allowing millions of people living with HIV/AIDS worldwide to finally have access the treatment they needed. It’s time to offer the same hope to those living with hepatitis C.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on May 21, 2015, and is available on the WAMC website.]

Posted in Uncategorized | Tagged , , , , | Leave a comment

Love (and Sex), Canadian Style

There’s a controversy brewing to the north of us. After Ontario Premier Kathleen Wynne announced that the most-populous Canadian province would update the sex-education curriculum used in public schools — modernizing its sex-ed materials to include discussions about gender identity, sexual orientation, masturbation and contraception — conservative politicians and pundits were quick to condemn the changes.

Religious groups and right-wing organizations like the Campaign for Life Coalition and Parents As First Educators also raised their voices in protest, citing concerns that the new curriculum was too extreme and violated personal values and parental rights. Some groups even called for a one-week strike, asking parents to pull their kids from school as an act of protest against the revised sex-ed curriculum.

In response, Planned Parenthood of Toronto started a Twitter campaign asking people to weigh in on why they supported the changes using the hashtag #SupportSexEd. Faster than one of the Canadian Clippers that chilled the Northeast to its core this past winter, responses to that plea flooded in. Within 24 hours, tens of thousands of people had tweeted their support of (or opposition to) comprehensive sex education in Canada (and elsewhere across the globe).

Canadian social media is now being consumed by an intense debate about sex and sex-ed. But this debate isn’t about whether sex education should be offered. Rather, it’s about how comprehensive the curriculum should be.

That’s a good thing. Those of us who live to the south could learn something from our neighbors. The sad truth of the matter is that American youth learn very little about sex and sexuality in public schools.

According to the Guttmacher Institute, a non-profit organization that works to advanced sexual and reproductive health and rights, only 22 states and the District of Columbia mandate sex education in all public schools. New York is not one of these states. Nor are many of our neighbors, including Massachusetts, Connecticut and Pennsylvania. Similarly, the three most populous states in the Union — California, Texas and Florida — do not require sex-ed to be part of the public curriculum.

Even when sex education is offered, much of what is taught is riddled with half-truths or bald-faced lies. Only 13 states require that the information provided be medically or scientifically accurate. Again, New York is not one of these states. A recent Congressional study catalogued many of the unproven claims, questionable conclusions or outright falsehoods that students have been taught in high school sex-ed classes across the country. These include such so-called “facts” as: use of contraception and abortion leads to depression and suicide, that condoms are ineffective in preventing the spread of HIV, and that touching another person’s genitals can result in pregnancy.

Our sex education curriculum is also full of holes. Thirty-seven states require that sex education, if it is offered, provide an abstinence-only message that emphasizes the importance of sex within marriage. In more than half of those states, teachers are forbidden to discuss contraception.

Among that illustrious list of states are the five that have the highest rates of teen pregnancy in the US: Arkansas, Mississippi, New Mexico, Oklahoma and Texas.

These states also tend have higher than average rates of sexually transmitted infections like gonorrhea and syphilis. It should come as no shock then that a west Texas school district recently made the national news for an outbreak of chlamydia among its students. One in 15 high school students in the Crane Independent School District, just outside of Odessa, tested positive for that sexually transmitted disease. Not surprisingly, Crane is one of the districts in Texas that offers no sex education classes to its students.

None of this makes any sense. Sex education is not the same as teaching kids to have sex. In fact, numerous studies have shown that teens are no more likely to engage in sex if they receive sex education than if they do not. About 50% of all teens report having sex before they graduate, regardless of whether or not their district offers sex-ed as part of the high school curriculum. More importantly, similar studies have found that rates of pregnancy and sexually transmitted infections are actually lower among teens that receive comprehensive sex education, as compared with those who receive abstinence-only education or those who get no sex-ed at all.

Today’s teens don’t learn about sex in the classroom. They learn about it by watching television, by going to R-rated movies, and by surfing the Internet. Sexually explicit material is ubiquitous in modern life. That’s not going to change.

