Despite a wealth of evidence that breastfeeding provides the most health benefits for infants, many barriers — including rigid work conditions and lack of family or community support — can interfere with a woman’s ability to start breastfeeding, or to keep breastfeeding for at least six months.
Health advocates have long criticized the popular hospital practice of distributing infant formula to new mothers, because doing so descreases the length of time that women breastfeed — even when they have indicated a desire to try breastfeeding, and sometimes instead of providing lactation support (read this previous post, which discusses a report on Chicago hospitals in low-income neighborhoods).
According to the Centers for Disease Control, 77 percent of infants in the United States start out being breastfed, which is an increase over recent years, yet fewer than half are still breastfeeding at the six-month mark.
Many hospitals have banned pharmaceutical or other industries from providing marketing materials directly to doctors, in order to avoid conflicts of interest, but many hospitals still provide free formula samples directly to patients.
The consumer advocacy organization looked at the top hospitals in the U.S. News and World Report rankings, both those with the gynecology specialty and maternal/newborn services and those on the general Honor Roll. It then surveyed those hospitals about their policies and practices, and checked against data from the national Ban the Bags campaign, which grew out of a Massachusetts effort to stop aggressive formula marketing.
Some of Public Citizen’s key findings:
Sixty-seven percent of top gynecology hospitals in gynecology reported not giving out bags sponsored by formula companies, formula samples, or other formula-related promotional materials
An additional 11 percent (5 of 45) limited samples and sponsored bags to those who request them, moms who are already planning to formula feed, or to Neonatal Intensive Care Unit patients
Eighty-two percent (14 of 17) of the best overall hospitals reported having a policy or practice against distributing these materials
Public Citizen recommends that the remaining hospitals on these lists also ban formula distribution, and discuss other interventions that public health departments and state legislatures can take to restrict the practice. As the report notes:
Numerous studies show that women are likely to breastfeed less, and for shorter durations, if they receive formula samples and promotional materials in hospital discharge packs. Formula bag distribution effectively influences new mothers to use formula because it sends a powerful message that hospitals endorse formula feeding, even where breastfeeding in hospitals is promoted.
One major effort to improve the support for breastfeeding in hospitals is the Baby-Friendly Hospital Initiative, endorsed by several major medical organizations. The Initiative sets standards for baby-friendliness, including breastfeeding support. The Initiative’s guidelines and evaluation criteria states that in baby-friendly hospitals, staff members should not receive donations from breast milk substitute providers, and mothers and their families should not be given marketing materials for formula or gift packs containing formula. The Baby-Friendly principles have been endorsed by several major medical organizations.
Ban the Bags provides a toolkit for advocating against these formula sample bags, which can be downloaded from its website, as a resource for taking action in your own community. As Ban the Bags puts it: “Hospitals should market health, and nothing else.”
Two major medical societies and an important research group have released a joint statement calling on health care providers to advocate for reduced exposure to toxic chemicals and pollutants that can can cause reproductive health problems, harm to pregnancies, and long-term health complications.
The organizations involved — American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women, American Society for Reproductive Medicine Practice Committee, and UCSF Program on Reproductive Health and the Environment – state that although hundreds of new chemicals are introduced in the United States each year, safety data and regulation are lacking:
Because of deficiencies in the current regulatory structure, unlike pharmaceuticals, most environmental chemicals have entered the marketplace without comprehensive and standardized information regarding their reproductive or other long-term toxic effects.
Among the recommendations for health care providers (the target audience for the statement): learn about patients’ exposures before pregnancy and during prenatal visits; encourage pregnant and breastfeeding women to carefully wash produce and avoid fish with high levels of mercury; include information about environmental hazards in childbirth classes; and promote healthy food systems and policy changes that reduce exposure.
It’s great to see the medical establishment recognizing the need for better study and regulation of toxic chemicals — and acknowledging both the impact on reproductive health and the disparities in exposure to pollution and toxins. This new committee opinion, intended as an informative guide for professionals, may bring much-needed attention to these issues among obstetricians, gynecologists, and other reproductive medicine practitioners.
The committee opinion acknowledges that certain recommended actions — like eating fresh, unprocessed foods, selecting organic produce, and avoiding canned food that might expose consumers to bisphenol A — are not realistic strategies for many low-income women and vulnerable populations. The authors rightly note:
In the United States, minority populations are more likely to live in the counties with the highest levels of outdoor air pollution and to be exposed to a variety of indoor pollutants, including lead, allergens, and pesticides than white populations. In turn, the effects of exposure to environmental chemicals can be exacerbated by injustice, poverty, neighborhood quality, housing quality, psychosocial stress, and nutritional status.
