Publicado por Rachel / del orginial en inglés: January 21, 2009

OBOS is committed to expanding our audience and in this spirit we’ve asked former board member Moises Russo to translate into Spanish several of our blog entries. We hope to translate more entries in the coming year.

En OBOS estamos comprometidos a expandir nuestra audiencia de lector@s  y en este espíritu le hemos solicitado a Moisés Russo, ex-miembro de la Junta de OBOS, que traduzca al español varios de los blogs que tenemos en la página electrónica. Esperamos continuar con dichas traducciones durante este año.

Un informe dado a conocer este mes por el Instituto Southwest de Investigación sobre las Mujeres y el James E. Rogers Collage de Derecho en la Universidad de Arizona, ha expresado preocupación por el trato a mujeres que se mantienen en centros de detención de inmigración en Arizona.

El informe “Prisioneras Invisibles” (PDF), describe condiciones en tres instalaciones penitenciarias de Arizona. La información fue obtenida a través de entrevistas llevadas a cabo con mujeres actual y anteriormente detenidas en las instalaciones y a abogados y proveedores de servicios sociales “que han trabajado de cerca con mujeres detenidas en el estado”.

Las demoras en recibir servicios médicos, cuidados inadecuados, y la falta de atención a los asuntos de salud mental son algunos de los problemas descritos. Los alegatos incluyen la negación de una bomba mamaria (sacaleche) a una mujer que se encontraba separada de su lactante, el rechazo a proveer vitaminas prenatales, una mujer con cáncer cervicouterino con meses de espera para poder ser atendida por una enfermera y una mujer que había sido víctima de mutilación genital femenina y que estaba teniendo dolor abdominal severo a la cual se le dijo que debía “ejercitarse y cuidar su dieta”, cuando la verdadera causa del dolor era un gran quiste que necesitaba extracción quirúrgica.

Según un artículo del New York Times en el informe, “Katrina S. Kane, quien dirige las operaciones de detención y remoción para la Autoridad de Seguridad  de Inmigración y Aduanas de Arizona, descarto el estudio como declaraciones faltas de evidencias de un número limitado de detenidas y sus abogados”.

Ella también afirmó que las denuncias de que una detenida no había recibido tratamiento para cáncer cervicouterino son falsas. Según el Times, un abogado de inmigraciones que tomó parte en el estudio “contrarrestó que las entrevistas con detenidas y mujeres anteriormente detenidas y sus abogados corroboraron el patrón de maltrato endémico”.

Last week, Raising Women’s Voices and Women of Color United for Health Reform delivered a letter [PDF] to House Speaker Nancy Pelosi, Senate Majority Leader Harry Reid and several committee chairs on health care reform. The letter — signed by Our Bodies Ourselves and many other supporting organizations — thanks these leaders for their support of healthcare reform and provides recommendations related to women’s health for inclusion in the final legislation.

The signing organizations believe that the final legislation must not add new barriers or burdens to women’s access to abortion coverage and should eliminate the controversial Nelson/Stupak amendments. Instead, they argue, the legislation should return to the Capps amendment [PDF], which “preserves the ban on use of federal funds for abortion coverage, but does not exclude abortion from private insurance policies for which women will be using their own funds.” (See the Planned Parenthood Action Center for a good discussion of the three provisions.)

The groups also recommend a requirement that women’s preventive health services and screenings be covered without co-pays or deductibles; coverage of more people through expansion of Medicaid eligibility; establishment of an “exchange”; coverage for legal immigrants without a five-year waiting period; and making coverage more affordable while keeping penalties for violating coverage mandates less burdensome for low-income people.

The letter also expresses support for expansion of translation/language services; bringing Medicaid payment rates up to the same level as Medicare payments (in order to increase the number of providers accepting Medicaid); and a mandate that all Health and Human Services agencies collect data on ethnicity and primary language along with gender, race and other categories .

RWV is also running a cartoon postcard campaign to encourage people to contact their legislators and express their dissatisfaction with current versions of health care reform.

Related: The Center for Reproductive Rights recently released a video questioning the singling out of abortion for restriction in health reform legislation. The video asks what else an individual might not want to pay for with their own tax dollars. Watch it below, or read the transcript at Feministe.

The federal Office of Minority Health is requesting comments on its National Plan for Action, which describes the current state of health disparities in the United States and proposes strategies for their elimination.

The Plan was developed following regional meetings in 2007-2009, during which:

Twenty common strategies were defined and organized around five core areas for improvement: awareness, leadership, health and health system experiences, cultural and linguistic competency, and coordination of research/evaluation. The Plan provides a roadmap – a starting point – of the collaborative strategies and collective actions. The information provided should serve as a menu from which specific actions at the neighborhood/area, community, state, tribal, regional, and national levels can be advanced.

Comments can be general or specific, with links provided at the end of each chapter for submission of more specific remarks. Comments are being accepted through February 12, 2010.