What can change is our attitude towards sex education. Providing comprehensive sex-ed in our public schools — education that includes a frank and open discussion of sexuality, of contraception and pregnancy, and of sexually transmitted diseases — won’t encourage teenagers to have sex. Their hormones will do that. Our teens are going to have sex anyway. What comprehensive sex education in our public schools can do is encourage them to have sex responsibly.

Comprehensive sex education also doesn’t take away an individual’s right to decide what values and morals around sexuality they want to teach their kids. Rather, it is a way to encourage teens and parents to have a frank and open discussion about sex, and what sex means within the larger context of their culture and their religion.

It’s time we started acting like adults (or Canadians) and mandate that our public schools provide comprehensive sex education to all adolescents.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on May 7, 2015, and is available on the WAMC website.]

Posted in Uncategorized | Tagged , , | Leave a comment

What’s the Matter with Indiana?

With all of the hoopla over Indiana’s recent enactment of its Religious Freedom Restoration Act (RFRA), a poorly-written law that gives businesses and individuals broad license to discriminate against members of the lesbian, gay, bisexual and transgender community, another travesty unfolding in that state has gone overlooked. Specifically, Indiana is experiencing the largest outbreak of HIV in the Hoosier State’s history, an epidemic sparked in part by partisan politics.

Just last week, Indiana Governor Mike Pence declared a public health emergency in Scott County after 79 people tested positive for the virus that causes AIDS, an outbreak fueled by rampant injection drug use. In past years, that rural county saw an average of only 5 new cases of HIV infection annually.

So what does partisan politics have to do with this public health emergency? Plenty. Consider, for example, Indiana’s ban on needle exchange programs.

HIV, hepatitis C (HCV), and other blood borne diseases are readily spread between drug users who share contaminated injection equipment. One of the easiest ways to prevent the spread of HIV among injection drug users (IDUs) is a needle exchange program, which allows drug users to obtain sterile syringes, hypodermic needles, and other paraphernalia without a prescription and at little to no cost.

Dozens of studies conducted in the United States and overseas have shown that needle exchange programs work extremely well. Among IDUs in New York City, for example, rates of HIV dropped four-fold when needle exchange programs were first introduced. In fact, the effectiveness of these programs in reducing rates of HIV infection among injection drug users is so great that US Office of National Drug Control Policy, the US National Institutes of Health, the US Surgeon General, the US Centers for Disease Control and Prevention, the American Medical Association, the World Health Organization and the United Nations Office on Drugs and Crime all encourage their use.

Despite this, needle exchange programs are still banned in 24 states, including Indiana. What is the argument that predominantly conservative politicians use to oppose these programs? That they encourage illicit drug use. But even this claim lacks credence. One study conducted in San Francisco found that drug use dropped three-fold among IDUs who used that city’s needle exchange program. Most of these programs also provide peer education and referrals to treatment clinics, helping participants break free of their drug addiction.

Thankfully, Governor Pence finally (sort of) gets it. He recently announced a 30-day moratorium on enforcing Indiana’s ban, stating that “I do not support needle exchanges as anti-drug policy, but this is a public health emergency. I’m going to make a decision on the best science and the best way to stop this virus and this outbreak in its tracks.” Public health officials in Indiana can now implement a needle exchange program should they want to. While it is too late for the 79 newly infected residents of Scott County, such a program may slow the spread of HIV to other Hoosiers.

Indiana’s now-suspended ban on needle exchange programs aside, politically motivated spending cuts are also to blame for the outbreak in Scott County. That county has been without a HIV testing clinic for nearly two years, the direct result of partisan wrangling about abortion.

Until 2013, the Scott County Planned Parenthood clinic was the sole provider of HIV counseling and testing in that rural community. That facility closed after Republican lawmakers cut state funding of Planned Parenthood because of their opposition to abortion. As a result, five clinics run by Planned Parenthood of Indiana & Kentucky were shuttered, including the one in Scott County.

None of those five now-closed clinics provided abortion services. Rather, like most Planned Parenthood clinics nationwide, they mainly provided other desperately needed health care services to poor men and women. Those services included family planning counseling; pregnancy testing and prenatal care; screening for breast, cervical and testicular cancer; testing and treatment for sexually-transmitted diseases; and HIV testing and education. Those services are now largely unavailable to the economically disadvantaged residents of Scott County.