The organizations add that “individuals alone can do little about exposure to toxic environmental agents, such as from air and water pollution, and exposure perpetuated by poverty,” and they therefore urge healthcare professionals to help advance policies that reduce exposure to toxins.
A pair of newly published studies in the journal Contraception look at the types and access to family planning services provided at community health clinics that are considered a popular primary care option for low-income women of reproductive age.
The studies, produced by researchers at the George Washington University School of Public Health, examine the services at Federally Qualified Health Centers (FQHCs). These health clinics provide primary and preventive care on a sliding scale, primarily to low-income and uninsured patients. It’s also worth noting that when states attempt to defund Planned Parenthood clinics, these are clinics to which many women may get directed for care.
The authors anticipate that these health centers will become an even more important part of care as the Affordable Care Act is fully implemented and Medicaid is expanded. One of the co-authors is Dr. Susan Wood, who resigned her post as director of the FDA’s Office of Women’s Health in 2005 in protest over delays in approving over-the-counter access to emergency contraception.
In the first study, “Scope of Family Planning Services Available in Federally Qualified Health Centers,” researchers surveyed several hundred FQHCs about on-site care, including approaches to pregnancy prevention and STI/HIV testing and treatment, as well as referrals of patients to other sites, staffing issues, and other aspects of care. While they found that almost all of the FQHCs provided at least one contraceptive method, the type and accessibility of those methods varied.
Slightly more than half of the centers were able to dispense oral contraceptives on site rather than sending patients elsewhere with a prescription. Slightly more than a third (36 percent) offered both oral contraception and longer acting IUDs and/or implants on-site. If a woman has to go to another location, there may be consequences such as incurring lost work time that may make it harder to follow through.
Also, only about a third of the surveyed centers received Title X family planning funding (it’s not clear whether some clinics had not applied, or did apply and were rejected). The researchers found that while pretty much all of the centers provided access to oral contraception, the Title X-funded clinics were more likely to provide the full range of contraceptive options.
- Likewise, the Administration for Community Living will not be able to fund programs in Senior Nutrition, Native American Nutrition and Supportive Services, Prevention of Elder Abuse and Neglect, and Protection and Advocacy for persons with developmental disabilities.
- Federal websites that provide health information to consumers, like womenshealth.gov and MedlinePlus, are not being updated during the shutdown. The longer the shutdown continues, the more likely it is that these sites will have information that is no longer current.
- Researchers trying to answer questions about women’s health are also affected, meaning important research databases on medical topics may not be fully updated or updated at all.
- The FDA will be unable to support the majority of its food safety, nutrition, and cosmetics reviews. While the agency is expected to continue managing emergencies and high-risk situations, it will not have the resources to deal with some inspections and less urgent product alerts.
Republicans tried to make restrictions on women’s preventive health care– including contraception coverage – a condition of not shutting down the government. As Cecile Richards writes, “The country wants Congress to focus on jobs and the economy, not on pushing an extreme agenda against women’s access to health care.”
And we really don’t want to bargain away our health.
Q. My wife and I are newlyweds. We are looking into family insurance plans and are curious about maternity coverage, rates and any limitations. I’m seeing a lot of companies don’t cover maternity benefits or impose six-month restrictions. It seems really complicated and not helpful, to say the least. Any information you can provide will help.
A. This is one of the problems that the health law was designed to address.
The Pregnancy Discrimination Act requires companies with 15 or more workers that offer health insurance to provide maternity coverage for workers and their spouses. But the law doesn’t apply to plans sold on the individual market.
Only 12 percent of those individual plans provide maternity coverage, according to an analysis published last year by the National Women’s Law Center. Plans that do cover maternity services may have a separate deductible of up to $10,000 and impose a waiting period of up to a year before members can use the services, the study found.
All that will change next year. Starting in January, the Affordable Care Act requires all new individual and small group health plans to cover 10 “essential health benefits,” and maternity and newborn care is one of them.
Insurers can’t impose waiting periods for maternity coverage nor charge women higher rates than men, as typically occurs now.
If you buy a plan on the individual market now, chances are you’ll pay extra for maternity coverage, if you can find it at all. But even if you buy a plan now, there’s nothing to stop you from shopping for a plan that meets the new maternity coverage requirements when your state’s health insurance marketplace launches in October. Your new coverage could begin in January, says Carrie McLean, director of customer care at online vendor eHealthInsurance.com.
If you and your wife do become pregnant before year’s end, you may benefit from another provision of the Affordable Care Act. Under current law, insurers on the individual market typically consider pregnancy to be a pre-existing medical condition and refuse to issue policies to people who are pregnant.