The second chapter, The Current Context, may also provide a good reference for anyone looking for data on/descriptions of existing health disparities, including a number of charts presenting rates of disease and health risk factors by race/ethnicity.

[Hat tip to Siobhan at Bringing Health Information to the Community]

That’s the topic of this live, interactive webcast, scheduled for today – Wednesday, Dec. 16 — at 1 p.m. ET.

Sponsored by the Kaiser Family Foundation, the webcast will examine aspects of the current Senate and House health reform bills that particularly affect women of color, who face additional health and access challenges.

You can join the live webcast here. An archived version, as well as a podcast and transcript, will be available later today.

Today’s panel will also address provisions in the bills that would affect access to and coverage of abortions, and recent findings from the U.S. Preventive Services Task Force.

Cara James, KFF senior policy analyst on race, ethnicity and health care, will moderate the discussion with:

• Alina Salganicoff, Ph.D., vice president, director, Women’s Health Policy, Kaiser Family Foundation
• Judy Waxman, J.D., vice president of Health and Reproductive Rights at the National Women’s Law Center
• Paula Johnson, M.D., M.P.H., executive director of the Mary Horrigan Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital and associate professor of Medicine, Harvard Medical School

Panelists will take questions before or during the live program. Send questions to ask [at] kff.org.

The webcast is part of KFF’s series examining current issues in health disparities.

Healthy People is a program of the U.S. Department of Health and Human Services that sets health objectives for the nation for a ten-year period. The current set of objectives is referred to as Healthy People 2010, but as 2010 is fast approaching, the department is considering a new set of health priorities to target through 2020.

The objectives typically cover preventable disease, increasing quality and length of life, and the elimination of health disparities across a range of focus areas. For example, Healthy People 2010 included an objective to “Reduce cesarean births among low-risk (full term, singleton, vertex presentation) women” and provided a 15% target c-section rate for first births, and 63% for births after previous cesarean. This target has not been met, with the CDC data from 19 states indicating that in 2006 – the most recent year of finalized data currently available – 23.5 of every 100 first, live births was by cesarean, and repeat cesarean rates were about 92%. It has been included again as-is for the 2020 objectives.

The agency is now accepting public comments on the proposed 2020 objectives. For each focus area (such as access to health services, maternal, infant, and child health, cancer, etc.), you can review objectives retained as-is, modified or dropped from the HP2010 goals, as well as clearly seeing objectives new to HP2020. You can then comment directly on an individual objective, and review comments already submitted.

A few examples of new objectives that may be of interest to readers:

• Decrease incidence of late-stage disease breast cancer.
• Increase the percentage of women in need of publicly supported contraceptive services and supplies who receive those services and supplies.
• Increase the percentage of employers who have worksite lactation programs.

There are many, many others which Our Bodies Our Blog readers may want to review and comment on, in focus areas such as maternal health, disability, cancer, older adults, sexually transmitted infections, adolescent health, family planning, violence prevention, and environmental health. You can create a profile on the site, or choose to view objectives and comment anonymously. Comments are being accepted through December 31, 2009.

Today pro-choice folks are converging on D.C. for a National Day of Action to support health care reform that includes a full range of reproductive health services for women and to oppose the Stupak Amendment, which prohibits abortion coverage in any public option and creates bureaucratic hurdles that could make it difficult for women to pay for abortion coverage with their own money.

Christine has written about the amendment several times on this blog, and the NPR pieces linked above also provide good background info.

Supporters include Planned Parenthood, NOW, YWCA, Choice USA, the Religious Action Center of Reform Judaism, NARAL Pro-Choice America, the Center for Reproductive Rights, the American Association of University Women, the Religious Coalition for Reproductive Choice, the ACLU, and others. Each of these organization websites has information on the basic schedule for the day, background materials on the issue, and tips for/ways of taking action for those not in D.C., including petitions, draft emails, and guidance for making phone calls to Senators/Representatives.

Tweets from the event can be followed at #stopstupak. Have photos or reports from the scene? Let us know in the comments!

New government guidelines recommending that women start screening for breast cancer at age 50 instead of 40 set off a round of criticism this week and caused much confusion for women who for years have been told that early detection saves lives.

But a number of women’s health organizations, including Our Bodies Ourselves, the National Women’s Health Network and Breast Cancer Action, for years have warned that regular mammograms do not necessarily decrease a women’s risk of death. Premenopausal women in particular are urged to consider the risks and benefits.

In fact, the NWHN issued a position paper in 1993 recommending against screening mammography for pre-menopausal women. It was a very controversial position at the time — even more so than now. The breast cancer advocacy movement was in its infancy and efforts were focused on getting Medicare and insurance companies to cover mammograms. What the NWHN found — and other groups have since concurred — is that the potential harm from screening can outweigh the benefits for premenopausal women.