In their zeal to demonize and defund Planned Parenthood over abortion, a still legal medical procedure that accounts for less than 3% of the total services that organization provides, Indiana lawmakers thus created the very conditions needed for an outbreak of HIV to occur.

Sadly, those conditions are being replicated elsewhere. Just last week, for example, Texas lawmakers announced a plan to cut $3 million from state-run HIV prevention programs and redirect the funds to faith-based abstinence-only education projects. That state currently ranks third nationwide in new HIV diagnoses. It is now likely to claim the top spot, a rather dubious honor.

So long as conservative politicians continue their efforts to defund Planned Parenthood, continue their ideological opposition to needle exchange programs, and continue to prioritize the needs and goals of their corporate donors over the health and welfare of their own citizens, outbreaks like the one in Scott County will continue to occur. I only hope that voters finally sit up and take notice of the very real public health threat that these policies present.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on April 9, 2015, and is available on the WAMC website.]

Posted in Crime, HIV/AIDS, Policy, War on Drugs | Leave a comment

Happy Birthday Obamacare!

This week, before a crowd of students attending the obligatory Monday morning convocation at Liberty University, Ted Cruz announced that he was running for President in 2016. This makes Mr. Cruz, a first-term senator from Texas, the first major Republican to officially declare their candidacy.

That Senator Cruz made this announcement on the 5th anniversary of the Affordable Care Act’s signing into law is not surprising. Mr. Cruz has made the repeal of Obamacare (as the Affordable Care Act is colloquially known) a cornerstone of his campaign. Curiously enough, the Senator will also soon be a beneficiary of this program.

Mr. Cruz’s wife Heidi, through whom he previously had health insurance, has taken an unpaid leave of absence from her job as a managing director for Goldman Sachs for the duration of the presidential campaign. The Cruz family will now obtain coverage through the federal insurance exchange program, and will receive the government health insurance subsidy provided to all lawmakers and congressional staffers under the Affordable Care Act.

A lot of pundits have called that hypocritical. I don’t quite see it that way. It’s not hypocritical to follow (and even benefit from) a law that you oppose and are working to repeal. It’s just tacky. What I do have an issue with, however, are the blatant lies told by Senator Cruz and his Republican colleagues about Obamacare.

In a recent interview, Senator Cruz explains his opposition to the Affordable Care Act thusly: “What is problematic about Obamacare is that it is killing millions of jobs in this country and has killed millions of jobs. It has forced millions of people into part time work. It has caused millions of people to lose their insurance, to lose their doctors and to face skyrocketing insurance premiums.” But none of that is true.

Consider, for example, the oft repeated claim that fewer people have health insurance now than before Obamacare was signed into law. The numbers that Cruz, House Speaker John Boehner, and other conservative politicians use to support that assertion? Between March 2010 and March 2015, approximately 6 million Americans received cancellation notices from their health insurance plans. In this same period of time, only 4.5 million Americans signed up for new plans through one of the federal- or state-run health insurance exchanges. That’s a net loss of 1.5 million from US health insurance rolls, right?

Wrong. What those figures don’t include is the number of people who signed up for new plans through other means, such as insurance brokers. It also ignores the 9.1 million people who signed up for Medicaid, the government-run insurance plan that was greatly expanded under the Affordable Care Act. A recent Gallup poll found that the number of uninsured Americans has fallen to 13.4%, a record low. That drop has been greatest in those states, like New York, that have openly embraced Obamacare by expanding Medicaid and by setting up state-based insurance exchanges.

Of course, all these people are paying vastly more for their health insurance now then before Obamacare became the law of the land. Or so opponents claim. But are they? In the years immediately prior to passage of the Affordable Care Act, individual health insurance premiums increased an average of 10 percent annually. By contrast, premiums for mid-level plans offered through health insurance exchanges increased by only 2 percent in 2015, and price for insurance plans in the largest metropolitan markets actually dropped.