Starting in January, “Nobody can ask them if they’re pregnant and then deny them coverage,” says Judy Waxman, NWLC’s vice president for health and reproductive rights.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
Women entering prisons often have poor physical health, in part due to poverty and lack of access to treatment for concerns such as addiction, abuse and mental health. An article in the Journal of Health Care for the Poor and Underserved looks at a different aspect of the health of incarcerated women: how healthcare systems in prison create further harm.
The women reported a wide variety of concerns, with one of the major issues being limited and complicated access to care.
While it’s a widespread belief that inmates have all of their medical care paid for, cost was a significant barrier for the women. The women earned 50 cents per hour in their prison-based jobs, and some of that income was diverted for fines and fees related to their incarceration, making even the mandatory $5 co-payments difficult. Once they have accumulated $5 for a visit, the inmates are only allowed to address one health concern per visit.
The women also reported being discouraged from seeking care, as well as fear of disciplinary action if they questioned a health care provider.
One woman reported: “I went to Medical, telling them I had more than just a cold. I got yelled at, called a hypochondriac, and escorted out with the threat of [being written up for] misconduct. Later I had an asthma attack and was diagnosed with asthma.”
Another reported that routine gynecological care such as Pap tests for cervical cancer is discouraged: “They try to make you not want your Pap because there are so many people waiting. They say, ‘You know, you don’t really have to have a Pap, right?’ They make you feel guilty if you want it.”
Poor dental care and eye care were also mentioned, with consequences that go beyond the medical. One woman with poor eyesight described not being able to do her mandatory homework because she could not obtain glasses, and she feared being disciplined for misconduct as a result. When dental care could be accessed, the women were concerned that the dentists would simply pull their teeth instead of providing other treatments.
The women also expressed concerns about the unhealthy diet causing weight gain and limited opportunities for exercise. Exercise classes were often scheduled during the prisoners’ work hours frequently canceled. Women who expressed a desire to quit smoking often could not afford the offered therapy — nicotine patches cost $187.50 for six weeks (375 hours of work at 50 cents per hour).
Women with disabilities face additional problems. Those using wheelchairs were assigned other inmates as “pushers”; these women received only 15 minutes of training on how to maneuver wheelchairs.
Harner and Riley do not offer solutions for the poor health care offered to women in prison, but they do provide characterization of the problems as expressed by the women themselves. The authors conclude with this statement: “Incarcerated women deserve timely, evidence-based, and respectful health care in prison.”
Raising Women’s Voices (RWV) launched a new website on Monday that aims to help the 19 million uninsured women in the United States learn more about and apply for health coverage available through the new health insurance marketplaces, or “exchanges.”
Enrollment for these exchanges, created as part of the Affordable Care Act, begins Oct. 1.
“Women are the primary health care decision-makers for many families and will probably be doing a lot of the shopping for health insurance in the new marketplaces,” Cindy Pearson, co-founder of Raising Women’s Voices, said in a statement. “That’s why it is especially important that women get the help they need in learning how to use the new marketplaces.”
RWV offers resources for advocates involved in outreach to uninsured women, including a fact sheet (pdf) that you can print and post to let uninsured women know about enrollment. The site also includes details on coverage available to LGBT women, women of color, students, and new mothers.
For example, midwives and birth centers can now be covered by Medicaid, and Pearson provides important details on preventive health services now covered for women:
All insurers now have to cover well-woman exams (thanks to the lobbying efforts of women senators such as Barbara Mikulski), contraception and breastfeeding (even the expensive stuff such as IUDs and breast pumps), cancer screening such as mammograms and Pap smears, domestic-violence screening and STI counseling. If you’re working for Catholic Charities or a religiously affiliated hospital, however, don’t bother asking your HR department about any of this: The Department of Health and Human Services (HHS) has created a work-around so that the bishops don’t have anything to do with your contraceptive coverage.
The print article includes a sidebar (inadvertently left out of the online article) on the not-so-good news: the limitations of the ACA for immigrants and Native Americans, and the political struggles over Medicaid expansion. Check out the full print article for this information and more on enrolling for health coverage, the effects of the ACA on LGBT families, and other issues.
For decades, doctors have been warned about the dangers of delivering babies early without a medical reason. But the practice remained stubbornly persistent.
Now, with pressure on doctors and hospitals from the federal government, private and public insurers and patient advocacy groups, the rate of elective deliveries before 39 weeks is dropping significantly, according to latest hospital survey from The Leapfrog Group, a coalition of some of the nation’s largest corporations that buy health benefits for their employees.