That statement is tricky, and based on the poor explanations I’ve seen that fail to specifically address the potential dangers, it’s no wonder women are frustrated. Some are even questioning whether the guidelines were unveiled as a cost-cutting measure — a sign of the “rationing” to come under health care reform. In addition to delaying routine screening until age 50, the guidelines recommend screening women between the age of 50 and 74 every two years. It’s important to keep in mind this is intended for women with no known risk factors; women in high-risk groups should start earlier, and it may be prudent to schedule more frequent mammograms.

Adding to the confusion, cancer groups are split. The American Cancer Society came out strongly against the new guidelines. The National Cancer Institute, meanwhile, said it would reconsider its own recommendations in light of new studies. Some doctors said they would proceed cautiously before revising screening advice for patients.

I don’t believe the new guidelines are politically motivated, nor are they “patronizing” to women simply because they call into question the stress related to biopsies and false positive results. Rather, the guidelines provide a useful framework for helping each of us to decide when is the best time to begin screenings and the intervals at which they should be repeated.

The guidelines are in sync with international recommendations; the World Health Organization recommends starting screening at age 50, and in Europe, mammograms are given to post-menopausal women every other year and detection rates are similar to the United States. During an interview on MSNBC on Tuesday, breast cancer expert Dr. Susan Love said the government’s guidelines bring us into line with the rest of the world and with current research. (Read more at her blog.)

You might be thinking: Wait a moment, isn’t earlier better? Why would delaying detection be in my best interest? I’m going to explain why, but let’s first take a closer look at the guidelines, which were released by the U.S. Preventative Services Task Force (USPSTF), an independent panel of experts in prevention and primary care. (The task force operates under the Agency for Healthcare Research and Quality, the research arm of the U.S. Department of Health and Human Services.)

The guidelines are an update of the 2002 USPSTF recommendation statement, which called for mammograms every one to two years, starting at age 40. Dr. Alfred Berg of the University of Washington, who chaired the task force in 2002, told The New York Times this week, “We pointed out that the benefit will be quite small.” He added that while older women experience the most benefits from the screening, mammograms still prevent only a small percentage of breast cancer deaths.

Breast cancer is the second-leading cause of cancer-related deaths in women (lung cancer is number one). According to the National Cancer Institute, about 192,370 women will be diagnosed with breast cancer in 2009, and 40,170 women will die of the disease this year. A woman who is now 40 years old has a 1.44 percent chance of being diagnosed with breast cancer over the next 10 years.

For the 2009 update, the panel, now with different members, examined the role of five screening methods in reducing breast cancer mortality rates: film mammography, clinical breast examination, breast self-examination, digital mammography, and magnetic resonance imaging. It also commissioned two studies:

1.) A targeted systematic evidence review of six selected questions relating to benefits and harms of screening.

2.) A decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals.

Here is the summary of the task force’s findings, published in the Annals of Internal Medicine. The grades are explained here; A is the highest recommendation (meaning there’s a high certainty the benefits are substantial), and D is the lowest. A rating of I indicates evidence is insufficient or conflicting.

The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms. This is a C recommendation.

The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. This is a B recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. This is an I statement.

The USPSTF recommends against teaching breast self-examination (BSE). This is a D recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. This is an I statement.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. This is an I statement.

Dr. Diana Petitti, a professor of biomedical informatics at Arizona State University and vice chair of the current task force, told The New York Times the panel knew the recommendations would surprise many women, but, she said, “We have to say what we see based on the science and the data.”

Frankly, I was surprised by the conclusion that self breast exams are not considered useful. News stories this week have included many anecdotes from women who found a lump that turned out to be cancerous, and every doctor I heard interviewed said that women should definitely contact their physician if they notice any changes in their breast. But what we’re learning is that feeling our own breasts for lumps is not statistically effective, and women who do self breast exams get twice as many biopsies.

The World Health Organization concurs: “There is no evidence on the effect of screening through breast self-examination (BSE). However, the practice of BSE has been seen to empower women, taking responsibility for their own health. Therefore, BSE is recommended for raising awareness among women at risk rather than as a screening method.”

Around 37 million mammograms are done each year. So what’s the problem there? For starters, mammograms use low-dose X-rays to examine the breast, and exposure to radiation can have a cumulative effect on the body. And they’re imperfect. About half of all premenopausal women, and one-third of postmenopausal women, have dense breasts, which makes their mammograms more difficult to read.

Mammograms produce false-positive results in about 10 percent of cases, leading to anxiety that can last for years, unnecessary and sometimes-disfiguring biopsies, and unneeded treatment, including surgery, radiation and chemotherapy — each of which present their own complications and health risks, including an increased risk of other cancers and heart disease.

According to the National Breast Cancer Coalition, U.S. estimates show a woman’s cumulative risk for a false-positive result after 10 mammograms is almost 50 percent. The risk for undergoing an unnecessary biopsy is almost 20 percent. Barbara Brenner, executive director of Breast Cancer Action, told me last year that research indicates that having more biopsies increases the risk of breast cancer, though the reason is unclear (read my post here).