Finally, one of the largest criticisms of Obamacare is that it is a “job killer.” Specifically, critics believe that cash-strapped employers unable to provide health insurance to their employees will be forced to lay off workers. Alternatively, since the Affordable Care Act only requires that health insurance coverage be provided to those who work more than 30 hours a week, employers will eliminate full-time positions in order to sidestep this mandate. Thankfully, this is also not the case. The United States has seen 60 months of consecutive job growth since the Affordable Care Act was passed, the longest stretch of employment gains in history. The number of Americans involuntarily working part-time jobs has also declined steadily.

In fact, none of the arguments or predictions used by conservative lawmakers opposed to the Affordable Care Act have proven to be true. The economy hasn’t collapsed, workers haven’t lost their jobs, the federal deficit hasn’t skyrocketed, insurance premiums haven’t risen steeply, and doctors haven’t fled the healthcare industry in droves. In addition, the number of uninsured has dropped and those who obtained new plans though the health insurance exchanges are largely happy with their coverage.

It’s time for opponents of Obamacare to accept these facts. The Affordable Care Act is not an unmitigated disaster, as Ted Cruz and other conservative politicians would like you to believe. Rather, it is an unprecedented success. It has achieved exactly what it set out to do by reducing the number of uninsured while containing health care costs.

Those on the right might have ideological objections to Obamacare. Some of these objections might even be valid. But if you’re going to spend most your time repeatedly trying to repeal this successful law, instead of tackling other looming crises like immigration reform and student debt, at least have the courage to stand up for your convictions and back them with concrete arguments and supporting data.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on March 26, 2015, and is available on the WAMC website.]

Posted in Health Care, Policy, Politics | Leave a comment

Caveat Scholasticus

Economists talk a lot about scarcity. Scarcity occurs when we have fewer resources than are necessary to fill our basic needs and wants. Price is usually a good indicator of scarcity. Despite the recent short-term glut of oil, for instance, increasing demand and decreasing supplies of fossil fuels means that gasoline prices will inevitably rise in the coming years.

Ethicists like myself also talk about scarcity. Medical resources are often in short supply and must be rationed. The limited number of beds in the intensive care unit means that doctors must sometimes make difficult choices about which critically ill patients are admitted to the ICU and which are not. Vaccines may also be rationed. In the event of a serious flu epidemic, for example, the New York State Department of Health has a four-tiered vacccine allocation system, with critically needed staff such as doctors, nurses, police and firefighters given priority over grocery clerks, plumbers, mechanics, and stay-at-home dads. But one thing we never thought would be an increasingly scarce resource, at least in the medical setting, was privacy

Everyone is increasingly concerned about privacy today, and rightfully so. In a progressively wired and interconnected age, there is little about a person that isn’t public knowledge. In fact, despite all our protestations, we as individuals are largely responsible for this loss of personal privacy.

We give up our personal privacy in a myriad of seemingly innocuous ways: posting status updates on Facebook and Twitter, writing blog articles, and uploading pictures to Instagram. Everything we say or do online leaves behind a trail of personal information that can be used by public agencies and private businesses to track us, watch us, and selectively market goods and services to us.

This is true even when it comes to our personal health. As mentioned before, much of this is our own doing. We comment about our various aches and pains online, use databases like WebMD to self-diagnose and self-treat minor illnesses and injuries, and purchase over-the-counter and prescription drugs using our CVS ExtraCare card. But one thing that we would never expect is that our conversations with our physicians and psychotherapists could also become public knowledge.

If anything, maintaining patient privacy and confidentiality is one of the key ethical obligations placed upon physicians. It is an obligation that has its roots in two millennia of Hippocratic practice, and it is the foundation of the doctor-patient relationship. Patients must feel that they can share all sorts of personal information with their physician, no matter how embarrassing or stigmatizing. This information is often necessary to ensure proper diagnosis, testing and treatment.

A sixteen-year-old girl who is experiencing pain when urinating, for example, may simply have a urinary tract infection. But she may also have a more serious condition like chlamydia, gonorrhea or some other sexually transmitted infection. If she is not willing to share the fact that she is sexually active, perhaps out of fear that her parents will find out, her doctor may inaccurately diagnose and treat her.