Babies born before 39 weeks are more likely to have feeding and breathing problems and infections that can result in admissions to neonatal intensive care units than those who are born later, studies show. The elective deliveries can also cause developmental problems that show up years after birth.
Inducing labor early also carries risks for mothers because it increases the chances they will need cesarean sections.
Since 1979, the American College of Obstetricians and Gynecologists has recommended against deliveries or induced labor before 39 weeks unless there is a medical indication, such as the mother’s high blood pressure or diabetes or signs that the fetus may be in distress.
Still, an estimated 10 to 15 percent of U.S. babies continued to be delivered early without medical cause, according to a report last year by the Department of Health and Human Services.
Leapfrog Chief Executive Officer Leah Binder said she’s encouraged by the latest figures, but says rates are still too high at many hospitals — with some as high as 40 percent. “This is a move in right direction, but more needs to be done,” Binder said.
Leapfrog wants to see rates no higher than 5 percent of all deliveries, a target achieved by nearly half of the reporting hospitals – up from 39 percent of hospitals in 2011.
State averages varied from a high of 26 percent in Pennsylvania to a low of 5.9 percent in Massachusetts and New York. Only states with at least 10 hospitals reporting data were counted toward a state average.
One reason some hospitals have been slow to lower their rate is a reluctance to pressure doctors to change their practice, she said.
Some rural hospitals may also have higher rates because doctors in solo practice sometimes schedule to deliver babies early to stagger their workload. Women who are unaware of the higher risks may also ask to deliver early out of convenience.
Average Early Elective Delivery Rates
State averages for states with more than 10 hospitals reporting
Some of the most dramatic improvements last year came from states such as South Carolina and Illinois where business groups and insurers have exerted pressure to decrease high-risk deliveries. In Illinois, the rate has been cut almost in half to about 7 percent through efforts by organizations such as the Midwest Business Group on Health.
Employers and insurers have gotten involved partly to reduce health costs, since stays in neonatal intensive care units can average well over $60,000.
This year, the South Carolina Medicaid program and BlueCross BlueShield of South Carolina stopped reimbursing providers for performing early deliveries without medical cause. In 2012, the state, working with the March of Dimes and other groups, asked hospitals voluntarily to reduce their rate of early deliveries. The rate of early elective deliveries in South Carolina hospitals fell to 10 percent last year from 19 percent in 2011, the Leapfrog data show.
“We are pleased to see these improved health outcomes,” said Kim Cox, spokeswoman for the South Carolina Department of Health and Human Services.
Texas Medicaid stopped paying for early elective deliveries in 2011, and New York and New Mexico are considering similar actions, according to state officials.
Some hospitals are moving on their own. Boston Medical Center reduced its rate to 5.3 percent last year from 22.5 percent in 2011 by reminding doctors that delivering babies even one or two days before 39 weeks would not be allowed without medical cause. The hospital also informed women about the policy during prenatal care.
“All of the nurses, midwives and doctors on Labor and Delivery are aware that decreasing elective deliveries prior to 39 weeks is an important goal for our service,” said Dr. Ronald Iverson, director of quality improvement for OB/GYN at Boston Medical Center.
Provided by Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
Even though they’re more effective at preventing pregnancy than most other forms of contraception, long-acting birth-control methods such as intrauterine devices and hormonal implants have been a tough sell for women, especially younger ones.
But changes in health-care laws and the introduction of the first new IUD in 12 years may make these methods more attractive. Increased interest in the devices could benefit younger women because of their high rates of unintended pregnancy, according to experts in women’s reproductive health.
IUDs and the hormonal implant – a matchstick-sized rod that is inserted under the skin of the arm that releases pregnancy-preventing hormones for up to three years — generally cost between $400 and $1,000. The steep upfront cost has deterred many women from trying them, women’s health advocates say, even though they are cost-effective in the long run compared with other methods, because they last far longer.
Under the Affordable Care Act, new plans or those that lose their grandfathered status are required to provide a range of preventive benefits, including birth control, without patient cost-sharing. Yet even when insurance is covering the cost of the device and insertion, some plans may require women to pick up related expenses, such as lab charges.
Long-acting reversible contraceptives (LARCs) require no effort once they’re put into place, so they can be an appealing birth-control option for teens and young women, whose rates of unintended pregnancy are highest, experts say.
Across all age groups, nearly half of pregnancies are unintended, but younger women’s rates are significantly higher, according to a 2011 study from the Guttmacher Institute, a reproductive health research organization. Eighty-two percent of pregnancies among 15- to 19-year-olds were unintended in 2006, and 64 percent of those among young women age 20 to 24 were unintended, the study found.