Women are constantly being told “early detection saves lives,” but in reality we know some breast cancers, by the time they’re found, cannot be treated. Other cancers will never be life-threatening, and some will respond to currently available treatments. Unfortunately, the type of cancer cannot be determined at the time of diagnosis, which means we don’t know for sure whether the treatment will cause more harm than the cancer.

If you’re reading this and thinking you still want to keep that scheduled mammogram, you should certainly do so.

“No one is saying that women should not be screened in their 40s,” said Petitti, the task force vice chair. “We’re saying there needs to be a discussion between women and their doctors.”

Dr. Amy Abernethy of the Duke Comprehensive Cancer Center said she agrees with updated recommendations.

“Overall, I think it really took courage for them to do this,” she said. “It does ask us as doctors to change what we do and how we communicate with patients. That’s no small undertaking.”

Finally, I want to address the insurance question. At this point, insurance companies and Medicare administrators are saying that they will continue to pay for mammograms. Here’s what may change in the future, according to The New York Times:

The guidelines are not expected to have an immediate effect on insurance coverage but should make health plans less likely to aggressively prompt women in their 40s to have mammograms and older women to have the test annually.

Congress requires Medicare to pay for annual mammograms. Medicare can change its rules to pay for less frequent tests if federal officials direct it to. Private insurers are required by law in every state except Utah to pay for mammograms for women in their 40s.

But the new guidelines are expected to alter the grading system for health plans, which are used as a marketing tool. Grades are issued by the National Committee for Quality Assurance, a private nonprofit organization, and one measure is the percentage of patients getting mammograms every one to two years starting at age 40.

That will change, said Margaret E. O’Kane, the group’s president, who said it would start grading plans on the number of women over 50 getting mammograms every two years.

For more information, here are some good stories and links:

NPR: All Things Considered looks at the research.

Washington Post: A good overview of the guidelines and cost controversy.

ScienceBlogs: “From my perspective, these new recommendations are a classic example of what happens when the shades of gray that make up the messy, difficult world of clinical research meet public health policy, where simple messages are needed in order to motivate public acceptance of a screening test,” writes Orac. “It’s also an example where reasonable researchers and physicians can look at exactly the same evidence for and against screening at different ages and come to different conclusions based on a balancing of the potential benefit versus the cost.”

Last week, the CDC issued revised vaccination criteria for U.S. immigration which will reverse the requirement that female immigrants seeking permanent residence or entry to the U.S. be immunized against HPV.

The new criteria require that any mandated vaccine must be age-appropriate for the immigrant applicant, and must either protect against a disease that has the potential to cause an outbreak or protect against a disease that has been eliminated or is in the process of being eliminated in the United States. As HPV does not meet these criteria, the vaccine will no longer be required starting next month (30 days after publication in the Federal Register).

We have written several times about the requirement, including the CDC’s initial comment on the matter and various action alerts/campaigns asking the agency to reverse the requirement.

As we and others noted, the requirement was problematic for multiple reasons, such the lack of an opt-out provision (in contrast to requirements for U.S. citizens), the expense of the series, the lack of significant public health risk posed by omitting this vaccine, and the vulnerability of the affected population.

In the revised criteria document, published in Friday’s Federal Register, HPV vaccination is specifically addressed as follows:

CDC has applied the criteria and determined that once these criteria become effective December 14, 2009, the HPV vaccine will not be required for aliens seeking admission as an immigrant or seeking adjustment of status to that of an alien lawfully admitted for permanent residence….Therefore, while HPV may be an age-appropriate vaccine for an immigrant applicant, HPV neither causes outbreaks nor is it associated with outbreaks (per explanation in the background section). Further, HPV has not been eliminated, nor is in the process of elimination, in the United States. Therefore, because HPV does not meet the adopted criteria, it will not be a required vaccine for immigrant and adjustment of status to permanent residence applicants.

Under the new criteria, the zoster (chicken pox) vaccine will also be removed from the requirements. The agency continues to recommend the two vaccines for U.S. citizens, but vaccine recommendations will no longer be automatically translated to mandates for immigration.

The National Latina Institute for Reproductive Health, the National Asian Pacific American Women’s Forum, and California Latinas for Reproductive Justice issued a statement commending the agency for the change and for “recognizing that all women and girls—regardless of their immigration status—must be treated with dignity in the context of any medical procedure, including the HPV vaccine.”

An Arizona woman’s dispute with her local hospital over its refusal to allow a VBAC (vaginal birth after cesarean), even though she has already undergone a VBAC at the same hospital, has caught the attention of CNN, which featured the story on its homepage today.

Joy Szabo, 32, told CNN she is grateful for the c-section performed during her second delivery, when doctors feared the baby wasn’t getting enough oxygen, but her third son was a vaginal birth and she thought this delivery would be, too (assuming there were no complications). Page Hospital has since changed its policy and no longer allows VBACs.