Maintaining patient privacy and confidentiality is so important that it has been put into practice and codified into law. Following a groundbreaking observation study of what doctors, nurses and medical students shared with each other in public elevators (spoiler alert: they shared way too much), many hospitals instituted strict policies about what can and cannot be said about patients in public settings. Anyone who has been to a hospital in recent years has undoubtedly seen the signs in the hallways and elevators reminding staff of this fact. Hospital staff can reprimanded and even fired for breaching confidentiality, as happened at Cedars-Sinai Medical Center after six employees inappropriately accessed the medical records of reality television star Kim Kardashian

State and federal laws restrict the types of information that can be shared about patients. One key federal law, the Health Insurance Portability and Accountability Act (HIPAA), places strict limits on who can access or share your medical records or your health insurance and billing information. Doctors, hospitals, and insurance companies bound by HIPAA regulations can face severe civil and criminal penalties for violating this law, including fines of $1.5 million and prison sentences of up to ten years.

Unfortunately, this privacy law is rife with loopholes. HIPAA only applies to so-called ‘covered entities,’ such as health providers and health insurance companies. It does not apply to others who may have private health information, such as life insurance companies, employers, workman’s compensation programs, law enforcement agencies, or schools. This is a significant problem, as highlighted by a recent case involving a student at the University of Oregon.

That student was allegedly raped by three University of Oregon basketball players. In a Title IX lawsuit filed against the school, she claims that the school deliberately delayed its investigation so that the men could play in an important NCAA tournament.

So what does this case have to do with medical privacy? The University is using the student’s own medical records to defend itself in court. Because the student sought clinical treatment and psychological counseling at the University health clinic, her medical record belongs to the school. A federal law known as the Family Educational Rights and Privacy Act (FERPA), ironically meant to the protect the privacy of a student’s educational records, exempts campus medical records from HIPAA’s privacy rules.

Sadly, as morally repugnant as this is, the University is well within its legal rights to do this. Until laws like HIPAA and FERPA are amended to close these loopholes, we all should be more than a little wary. Students, for example, may wish to seek off-campus counseling or treatment in order to protect the privacy of their records, even if this means that they or their families may be forced to shoulder the cost. Meanwhile, the rest of us should be a little more diligent about the types of medical information we share with agencies and organizations not covered by HIPAA, and to pause for a moment before we complain about our neck aches and back pains on social media.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on March 12, 2015, and is available on the WAMC website.]

Posted in Clinical Care, Policy, Privacy | Leave a comment

When Doctors Discriminate

Most of you have probably never heard of Jami and Krista Contreras, a Michigan couple and the proud parents of a six-month-old girl named Bay. Shortly after Bay was born, the Contrerases began interviewing pediatricians, looking for one who practiced holistic medicine.

After meeting with nearly a dozen doctors, the newly married couple finally settled on Dr. Vesna Roi, a pediatrician in private practice with nearly 19 years of experience caring for children like Bay. On the morning of their first appointment, however, Dr. Roi refused to see them. The reason: the Contrerases are a same-sex couple.

In a handwritten letter delivered to Jami and Krista by another doctor at the pediatric clinic, Dr. Roi apologized but stated that, “after much prayer following your prenatal [visit], I felt that I would not be able to develop the personal patient doctor relationship that I normally do with my patients.” Dr. Roi’s religious faith, it seems, makes her uncomfortable around lesbian couples.

I actually have some sympathy for Dr. Roi. She clearly felt that she could not give the Contrerases, or their daughter Bay, the level of care that they deserved. In fact, a strong doctor-patient relationship is the key to quality health care. If Dr. Roi felt uncomfortable around Jami and Krista, or felt uncomfortable in asking them questions about those aspects of their personal lives that could affect the health of their daughter, she might overlook pieces of information that were important for Bay’s preventative care or therapeutic treatment. The Contrerases might also pick up (consciously or subconsciously) on Dr. Roi’s unease, and be less than forthcoming about their concerns or opinions. Given this, Dr. Roi was not the right pediatrician for Bay.

Vesna Roi also had the right to refuse the Contrerases as patients. For the most part, doctors are legally bound to treat patients only once they have entered into a care relationship. Even then the doctor can terminate the physician-patient relationship under certain circumstances (if, for example, a patient is non-compliant with treatment, the patient is abusive to providers, or the services sought are not covered by the patient’s health insurance). But the physician must provide a reason for terminating the relationship and must ensure continuity of care.