Although the use of LARCs has more than doubled in recent years, it is a small part of the contraceptive market. Among women who use birth control, 8.5 percent of women used one of those methods in 2009, according to the Guttmacher Institute. The use of LARCs by teenagers was significantly lower at 4.5 percent, while 8.3 percent of 20- to 24-year-olds chose this type of contraception.
Yet many young women are unaware that long-acting methods could be good options for them, in part because their doctors may be reluctant to prescribe them, experts say. That is partly the legacy of the Dalkon Shield, an IUD that was introduced in the 1970s whose serious defects caused pain, bleeding, perforations in the uterus and sterility among some users. The problems led to litigation that resulted in nearly $3 billion in payments to more than 200,000 women.
In addition, providers may hesitate because there’s a slightly higher risk that younger women will expel the device, experts say.
But expulsion is a problem more likely associated with the size of the uterus, which is not necessarily related to a patient’s age, says Tina Raine-Bennett, research director at the Women’s Health Research Institute at Kaiser Permanente Northern California and chairwoman of the ACOG committee that released the revised opinion on LARCs. “Expulsion is only a problem if it goes unrecognized.” (Kaiser Health News is not affiliated with Kaiser Permanente.)
The new IUD Skyla became available in mid-February. It is made by Bayer, the same company that makes Mirena, another IUD sold in the United States. Unlike Mirena, which is recommended for women who have had a child, Skyla has no such restrictions (nor does ParaGard, the third type of IUD sold here). Mirena is currently the subject of numerous lawsuits alleging some complications, such as device dislocation and expulsion.
Skyla is slightly smaller than the other two IUDs on the market and is designed to protect against pregnancy for up to three years, a shorter time frame than the others.
This shorter time frame may make Skyla more attractive to younger women who think they may want to get pregnant relatively soon, some experts say, although any IUD can be removed at any time.
“More providers are spreading the word that it’s okay, and more young women are demanding it,” says Eve Espey, a professor of obstetrics and gynecology at the University of New Mexico.
This article was produced by Kaiser Health News with support from The SCAN Foundation. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
The United States has had a shortage of primary care providers for quite a while, and the doctor shortage is not expected to ease up anytime soon, with more people gaining access to health coverage along with the increased health needs of aging Baby Boomers.
Many of us may have encountered an NP or PA at a Planned Parenthood or other women’s health clinic. Nurse practitioners typically have a master’s degree in nursing plus specialty certification, while physician assistants graduate from a 2- to 3- year physician assistant education program. Both NPs and PAs may specialize in areas such as family medicine, women’s health, pediatrics, emergency care, or other areas.
Michelle Andrews of Kaiser Health News provides a quick, basic overview of how NPs and MDs compare in the video below:
NPs provide a variety of critical health services, including evaluating patients, making diagnoses, ordering and interpreting diagnostic tests, writing prescriptions, and managing acute and chronic health conditions—including the oversight of patients with multiple and complex chronic illness. NPs are providers of choice for millions of individuals and families. They are especially educated and prepared to care for vulnerable populations such as the elderly, the medically underserved, and those who live in rural areas that have more acutely experienced the primary care provider shortage.
PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice and prescribe medications [...] PAs deliver high-quality care, and research shows that patients are just as satisfied with PA-provided care as they are with physician care.
So if you visit a primary care or women’s health clinic, a walk-in clinic, or other medical office, you might just find yourself in the care of a nurse practitioner or a physician assistant — and now you’ll know a bit more about their education and role.
The AHRQ conducts systematic reviews of medical evidence to better inform providers and patients about which treatments seem to work. It does so by evaluating how new treatments stack up to other existing therapies, and by evaluating whether there is good supporting evidence to recommend them. This research, then, helps people make smarter decisions about medical care by analyzing what is known and by making available information about the comparative effectiveness of different treatments.
Sounds like a useful thing, right? So why might Republican lawmakers want to defund an agency that helps us understand more about which medical care is most effective? I have a couple of ideas.
First, it allows Republicans to recycle anti-Obama talking points about both the stimulus bill and the Affordable Care Act. The provision in health care reform that makes preventive services available to insured patients with no copay — such as the many preventive services for women that are now covered — requires that that list of services be based on the U.S. Preventive Services Task Force’s evidence-based recommendations. Although AHRQ and USPSTF aren’t exactly the same thing, it gives opponents a chance to confuse voters by conflating evidence-based reviews to inform care with rationing to limit care.
Likewise, when funding for comparative effectiveness research — primarily conducted through AHRQ — was included in the 2009 stimulus bill, it kicked off conservative outcry about “rationing” of care. A political analyst for Consumers Union called that outcry ”a very clever effort by a bunch of well-paid lobbyists funded by people who don’t want the American people to know some pills work better than others.”