VBACs carry a less-than-1-percent increased risk of a uterine rupture, which could cause brain damage in the baby or even death, according to the American College of Obstetrics and Gynecologists. Childbirth Connection, a nonprofit organization that advocates for evidenced-based maternity care, notes that research “suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries.”

C-section risks to the baby include breathing problems around the time of birth and asthma later in life. The mother is at greater risk for more severe pain and infection. The bottom line, based on the latest research, is that if you “do not have a clear and compelling need for a cesarean in the present pregnancy, having a VBAC rather than a repeat c-section is likely to be safer for you in this pregnancy (and) far safer for you and your babies in any future pregnancies,” according to Childbirth Connection.

“I know there’s a risk with a VBAC, but we think the risks of surgery are worse,” said Joy Szabo. “And I don’t want to have to recover from surgery when I’ll have four children at home, at least not voluntarily.”

From CNN:

After their discussion with their doctor, the Szabos made an appointment to speak with Page Hospital’s CEO, Sandy Haryasz. When the couple told her about their desire for a vaginal birth, they say Haryasz would not budge, even telling them she would get a court order if necessary to ensure Joy delivered via C-section.

“I was a bit flabbergasted, because that seemed rather extreme,” Joy says. “I’d already had a VBAC at Page and it went fine. And if something happened, I know they can do an emergency C-section, because they did one for Michael.”

At issue are ACOG’s recommended guidelines concerning physician and anesthesiologist staffing for VBACs. Banner Health, which owns Page Hospital, released a statement that said ACOG guidelines recommend “24/7 coverage of both physician and anesthesiologist,” and that “two physicians be immediately available during the entire period of labor.” But an ACOG spokesperson disputed that interpretation, noting that physician and anesthesia availability are only two criteria to consider.

Still, ACOG’s guidelines have scared many hospitals away from allowing VBACs (which in turn has inspired suggestions on how to protest a VBAC denial). International Cesarean Awareness Network conducted a survey earlier this year of 3,000 hospitals and found that 821 ban VBACs outright, and and 612 have “de facto” bans, meaning surveyors were unable to identify any doctors practicing at the hospital who would provide VBAC support.

The information gathered led to the creation of a VBAC Policy Database, which can be searched by VBAC policy, or browsed by state.

Another report, Hospitalizations Related to Childbirth, which examined data on childbirths occurring in U.S. community hospitals in 2006, found that childbirths by c-section increased from 21 percent  in 1997 to 31.6 percent in 2006, a jump of 51 percent. Meanwhile, there was a 73 percent decline in VBACs, from 35 percent of childbirth-related hospitalizations in women with a previous c-section in 1997 to almost 10 percent in 2006. (Rachel discusses the report here.)

As for the Szabos, rather than agree to a surgical delivery regardless of medical need, Joy Szabo plans on driving 350 miles a week or so before her Nov. 21 due date to be near a hospital in Phoenix that will allow a VBAC. It is unlikely her husband, Jeff, who is staying behind with their three sons, will be able to make it to the hospital for the delivery.

The Szabos’ story was first covered by a local newspaper, the Lake Powell Chronicle (via The Unnecessrean), and has caused an uproar. It’s unlikely we’ve heard the last of this …

For more reading:
In addition to visiting Childbirth Connection, “Our Bodies, Ourselves: Pregnancy and Birth” has a section on VBACs and repeat c-sections. Lamaze International also offers articles on healthy birth practices supported by research studies examining the benefits and risks of maternity care practices.

The Senate Finance Committee today began its mark up on the health care overhaul bill put forth by Sen. Max Baucus (D-Mont.). C-SPAN is covering it live; you can watch streaming video here.

Baucus, chair of the committee, seemed to anger all Republicans and Democrats when he released a bill last week that was more conservative than what most Democrats in Congress wanted, yet not conservative enough for any Republican to sign on.

Other committee members have since contributed 534 amendments (here they are, in a 348-page document [pdf]), including three different amendments calling for a public health insurance option to compete with private insurers.

*A recent survey of more than 5,000 doctors by the Robert Woods Johnson Foundation found that the overwhelming majority support expanding health care coverage to include both public and private insurance options. Baucus’s bill shuns the public option in favor of co-ops, which are not considered much of a threat to the insurance industry.

Baucus also faces criticism on funding.

Richard J. Kirsch, national campaign manager of Health Care for America Now, told The New York Times: “The tax credits in the original Baucus plan were so low they would make premiums unaffordable for many moderate- and middle-income people, who could also face high out-of-pocket costs. And if they don’t pay the premiums, they might have to pay a fine.”

Baucus (above left, greeting the committee’s ranking Republican, Sen. Charles Grassley of Iowa) has said he will make some modifications to the bill to provide more assistance to moderate-income Americans who need help buying insurance.