Ethically, Dr. Roi is on shakier ground. If she felt that she could not establish the necessary doctor-patient relationship with the Contrerases, she probably shouldn’t take them on as patients. But Dr. Roi should have been upfront with the Contrerases sooner, rather than waiting until the morning of Bay’s first pediatric appointment to inform them of her reluctance.

Moreover, while the American Medical Association (AMA) and other professional organizations recognize the right of clinicians to refuse to provide specific treatments if they are incompatible with a doctor’s personal, religious or moral beliefs, it’s hard to see how such “conscience clauses” apply in this case. Conscience clauses are meant to apply to specific medical procedures, most notably abortion and sterilization, rather than to specific classes of patients. If we allow a physician like Dr. Roi to reject patients on the basis of sexual orientation (whatever her personal, religious or moral reason), should we also allow a doctor to turn away patients who are Black or Latino? To turn away patients who are Muslim, Jewish or Atheist? To turn away patients who are women?

Of course we would never allow this. It is morally reprehensible. This is why the AMA, the American Academy of Pediatrics and other professional organizations that respect the conscience of physicians also make it clear that doctors should not refuse care based on race, gender or sexual orientation.

It would also be illegal to refuse a patient based on race, religion or gender under the federal Civil Rights Act of 1964. Sadly, this is not the case for sexual orientation or gender identity. Lesbian, gay, bisexual or transgender (LGBT) individuals are not protected by the Civil Rights Act, but rather by a patchwork of state laws and local anti-discrimination ordinances.

Only twenty-two states have laws that prohibit discrimination based on sexual orientation in “public accommodation” (e.g. businesses that serve the public, including pediatric clinics like Dr. Roi’s). Only fourteen states extend those same protections to gender identity. Michigan is not one of those states, so that what Dr. Roi did is morally questionable but it is not legally actionable. Had she lived here in New York, she could have been sued (unless one of the Contrerases had been transgendered, since the Empire State still allows discrimination based on gender identity).

We need these laws, both at the state and the federal level. Sure, people like Dr. Roi may be uncomfortable in dealing with lesbian patients or gay clients. But that’s not a reason to legally allow or publicly condone discrimination based on sexual orientation or gender identity.

The same arguments were used for years to justify discrimination against women, Black and Jews, until the Civil Rights Act forced people to challenge their biases and question their assumptions. It’s time to do the same for the LGBT community.

As I said before, Dr. Roi was not the right pediatrician for Bay. But she could be, once she learns to look beyond her personal prejudices and see the Contrerases for who they are: human beings with the same needs, fears, and hopes as her. But it might take a legal nudge to get Dr. Roi and others like her to take that first step.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on February 26, 2015, and is available on the WAMC website.]

Posted in Discrimination, Health Care, Homosexuality, Human RIghts, Policy | Leave a comment

How to Die in Canada

Last week, our neighbors to the north took a huge step towards legalizing physician aid-in-dying. On Friday, the Supreme Court of Canada unanimously struck down that country’s ban on the practice, suspending two sections of the Criminal Code that outlawed assisted suicide and euthanasia, and ordering the Canadian Parliament and the various provincial legislatures to draft new legislation that would allow physician aid-in-dying.

This is not the first time that Canada has dipped it toe into these treacherous waters. Earlier this year, the Canadian province of Quebec passed Bill 52, also known as ‘An Act Respecting End-of-Life Care’. That Act, which would have taken effect in December, would grant terminally ill Quebecers the right to request a physician’s aid in dying.

In order to qualify for medical assistance in ending their lives, however, these patients must have “an incurable illness that is causing unbearable suffering”. They would have to be in constant and unbearable pain that doctors couldn’t relieve with treatment. The request for aid-in-dying would also have to be made in writing, witnessed by the attending physician, and approved though consultation with a medical team after two doctors determine that the patient is competent to make this request.