And that brings us to a second reason. Comparative effectiveness research can identify where highly advertised expensive new drugs or treatments aren’t any more effective than less expensive therapies or placebo. For example, a recent AHRQ review concluded that the heavily advertised drugs for urinary incontinence may help less than basic lifestyle changes and may not provide enough benefit compared to placebo to offset the cost and side effects for many patients.
For another example of hostility toward evidence-based reviews, it was a similar process that resulted in the recommendation that women in their 40s who are not at high risk for breast cancer don’t necessarily need regular mammograms – a finding that makes a lot of sense based on the medical evidence, but was controversial both among health care institutions getting paid for doing mammograms and the giant, screening-focused Komen organization.
So the pharmaceutical industry, health care lobbyists, and other associations with vested interests might have a pretty strong interest in minimizing research that could negatively affect industry bottom lines. Both major political parties take a lot of money from pharmaceutical companies, which might be why we haven’t heard as much political opposition to this move as you might expect.
Some expert health professionals, though, have not been so quiet on the proposed elimination. The American Academy of Family Physicians wrote a letter urging Congress not to defund the agency, calling the move, “pennywise and pound foolish,” and pointing out that “this research helps Americans get their money’s worth when it comes health care. We need more of it, not less.” The president of the Association of American Medical Colleges has also spoken out against the provision.
In a recent op-ed in the Philadelphia Inquirer, Jeffrey C. Lerner, president of the ECRI Institute (a center that does evidence-based medicine research for AHRQ), explains the value of AHRQ’s work for patient safety and effective health care and notes that this isn’t the first political attempt to kill the agency. He asks an essential question — “Why is objective information so threatening?” — and goes on to write:
The answer is that objective information shakes up the status quo. Many constituencies think objective information is information that supports their perspective, and are resistant to change, no matter what the evidence shows. So, truly objective information is a very dangerous weapon.
But it is tough to argue publicly that objectivity is bad, so a time bomb is buried in this House bill in an attempt to avoid having to first openly engage the public in a national debate on the best ways to improve quality and reduce unnecessary expenditures.
How will we find out what quality is and how will we find out what unnecessary expenditures are? Without AHRQ, we won’t.
It’s not completely clear what will happen next in the effort to defund AHRQ, as the 2013 spending decisions will be delayed until after the presidential election. It’s worth keeping an eye on, though, and we’ll update as this moves forward.
[Disclosure: some of my work involves systematic reviews/comparative effectiveness research funded by AHRQ.]
Countdown to Coverage is a campaign to help women understand the concrete ways that the Affordable Care Act can improve our health. This blog entry is the first in a series designed to answer the question, What’s in it for women?
by Leana S. Wen, MD
As an emergency physician, I tend to work on the other side of preventive care services. I see what happens when women don’t know about safer sex and birth control, and end up with complications from sexually transmitted infections. I see what happens when women do not get routine screening for cervical cancer and struggle with life-threatening cancer. I see what happens with out-of-control hypertension and diabetes, and the heart attacks and strokes that are detected far too late.
These experiences have shown me that prevention is the best medicine. That’s one big reason why the Affordable Care Act provision requiring new insurance plans to cover women’s preventive care without any extra charges or co-pays is a real victory for women. These requirements, which go into effect Aug. 1, will be phased into existing insurance plans over time.
Because of this change, women will be able to obtain complete contraceptive care, screening for sexually transmitted infections, and screening and counseling for intimate partner violence. This builds upon earlier requirements that insurance companies cover — at no additional cost to women — mammograms and screenings for cervical cancer. It’s clear to me that these mandates will significantly improve women’s health and lives and ultimately lead to a reduction in health care costs.
The Well-Woman Visit One of the easiest ways to obtain preventive services is through a well-woman visit. These visits, which will soon be covered with no co-pay, give you the opportunity to ask key questions about birth control, sexually transmitted infections, and other reproductive issues, along with questions about diet and exercise and any health concerns you may have. You can also discuss changes in your family’s medical history that are important for your health care provider to consider. For example, when my mother was diagnosed with breast cancer, my doctor recommended that I get earlier screenings.
Along these same lines, your health care provider may have questions or issues to discuss with you. Smoking, drinking and recreational drug use can create and contribute to health problems, and often need to be discussed and addressed multiple times before change happens. Well-women visits also give your health care provider a chance to screen for potential high blood pressure, diabetes, depression, domestic violence, and more.