The Amendments

Igor Volsky at Wonk Room breaks down some of the most important amendments into categories for coverage, financing and delivery reforms. View the complete list here.

Volsky’s charts also include some of the more outrageous Republican amendments, such as this gem from Sen. John Kyl (R-Ariz.): “Prohibit the federal government’s takeover of health care.”

Ezra Klein, who previously described the Baucus bill as “a very good platform with some very severe failings,” offers five recommendations to improve it, including phasing in Sen. Ron Weyden’s Free Choice amendment and creating real competition for insurance companies. Klein also prepared a good summary of the amendments Sen. Olympia Snowe (R-Maine) has offered, including a public plan trigger.

About Abortion

Sen. Jay Rockefeller (D-W.V.) has proposed a number of useful amendments, including establishing a public insurance option and limiting out-of-pocket costs. But it’s his amendment #C6 (see page 12) that really intrigues me. A hero last week to progressives for his strong stance against a Senate bill that lacks a public option, Rockefeller disappointed many of those same advocates for denying women enrolled in the public plan access to abortion services:

This amendment would add a strong public health insurance option, the Consumer Choice Health Plan (CCHP), to the exchange to compete directly with private plans. Like private health plans, CCHP would be offered to all individuals and businesses purchasing health insurance through the national health insurance exchange. […] At a minimum, the Consumer Choice Health Plan would be required to follow the same insurance regulations as private plans operating in the exchange. CCHP would also be required to offer the same type of plans as private plans participating in the exchange.

Well, not exactly. The CCHP, according to Rockefeller, “shall not include abortion, except in cases of rape, incest, or the life of the mother. It also prohibits the expenditure of Federal funding for abortion and it requires the segregation of funds to ensure that no Federal dollars pay for abortions.”

Did you get the underlined points? His emphasis, not mine.

The Hyde Amendment, enacted in 1976, already prohibits spending federal dollars to pay for abortions for women on Medicaid. Rockefeller’s amendment would expand the restriction to all women who choose the public option.

The Center for Reproductive Rights is urging supporters to call members of the Senate Finance Committee and ask them to vote against anti-choice amendments. You can also contact your senators and ask them to stop anti-choice amendments from being included in the health care bill.

More good reading on health care reform and the abortion debate:
- Frances Kissling, “Exploiting the Healthcare Debate to Restrict Abortion”
- Molly M. Ginty, “Obama Fuels Battle Over Funds for Abortion”
- Politifact, a project of the St. Petersburg Times, is running a Truth-O-Meter on federal subsidies and abortion
- Rep. Lois Capps, “The Truth About the Capps Amendment”
- David Crary (AP), “Abortion-Rights Forces Vexed by Health Care Debate”

Baucus Bill is “Bunk for Women”

In a post at Raising Women’s Voices outlining five reasons why the Baucus bill is no good for women, Amy Allina writes that the bill “imposes politics and ideology on what should be a purely medical decision — the question about what services an insurance plan will cover. It singles out abortion for special exclusions, rather than treating it like other medical care, by adopting language that was developed by the House Energy and Commerce Committee as a compromise to prevent anti-choice legislators from using the health reform bill as a vehicle to impose sweeping new restrictions on abortion.”

Another reason: Under the Baucus bill, older Americas could pay up to five times as much as younger customers. The bills to come out of the House allowed only a 2:1 ratio.

“Women, who live longer on average than men, are more likely to bear the costs of this age rating,” notes Allina.

Doing away with any niceties, James Ridgeway, in a post titled “How the Baucus Plan Screws Older People,” writes that “the people who stand to get screwed most by the plan are those who aren’t old enough to qualify for Medicare, but are still old enough to be discriminated against by insurance companies.”

Ridgeway quotes Uwe Reinhardt, an economics professor at Princeton University, who estimates that the age rating will enable insurers to cover roughly 70 percent of the added risk they’ll take on by extending insurance coverage to everyone.

“You’re just using age as a proxy for health status,” said Reinhardt.

Maggie Mahar, author of “Money-Driven Medicine: The Real Reason Health Care Costs So Much,” breaks down even further who benefits when health insurance premiums are allowed to vary based only on tobacco use, age, family composition and where you live (allowing for differences in local cost of care).

She writes at HealthBeatBlog.com:

If you smoke, they can charge you 50 percent more; if you have children they can charge you 50% more than they would charge a childless couple, and if you are a single parent, they can charge you 80% more than they would charge a single adult. (Since children’s health care costs are, by and large, significantly lower than adults’ costs, that seems a pretty steep surcharge for the sin of single parenthood.)

I can imagine that some readers would say that it is only fair to charge smokers more. But consider this: the vast majority of adult smokers in the U.S. are poor. Many will qualify for full subsidies; others will be eligible for partial subsidies. So who will pay 50% more for their health care—you, the taxpayer. If he receives a subsidy, the 50% surcharge isn’t likely to induce a smoker to stop smoking. This is simply another way to funnel more taxpayer money to private sector insurers.