The Supreme Court ruling went much further than what Quebec’s law would allow. The nine Canadian justices ruled that physician-assisted suicide should be made available to any competent adult who “clearly consents to the termination of life and has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”

By including references to disability and psychological suffering, the Court potentially opened the doors not only to those with terminal illnesses, but also those with chronic but not life threatening illness or disabilities, as well as those suffering from mental illness.

It is unclear how Canadian legislators and medical professionals will respond to this ruling, but they will face a number of challenges in devising an aid-in-dying process that will allow seriously ill patients to end their lives peacefully while still protecting their rights and safety.

But this is a Canadian problem, right?. Why should we care what is happening in the Great White North? Rulings by that country’s Supreme Court have no bearing on US law. Moreover, any aid-in-dying process that our neighbors create is likely to be limited to the citizens and residents of Canada, preventing so-called ‘euthanasia tourism’.

But we should care about what’s happening in Canada because the aid-in-dying movement is also becoming an increasingly powerful voice in US medical practice (particularly following the death of Brittany Maynard, the terminally ill 29-year-old who spoke publicly about moving from California to Oregon in order to legally end her life). American policymakers and physicians can learn a lot from watching the Canadian experiment.

Currently, only five states allow physician aid-in-dying: Montana, New Mexico, Oregon, Vermont, and Washington. In three of those states, laws allowing terminally ill patients to request a doctor’s assistance in ending their own lives were passed by popular referendum or legislative votes. Similar legislative bills or public referendums have been proposed in other states, and popular support for physician aid-in-dying is increasing.

Just last November, for instance, Massachusetts’ voters narrowly defeated a referendum called Question 2 that would have legalized physician aid-in-dying in that state. That narrow 51-49 loss occurred only after well funded and politically savvy opponents were able to reframe discussion about the referendum. The public debate about Question 2 became less about the rights of the terminally ill and more about potential abuses of the disabled and the elderly. But recent polls suggest that nearly two-thirds of voters in the Bay State now support physician aid-in-dying, and a new bill to legalize the practice is currently winding its way through the Massachusetts legislature.

Those of us who live in the Empire State may never get a chance to vote on physician aid-in-dying as New York does not have a popular initiative and referendum process. Efforts have been made to introduce aid-in-dying bills in the state legislature, but these bills face an uphill battle due to strong opposition by religious groups, disability advocates and conservative lawmakers. But this doesn’t mean that physician-assisted suicide won’t soon be legal in New York.

As with Montana and New Mexico, physician aid-in-dying may become legal in New York via court ruling. Just last week, a group of terminally ill patients and clinicians filed a lawsuit asking the New York Supreme Court to invalidate the state’s current prohibition on assisted-suicide.

Currently, a doctor who prescribes a fatal dose of medication to a terminally ill patient can be prosecuted for manslaughter under New York’s Assisted Suicide Statute, which makes it a crime to “intentionally cause or aid another person to commit suicide.” To date, no doctor has ever been prosecuted under this statute. Despite this, the plaintiffs argue that current assisted suicide laws violate the equal protection clause of the State Constitution. For example, physicians are already help some terminally ill patients die (by removing life support) but they cannot help patients who do not rely on continuous medical intervention to live.

Whether or not the New York Supreme Court will rule for the plaintiffs in this case remains to be seen, but the tide of public opinion is clearly shifting in favor of physician aid-in-dying. Physician aid-in-dying may not become the law of the land in New York anytime soon (be it by legislative action or judicial fiat), we need to start talking about it.

No matter which side of the debate you are on — either for or against physician aid-in-dying — we need to have a thoughtful and respectful discussion about dying, about the rights of the terminally ill, and about the role that physicians should play in helping patients attain a peaceful death. And we should watch the Canadian experiment carefully (and the experience of Montana, New Mexico, Oregon, Vermont, and Washington), and learn from their success and mistakes.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on February 12, 2015, and is available on the WAMC website.]

Posted in End-of-Life, Physician Aid-in-Dying, Policy | 1 Comment

V-Ticket to Ride

I haven’t been to Disneyland since my senior year in high school, and I’ve actually never visited one of the Disney World resorts. Frankly, I never really cared for the noise, the crowds and the artificiality of the Disney parks. The fact that one of these amusement parks is now the center of an infectious disease outbreak makes my aversion even more intense.