The well-woman visit is important for another reason: It gives you and your health care provider a chance to get to know each other. Most people go to their provider or to a clinic only when there’s a problem, but the best time to get to know your provider isn’t when you’re in distress from a painful or troublesome condition. Studies have shown that health care providers make more accurate diagnoses when they know their patients and can put the symptoms in the context of your life. A well-woman visit is a precious opportunity to build this trusted relationship.
As an emergency physician, I am excited about the new provisions taking effect Aug. 1, which include annual well-women visits for those who want them. I would much rather women regularly visit their health care providers than come to the E.R. later suffering from preventable problems. So please take this opportunity and make an appointment with your provider. The importance of investing in your health is too crucial to ignore.
Plus: Want to learn more about the Affordable Care Act? These resources from Countdown to Coverage provide detailed information about coverage for women, including specific information for LGBT people, women of color, young women, older women, moms and families, and more.
Leana S. Wen, M.D., is an emergency physician at Brigham & Women’s Hospital and Massachusetts General Hospital and a clinical fellow at Harvard Medical School. She is the author of a forthcoming book on patient advocacy, “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.” For more information, visit her blog When Doctors Don’t Listen or her website. You can also follow her on Twitter @DrLeanaWen.
The National Latina Institute for Reproductive Health issued a press release, Supreme Court decision means health care access for Latinas, calling the decision “a significant victory for Latinas, who are more likely than other groups to face structural barriers that prevent them from accessing health care and preventive services.” They also note, however, that works remains to be done and many immigrants still lack access to essential care.
Physicians for Reproductive Choice and Health’s board chair Douglas Laube released a statement for the organization, writing:
Thanks to today’s ruling, we can move closer to the day when our patients won’t go without basic medical care because they can’t pay for it. The Affordable Care Act has already begun to change health insurance in the United States for the better, doing away with pre-existing conditions, gender-rating (making insurance more expensive for women than men), and other practices that have hurt women’s health.
• More than 45 million women have already received coverage for preventive health screenings at no cost since August 2010 thanks to the Affordable Care Act – including mammograms and Pap tests – and millions more will be able to get free screenings in the coming years.
• 3.1 million young adults have already been able to stay on their parents’ insurance because of the Affordable Care Act. In the next year, millions more who would have otherwise lost coverage will continue to be insured under their parents’ plan.
• Women are guaranteed direct access to ob/gyn providers without a referral, as a result of the Affordable Care Act.
• Starting in August, birth control will be treated like any other preventive prescription under the Affordable Care Act, and will be available without co-pays or deductibles.
I think it’s important — because I watched some of the commentary last week — to remind people that this is not an abstract argument. People’s lives are affected by the lack of availability of healthcare, the inaffordability of healthcare, their inability to get healthcare because of preexisting conditions.
The law that’s already in place has already given 2.5 million young people healthcare that wouldn’t otherwise have it. There are tens of thousands of adults with preexisting conditions who have healthcare right now because of this law. Parents don’t have to worry about their children not being able to get healthcare because they can’t be prevented from getting healthcare as a consequence of a preexisting condition. That is part of this law.
And, as of 2014, adults would also be protected. Women could no longer be denied coverage based on pre-existing conditions such as pregnancy or domestic violence. The law would also eliminate gender rating, in which women end up paying more than men for insurance coverage.
Millions of seniors are paying less for prescription drugs because of this law. Americans all across the country have greater rights and protections with respect to the insurance companies, and are getting preventive care because of this law.
So, that’s just the part that’s already been implemented. That doesn’t speak to the 30 million people who stand to gain coverage once it’s fully implemented in 2014.
And I think it’s important, I think the American people understand and I think the justices should understand that in the absence of an individual mandate, you cannot have a mechanism to ensure that people with preexisting conditions can actually get healthcare.
We have to wait until sometime in June to find out if Obama is right, but there’s been no shortage of guess work underway to determine 1.) whether the Supreme Court will uphold the individual mandate requiring almost every American to buy health insurance; and 2.) what will become if health care reform if it does not.
Writing in The New Yorker, Jeffrey Toobin notes that the “heavy burden” of justification for the mandate — which Justice Anthony M. Kennedy asked Donald Verrilli, the solicitor general, to address — should instead be placed on the law’s challengers.
“The involvement of the federal government in the health-care market is not unprecedented; it dates back nearly fifty years, to the passage of Medicare and Medicaid,” writes Toobin. “The forty million uninsured Americans whose chances for coverage are riding on the outcome of the case are already entered ‘into commerce,’ because others are likely to pay their health-care costs.”
“Acts of Congress, like the health-care law, are presumed to be constitutional,” he later adds, “and it is—or should be—a grave and unusual step for unelected, unaccountable, life-tenured judges to overrule the work of the democratically elected branches of government.” Toobin then demonstrates how the justices’ questions reflected a troublesome meddling in policies set by Congress.