Single parents also tend to cling to the lower rungs of the income ladder. Many will qualify for at least a partial, if not a full subsidy. Who pays the extra 80%? That’s right—you and I.

Finally, if insurers can charge 50-somethings five times as much as they charge 20-somethings (who the Baucus plan refers to as “young invincibles”), a great many of them are going to need subsidies. More tax-dollars winging their way to Aetna.

There is, however, an exemption from the mandate for people over 50 if coverage is deemed unaffordable — which makes no sense, really, since this the time they’re likely to need health care more, not less.

As Mahar concludes, “Somehow, this isn’t what I thought they meant by ‘universal coverage.’”

The Dallas Morning News has an article on young people’s access to contraception in that state, which explains that:

Texas, a leader in teen pregnancy and the state where more teens give birth to subsequent children than in any other, maintains one of the most restrictive policies in the nation for minors to obtain prescription birth control. Not even young parents in Texas can get birth control without their own parents’ permission at nearly a third of the family planning clinics on contract with the state health department.”

(emphasis added, hat tip to the National Partnership for Women and Families)

The Des Moines Register has a great recent commentary from Sally Pederson and Joy Corning, former lieutenant governors of Iowa in which they respond to Rush Limbaugh’s apparent statement that “reproductive health care is abortion.” They list numerous other types of needed care for women’s reproductive health, discuss health care reform, and observe that “this kind of outrageous and polarizing language gets the listeners’ attention, but undermines the health care of millions of women and the thousands of health centers that serve them.”

Last week we presented Stephen Colbert’s hilarious send-up of the not-so-hilarious news that Wyeth pharmaceutical company had hired ghostwriters to write 26 scientific papers about hormone replacement therapy.

These articles, which emphasized the benefits of taking HRT and de-emphasized the risks, appeared in medical journals between 1998 and 2005. No coincidence that sales of Wyeth’s hormone drugs, Premarin and Prempro, soared, reaching nearly $2 billion in 2001. Usage began to drop in 2002, when the Women’s Health Initiative, a study of postmenopausal women, found surprisingly higher risks of heart problems and breast cancer in women taking hormone drugs.

More than 8,000 women have since sued Wyeth, claiming the hormone drugs caused them to develop illnesses. Lawyers for the women uncovered the ghostwriting documents, which were made public after a request in court from PLoS Medicine, a medical journal from the Public Library of Science, and The New York Times.

Natasha Singer broke the Wyeth story in Times, and in an excellent follow-up she focuses on a connected problem: doctors at medical schools attaching their names to articles written on behalf of drug companies.

“Allegations of industry-sponsored ghostwriting date back at least a decade, to scientific articles about fen-phen, the diet drug combination that was taken off the market in 1997 amid concerns that it could cause heart-valve damage,” writes Singer. “But evidence of the breadth of the practice has come to light only gradually, most recently in documents released in litigation over menopause drugs made by Wyeth.”

Court documents (above) include a description of DesignWrite’s plans for developing, writing and placing articles commissioned by Wyeth.

The practice has attracted the attention of Sen. Charles Grassley (R-Iowa), who has led investigations into conflicts of interest in medicine.

Grassley wrote a letter to Raynard Kington, the acting director of the National Institutes of Health, a federal agency that invests more than $30 billion in medical research each year, most of which is awarded through competitive grants to researchers at universities, medical schools and other research institutions.

In the letter, which was obtained by The New York Times, Grassley identifies researchers at Columbia University and University of Maryland who were recipients of NIH grants and who have signed on to ghostwritten publications. The senator asks the NIH to clarify its current policy on ghostwriting with regards to NIH-funded researchers and institutions.

Singer writes that with many of the nation’s top doctors depending on federal grants, “attaching fresh conditions to those grants could be a powerful lever for enforcing new ethical guidelines on the universities,” but NIH has, up to now, taken the same hands-off stance as many universities:

Many universities have been slow to react to evidence about the extent of the practice. In December, for example, Mr. Grassley released documents indicating that DesignWrite had drafted an article that was published under the name of a gynecology professor at New York University School of Medicine. Eight months later, a spokeswoman said the school had not looked into the matter.

These revelations are startling, especially considering how rigorous, independent scholarship is at the very core of a university’s mission. Here’s another example:

One of the authors discussed in DesignWrite documents is Dr. Michelle P. Warren, a professor of obstetrics and gynecology at Columbia. Her article was published in The American Journal of Obstetrics and Gynecology in 2004, when women feared that Wyeth’s brand of hormone drugs could be causing particular problems. The thesis of the article was that no one hormone therapy was safer than another.

The published article acknowledged help from four people. But it did not disclose that DesignWrite employed two of those people and the other two worked at Wyeth. Court documents show DesignWrite sent a prepublication copy to Wyeth for vetting and charged Wyeth $25,000 for the article, information not disclosed in the paper.