Public health officials in California recently confirmed that an outbreak of measles in that state has been linked to the Disneyland theme park in Anaheim. Over 90 new cases of measles have been reported in California and seven neighboring states during the past two weeks, with over 50 of those cases originating in the Magic Kingdom. Most of those cases occurred among unvaccinated kids.

To put this outbreak into context, consider that in 2000 the US Centers for Disease Control and Prevention (CDC) declared that measles had been eliminated from the United States due to vaccination programs and a strong system for detecting, reporting and responding to outbreaks. Only 37 confirmed cases of measles were reported that year, all of which were imported from other countries.

What a difference 15 years can make. In 2014, the United States experienced a record number of measles cases. 644 cases of measles were reported to the CDC, more than the total number of cases in the previous four years combined. If this year’s Disney outbreak is any predicator, we are likely to surpass the 2014 record.

The disease itself is still largely imported from overseas, but it spreads like wildfire among unvaccinated Americans. This is because measles is one of the most infectious diseases known to man. On average, a person with measles spreads it to 18 other people. By contrast, a person with Ebola (the deadly disease that caused widespread panic last year) is only likely to transmit that virus to one or two others, and only in places that lack a robust public health system. An outbreak of Ebola in the US is highly unlikely, whereas measles outbreaks will probably become commonplace.

The anti-vaccination movement is solely to blame for the re-emergence of measles as a public health threat. The easiest way to prevent the spread of measles is vaccination. If 95% of the people in a community are vaccinated against measles, outbreaks cannot occur. Unfortunately, rates of vaccination have fallen to their lowest levels since the start of widespread measles immunization programs in 1963. For example, over 40% of kindergarteners in Orange County, home to Disneyland and epicenter of the current outbreak, are not vaccinated against measles.

Those opposed to vaccination, including such public health luminaries as disgraced British researcher Andrew Wakefield and former Playboy Playmate Jenny McCarthy, have successfully convinced a large swath of the American public that vaccines are dangerous. Despite scientific evidence to the contrary, claims have been made that vaccines cause autism, cancer, asthma, allergies, and a host of other acute and chronic ailments. These so-called “anti-vax” claims have been largely accepted by a gullible populace. According to a recent survey, barely 51 percent of Americans believe that vaccines are safe and effective. About the same number of people also believe in astrology, creationism and ghosts.

Since the Disneyland outbreak began, a number of prominent anti-vaxxers have also argued publicly (including on the CBS Evening News) that measles is not a disease to be feared. Nothing could be further from the truth. Measles is a dangerous and deadly illness. Before the first effective vaccine was developed, approximately 4 million Americans contracted measles each year. Of those, 3 in 10 developed complications like pneumonia. Nearly 50,000 people were hospitalized, 1,000 were permanently disabled due to measles encephalitis, and 500 died.

When confronted with the lack of compelling data to support their claims, anti-vaccination activists often fall back on the most American of arguments: individual freedom and personal liberty. Specifically, many anti-vaxxers believe that the government cannot tell them what they should or should not put into their (or their child’s) body. But this position has limits, particularly when individual actions jeopardize the lives of others.

That is exactly the case here. When someone refuses to vaccinate themself or their kids, they put others at risk, including children who are too young to be vaccinated or elderly whose resistance to measles and other preventable diseases has waned.

It’s time for clinicians, public officials, and politicians to take a stand on vaccination, and take a stand against the claim that personal liberty trumps public safety. Pediatricians and other physicians should refuse to accept new patients who chose not to immunize themselves or their children. School officials should no longer allow unvaccinated children to attend public schools, except in rare cases where vaccination is contraindicated medically. Finally, local, state and national politicians should no longer make it easy for parents to obtain philosophical or “personal belief” exemptions from vaccination requirements and other public health statutes.

If you don’t like vaccines and refuse to get immunized, that is your right. But you shouldn’t expect to line up for Space Mountain or the Pirates of the Caribbean with the rest of us.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on January 29, 2015, and is available on the WAMC website.]

Posted in Public Health, Vaccines | Leave a comment