The Individual Mandate – A Not-So-Brief History
The individual mandate, as explained in this NPR story, has Republican roots dating back to 1989. Rachel Maddow discussed the party-line history during a recent segment, summed up as: “When Republicans proposed it — great idea, a conservative solution. When a Democrat has the idea, it’s socialism, tyranny and unconstitutional.”
Though Republicans circa 2012 would like Americans to believe the individual mandate is indeed “unprecedented,” Linda Greenhouse, who covered the Supreme Court for The New York Times for 30 years and who now writes a column on legal issues, applies the description to the politics of this debate:
What’s unprecedented is the singular determination of the Republicans both on Capitol Hill and in the statehouses to deprive President Obama of his major domestic achievement. Republican officeholders in all 26 states joined together in the case now known as United States Department of Health and Human Services v. State of Florida. In 22 of those states, the officeholder was the attorney general. In four states with Democratic attorneys general (Nevada, Wyoming, Iowa and Mississippi), Republican governors filed in their own names. If any of them noted any irony in the fact that not so long ago, the individual mandate was an idea cooked up by conservative policy wonks to counter more fundamental reform sought by the Clinton administration, they offer no sign.
The countless unprecedented things that Congress has done over the centuries were not, for that reason, unconstitutional. Social Security, Medicare, the Employee Retirement Income Security Act (Erisa), and the Emergency Medical Treatment and Labor Act, the 1986 law passed to prevent hospitals from refusing to care for uninsured patients in acute distress, all come to mind. (From the perspective of today’s toxic politics, it’s a miracle that any of these laws actually got passed, but that’s a separate issue.) So there must be some problem with the Affordable Care Act other than “never before.”
There are other federal mandates involving health care already on the books, including the Medicare payroll tax on workers and employers, and the 1996 Newborns’ and Mothers’ Health Protection Act, which requires plans offering maternity coverage to pay for at least a 48-hour hospital stay (96 hours following a c-section).
Isn’t It Ironic (Don’t You Think)
Some Republicans who can’t help but fly into an apoplectic rage upon hearing the term “mandate” in the context of health care reform remain surprisingly calm when mandating medical procedures for women.
Yes, I’m referring to government-mandated ultrasounds. Currently, seven states — most recently Virginia — mandate that an abortion provider perform an ultrasound on a woman seeking to have an abortion. These states, along with more than a dozen others, also require the provider to ask the woman if she’d like to view the image.
The Guttmacher Institute notes: “Since routine ultrasound is not considered medically necessary as a component of first-trimester abortion, the requirements appear to be a veiled attempt to personify the fetus and dissuade a woman from obtaining an abortion. Moreover, an ultrasound can add significantly to the cost of the procedure.”
The Road Ahead
The question of whether other parts of the Affordable Care Act can proceed without the individual mandate will continue to be debated until June. If the mandate alone is struck, insurance premiums would likely increase because insurance companies won’t have the built-in benefit of a broader insurance pool.
“Republicans would blame Obama for making health insurance more expensive. Democrats would blame insurers for the higher premiums. In other words: Déjà vu and total gridlock,” writes Jennifer Haberkorn of Politico. Her story explains what’s likely to happen if the Supreme Court strikes just the mandate, or the mandate and insurance reforms, along with the political fall-out if most of the law falls or is upheld.
Josh Gerstein, also of Politico, looks at the effects beyond health care reform: “If the justices knock out key parts of the law or bring down the whole thing, the reverberations could be felt across the legal landscape for generations to come, radically reining in the scope of federal power, according to supporters of the law and others who closely track the high court. And if the justices decide the individual mandate is a constitutional overreach, these observers say, federal labor and environmental laws could be the next on the firing line.”
If you think that seems too dire a prediction, consider Dahlia Lithwick’s reaction to comments made by the court’s conservative justice’s last week: “[A]s the justices pondered whether the individual mandate—that part of the Affordable Care Act that requires most Americans to purchase health insurance or pay a penalty—is constitutional, we got a window into the freedom some of the justices long for. And it is a dark, dark place.”
Those who would welcome the disintegration of health care reform include The Cato Institute’s Michael Cannon. He told NPR that if the entire law were to go away, “we would have just dodged this whole nasty debate over religious freedom and abortion.”
Meaning: There would be no increased access to preventive health care such as contraception, breastfeeding support, and screening for breast and cervical cancers and HIV. But hey, women’s health is so darn offensive when you get down to it, better to just cast it off. Thanks, but we’ve been there.
On the other hand, maybe a defeat at the hands of the Supreme Court will open new doors, for everyone.