In a phone interview, Dr. Warren said the article was intended to clear up confusion over the risks of hormone drugs. She said she worked on the project in phone conversations and in meetings — contributions not reflected in the court documents, she added. She said that it was a mistake not to have disclosed the writers’ payment and affiliations in the acknowledgment; articles published today involve more detailed disclosures, she said.

DesignWrite scoured the scientific literature on hormone therapy for the article, she said. “I would never undertake this without some help,” said Dr. Warren, who is the Wyeth-Ayers Professor of Women’s Health at Columbia. “It’s too much work. I am not getting paid for it.”

Singer notes that Columbia instituted a new policy in January prohibiting “medical school faculty, trainees and students from being authors or co-authors of articles written by employees of commercial entities if the author’s name or Columbia title is used without substantive contribution.” It also requires “any article written with a for-profit company to include full disclosure of the role of each author, as well as any other industry contribution.”

Smart steps, but Columbia is late to make amends. The impact of years of medical professionals and patients relying on biased data is unknown.

Go read the full article, which includes comments from bioethicists understandably alarmed by how all this affects the reputation of respected academics and institutions. Kudos, too, to artist Minh Uong, for the wonderful graphic of medical research in air quotes. It’s a sad but fitting metaphor for the lack of trust.

In a piece for Seattle’s Crosscut, “Take away the incentives for too many c-sections,” Carolyn McConnell makes a case for reducing the seemingly ever-increasing rate of c-sections (currently ranging from 14-48% in that state) by reducing the financial incentives that may encourage physicians to perform them more than necessary.

McConnell explains that beginning this month, Washington state, through Medicaid reimbursements, will pay hospitals the same amount for an uncomplicated C-section as for a complicated vaginal birth. She notes that “Almost half of all births in Washington are paid by Medicaid, so this measure will have a significant effect on the economics of birth in the state.”

Until recently, the reimbursement policy seemed to favor c-sections; the author says:

On average, Medicaid pays $5,000 more for a C-section than for a vaginal birth, and private insurance pays a far greater premium. You don’t have to be a cynic to wonder if that could have something to do with the rise in unnecessary C-sections.

The state’s chief medical officer for Medicaid, Dr. Jeff Thompson, was interviewed for the piece. He explains that while there is no medical explanation for increasing rates of c-section, there’s no good way for the state to determine – for reimbursement purposes – which of those procedures were truly necessary. He explains that “Medicaid won’t pay for an unnecessary C-section, so hospitals have to code every section as necessary,” and that equalizing reimbursement for vaginal births and cesarean deliveries helps to eliminate the potential financial incentive to perform unnecessary procedures.

Thompson indicates that since the policy took effect, hospitals have been calling to request advice on revising protocols that help determine when a c-section should be performed – a sign that they may be changing their actions based on this simple change in reimbursement policy.

McConnell wonders what effect a similar nationwide approach might have, and concludes:

With C-sections accounting for 45 percent of the $86 billion the U.S. spends on childbirth each year, lowering the C-section rate could go a ways toward paying for President Obama’s goal of getting health coverage to everyone in the country. If Washington’s realignment of childbirth incentives works, it will be one piece of evidence that Obama’s rhetoric just might be right: Not only can we afford health care reform, we can’t afford not to do it.

McConnell also writes at the blog Rock the Cradle.

President Obama yesterday held an AARP-sponsored town hall on health care reform that was streamed live online — you can watch it now at the AARP website. A White House transcript is also available here.

If you scroll down about 2/3 of the way through the transcript, you’ll find that Obama was asked and answered another question along the lines of the “health reform = death for old people” rumors Christine addressed in a recent post. The audience member says, “I have been told there is a clause in there that everyone that’s Medicare age will be visited and told to decide how they wish to die.”

The comment refers to a section of the House reform bill that would provide for consultation every five years about advance care planning, including explanations of things like living wills and power of attorney that people may want to consider, as well as information about end-of-life services such as hospice and palliative care.

As the moderator of the town hall noted, “This is being read as saying every five years you’ll be told how you can die.”

Obama replied:

Well, that would be kind of morbid. I think that the idea in that provision, which may be in the House bill — keep in mind that we’re still having a whole series of negotiations, and if this is something that really bothers people, I suspect that members of Congress might take a second look at it. But understand what the intent is. The intent here is to simply make sure that you’ve got more information, and that Medicare will pay for it.

So, for example, there are some people who — they get a terminal illness, and they decide at a certain point they want to get hospice care. But they might not know how to go about talking to a hospice, what does it mean, how does it work. And they don’t want to — we don’t want them to have to pay for that out of pocket. So if Medicare is saying you have the option of consulting with somebody about hospice care, and we will reimburse it, that’s putting more power, more choice in the hands of the American people, and it strikes me that that’s a sensible thing to do.

Rachel Maddow last night had a segment on Republicans’ interpretation of the bill: